A clinico pathological study of fibroadenoma of the breast

Hebsur N. I.1, Mulkipatil S. Y.2, Narayanaswamy R. R.3

1Dr. Narayan chandra. I. Hebsur, Associate Professor, 2Dr. Shivanagouda.Y. Mulkipatil, Assistant Professor, 3Dr. Narayanaswamy R. R, Resident, all authors are affiliated with Department of Surgery, Karnataka Institute of Medical Sciences, Vidyanagar, Hubballi, Karnataka 580022, India

Corresponding Author: Dr S. Y. Mulkipatil, Assistant Professor, Department of Surgery, Karnataka Institute of Medical Sciences.Residential Address: Shivashri, No-17, Manoj Heights, Near Sukruti Public School, Vidyanagar, Hubli, Karnataka, India, Email; drsympatil@yahoo.com

Abstract

Introduction: Fibroadenoma of the breast is a common cause of a benign breast lump in premenopausal women. Though considered as a risk factor for developmentof breast cancer, its reporting has been overshadowed by that of breast cancer. Objective: Toanalyze the occurrence of fibroadenoma among different age groups, rural or urban background and among married and unmarried patients and to correlate clinical diagnosis with the histopathological diagnosis. Materials and methods: This study includes total of 40 cases during the period from November 2009 to October 2011 using the records maintained at KIMS(Karnataka Instituteof Medical Sciences) Hospital, Hubli. Results: From this study it is observed that the mean age of presentation was 25.55 years (range 15-48years). Itpresented as painless lump(75%), 80% of patients had the symptoms < 12 months (range 1 month -11 years). 24 cases (60%) had their fibroadenoma lump in their right. 32% of the patients had their fibroadenoma in upper lateral quadrant, slightly more compared to upper medial quadrant (30%). 28 patients (70%)had one lump, 45% of cases measuring less than 3 cm in size (range 1-11cms), 20% of cases had giant fibroadenoma. Tissue diagnosis was performed in 37 patients. 4 recurrent fibroadenoma cases operated in this study among which recurrence of 1 case occurred during the study period. Conclusion: Fibroadenoma is a source of anxiety in teenage group and it should be dealt by surgical excision.

Key wards: Benign; Breast Disease, Fibroadenoma

Manuscript Received: 8th January 2018, Reviewed: 18th January 2018
Author Corrected: 25th January 2018, Accepted for Publication: 2nd February 2018

Introduction

Benign breast diseases are a common problem presenting in a day to day surgical practice. Fibroadenoma of the breast is a common cause of a benign breast lump in premenopausal women. These lumps are painless, usually solitary, but rarely may be multiple and bilateral, varies in size and grows slowly. Although it is tempting to dismiss fibroadenomata as relatively unimportant lesions because they rarely cause serious clinical problems, they cannot be regarded too lightly. They are extremely common, and in an age of increasing breast awareness, since they invariably present as a palpable mass, may cause considerable anxiety in patients until the correct diagnosis of benignity is established. They may pose diagnostic problems in assessment of fine needle aspiration cytology (FNAC) and those lesions which have not presented clinically may be detected in mammographic screening, where carcinoma is an important differential diagnosis1

There is a wide spectrum of benign breast disorders in India but its reporting has been overshadowed by that of breast cancer. Benign breast disorders have an incidence of 1.5/1000 of total hospital admissions, 6.4/1000 of surgical admissions and 8.1 /1000 of adult female admissions. A recent pathological review shows fibro-adenoma as the most common lesion followed by cysto-sarcoma phylloides and fibrocystic diseases of breast2.
Rangabashyam et al in clinical study also showed fibro-adenoma as the most common breast lesion but it was followed by inflammatory lesions and fibro-adenosis3

Fibroadenomas present as firm, nontender, clearly demarcated masses usually 2 to 3 cm in size, though they may range from < 1 cm to greater than 10. They are most commonly found in the upper-outer quadrant of the breast. These benign masses may enlarge slowly without associated pain or nipple and skin changes, but fluctuations in size may occur with the menstrual cycle; when symptoms are present, they last an average of 5 months.Patients may also have associated breast asymmetry. Multiple fibroadenomas occur in 10 to 25% of cases4.Fibroadenoma is a biphasic tumor, i.e. it is composed of an epithelial and a stromal component. The epithelial component of fibroadenoma can display aberrations similar to those of the epithelial component of the normal breast5.

Fibroadenoma can be diagnosed through a combination of clinical examinations, imaging and non surgical tissue biopsy (the triple test). A clinical diagnosis of fibroadenoma alone is unreliable and does not exclude malignancy even in younger women. Fine needle aspiration is the most accurate means of establishing the diagnosis. Symptomatic fibroadenomas were treated by surgical excision and this option should always be offered. There is increasing evidence that conservative approach is safe and acceptable, provided the result of an adequate triple test is both negative for cancer and consistent with fibroadenoma.

In older age group particular attention must be given to its associated carcinoma. In this context, the aim of the present study is to analyze the occurrence of fibroadenoma among different age groups, rural or urban background and among married and unmarried patients and to correlate clinical diagnosis with the histopathological diagnosis and to ascertain the management of fibroadenoma.

Materials and Methods

The study is a cross-sectional study conducted byDepartment of Surgery, Karnataka Institute of Medical Sciences, Hubballi.This study includescases of fibroadenoma admitted during the period from November 2009 to Oct 2011 consisting of five cases in 2009, 13 cases in 2010 and 22 cases in 2011 obtained using the records maintained at KIMS Hospital. A total of 40 cases were obtained, among these 37 patientsunderwent surgery and 3 patients received conservative management.

Only those cases whose diagnosis of fibroadenoma had been confirmed from biopsy were included. Those patients in whom FNAC shows features suggestive of fibroadenoma but HPR report inconclusive of fibroadenoma are not taken as a part of the study group.           

The profile of patients were recorded in the proforma which include age, marital status, rural or urban background duration of symptoms, premenstrual and post menstrual symptoms, number of lumps, size and location of lumps. Enquiry was also made regarding use of contraceptives and h/o previous surgery for fibroadenoma. In addition to this, the routine investigation including FNAC was done on all cases. The data was entered into Microsoft excel and analyzed using SPSS ver 20 to compute the frequency and percentages.

Results

In the present study, 40 cases were examined and all the cases were diagnosed as fibroadenoma, of which 8 were Giant fibroadenomas.72.5% had fibroadenoma in the age group of 16-30 years and only 22.5% had between 31-45 years of age. Put together 95% of the cases had fibroadenoma in the age group of 16-45 years. The "mean age was 25.55 years. Further, the youngest patient diagnosed for fibroadenoma was 15 years old girl and oldest was 48 years old woman. Similarly, the youngest patient examined for giant fibroadenoma was 17 years old girl and oldest was 48 years old woman. In this study, occurrence of fibroadenoma among women ranges from 15-48 years.

Out of 40 patients 24 patients (60%) were from rural area and 16 patients (40%) were from urban background. Out of 40 patients 30 patients were married and 10 patients were unmarried and also it is quite evident from this study that incidence decrease with increase in number of live births.

Table- 1: Demographic characteristics of confirmed cases of fibroadenoma.

Patient characteristic

Diagnosis

Number of cases

Percentage

Age group (years)

0-15

1

2.5

16-30

29

72.5

31-45

9

22.5

46-60

1

2.5

Background

Rural

24

60.00

Urban

16

40.00

Marital status

Married

30

75. 00

Unmarried

10

25.00

Unmarried

10

25

Parity

(a)Nullipara

11

27.5

(b)Para-1

4

10

(c)Para-2

8

20

(d)Para-3

5

12.5

(e)Para-4

2

5

Table-2: Clinicalpresentation of subjects

Patient characteristic

Diagnosis

Number of cases

Percentage

Frequency of symptoms

Painless lump

27

67.5

Painful lump

13

32.5

Nipple discharge

1

2.5

Premenstrual mastalgia

3

7.5

Duration of symptoms, among patients (in months)

0-12

32

80.00

13-24

2

5.00

25-36

1

2.5

37-48

0

0.00

49-60

1

2.5

61-72

1

2.5

>72

3

7.5

The main complaint of the patients was lump in the breast. The duration varied from 1 month to many years. Out of 40 cases, 13 cases complained pain in the breast. More than three-fourth of them had symptoms between one month to one year and only 2.5% of the patients had symptoms between 5-6 years. Out of 40 patients, 24 cases were distributed in the right and 11 in left breast and 5 patients had bilateral lesion.

Table-3: Examination findings of confirmed cases of fibroadenoma

Patient characteristic

Diagnosis

Number of cases

Percentage

Number of lumps per case

One

28

70.00

Two

9

22.50

More than two

3

7.50

Location of lumps

Right Breast

24

60.00

Left Breast

11

27.50

Bilateral

5

12.50

Quadrant wise distributions

Upper Lateral

16

32.00

Upper Medial

15

30.00

Lower Lateral

10

20.00

Lower Medial

3

6.00

Central

3

6.00

Multiple

3

6.00

Lumps Size
in cm

Up to 3

18

45.00

>3 up to 5

14

35.00

>5 up to 10

7

17.5

>10 up to 20

1

2.5%

Out of the 40 patients studied the main complaint among these is lump in the breast and 13 patients complained pain in the lump. But only 3 did complain of pain during premenstrual period but there was no increase or decrease in size during the menstrual cycle or period. The quadrant wise distribution of lumps showed that 32% of the patients had their lumps in their upper lateral quadrant of the breast a little more than upper medial quadrant (30%). 20% in lower lateral, 6% in lower medial quadrant and 6%   had centrally. Out of 40 cases 28 patients (70%) had solitary lump in the breast, 9 patients (22.5 %) had 2 lumps and 3 patients (7.5%) had more than two lumps (multiple). 45% of the cases had lump size of <3cm, 35% between 3 to 5 cm, 17.5% between 5 to 10 cm and 1 patient (2.5%) between 10-20 cm.. The largest was measuring about 11x11cm and smallest being lxl cm.

Table-4: Clinicopathological diagnosis of confirmed cases of fibroadenoma

Patient characteristic

Diagnosis

Number of cases

Percentage

Diagnosis

Fibroadenoma total cases

40

100.

Giant Fibroadenoma

8

20

HPR features

Without complex features

31

83.7

With foci of fibrocystic changes

4

10.8

With foci of duct papilloma and fibrocystic changes

1

2.7

With foci of squamous metaplasia

1

2.7

Out of 40 cases, FNAC was done for all patients and there were no false negatives. Excision was done in 92.5% of patients; quadrantectomy was done for one patient. This implies surgical excision was the preferred treatment and 3 patients were treated conservatively. Thirty-seven patients, who were treated surgically, wound healed well within seven days and 2 patients had delayed would healing due to wound infection and 5 patients did not came for follow up.

None of the cases was seen on oral contraceptive use and have not reported changes in size of lump during pre and post menstrual period.

Discussion

Fibroadenoma is present in younger age to older age and it is operated more often. 72.5% of the cases diagnosed were belong to 16-30 years and 22.5% were belong to 31-45 years possibly, the reason may be due to hormonal dependency, which is a possible contribution to lump formation and evolution. Added to this, Giant fibroadenomaiscommon during puberty. Similar findings were observed by Other authors [6-10].

The fibroadenoma is found to be more in rural background compared to urban background. This trend may be due to the fact that rural population is more in the catchment area besides exposure to mass media sources and awareness by field health workers.

This study indicates fibroadenoma was more among married women compared to unmarried women, possible reason may be due to early menarche and early marriage. Similar findings were observed byZakiaCoriaty Nelson. He also observed that there is decreasing risk of fibroadenoma with increasing number of live births9

It is interesting to note that the duration varies from few months to many years, may be due to slow growing tumor and painless condition of fibroadenoma. When proper care is not taken there could be a fear of malignancy7.

In our study fibroadenoma is more common in right breast. This finding similar with some authors6 and contradictory to G.C.Raju et al7, N.J.Carty et al10 besides, upper lateral quadrant (32%) involvement slightly more compared to upper medial quadrant (30%) which is in consistent to N.J.Carty et al10. Bilateral involvementfound in 5 cases, this finding is in line with similar studies [6-10].

None of the cases were reported regarding the change in size of the lump during the pre and post menstrual cycle and during pregnancy. Post menstrual changes may result in regression, calcification or both.None of patients in this study has family history of breast cancer and therefore no definite relationship has been made with regard to occurrence of fibroadenoma.

No significant trends in risks with ages at first live births or menarche, duration of breast feeding, number of children breastfed were observed. As none of the cases studied had the history abortions, miscarriage, or stillbirth and hence no association has been made in relation to fibroadenoma.

None of the patients in this study had past history of benign breast lesions and hence no association has been made in relation to fibroadenoma.

FNAC was used as an investigation tool for the management of fibroadenoma. This could be due to reliability, simple, easier and less time consuming. Hence, FNAC was used as one of the investigation to distinguish fibroadenoma from other breast diseases. Diagnosis was discussed with the patient and the choice of excision or follow up offered. In this study it is to be noted that surgical excision was the preferred treatment, simple excision was done to the majority of cases and quadrantectomy for one recurrent giant fibroadenoma case was performedbesides 3 patients whose size of the lump was <3 cm agreed for conservative management. Further, there is increasing evidence that conservative approach is safe and acceptable, provided the result of an adequate triple test is both negative for cancer and consistence with fibroadenoma, as reported by other studies[10-14]and without the availability of FNAC of fibroadenomas, diagnosed clinically should not be treated conservatively.

Malignant transformations in the epithelial componentsof fibroadenomas are generally consideredrare. The incidence of a carcinoma evolving within afibroadenoma was reported to be 0.002-0.0125%. About 50% of these tumors were lobular carcinoma insitu (LCIS), 20% were infiltrating lobular carcinoma,20% were ductal carcinoma in situ (DCIS), and theremaining 10% were infiltrating ductal carcinoma. The clinical, sonographic and mammographicfindings are usually similar to those of benignfibroadenomas, and the malignant changes are oftennoted only when the fibroadenoma is excised. Hence, surgery is advocated in all questionable caseswhere biopsy or FNAC is inconclusive15.

Conclusion

Fibroadenoma is present in younger age to older age and it is operated more often. This study indicates most of the patients are married women, painless lump is the commonest presentation, incidence decreases with increase in number of live births, usually solitary, grows slowly, upper lateral quadrant commonly involved, incidence increases with history of premenstrual mastalgia. In some of the cases noticed in both right and left breasts, and the number of lumps in each case was varied, beside size.  FNAC plays an important role as a valuable tool in diagnosis of fibroadenoma and FNAC is essential to exclude malignancy if conservative treatment is considered and helpful in identifying benign lesion. By and large fibroadenoma is a source of anxiety in teenage group and it should be dealt by surgical excision. An early surgical excision is effective with regard to the best possible cosmetic outcome. Further co-existence of fibroadenoma and breast cancer is relatively rear but it should not be ignored by breast surgeons and patient should be informed properly.

Contribution from authors
•    Dr Narayan Hebsur- The objectives and study design were formulated.
•    Dr S.Y Mulkipatil- Contributed to the preparation of the manuscript and Data analysis.
•    DrNarayanswamy- helped in data collection.

What this study adds to existing knowledge?
This study indicates most of the patients of fibroadenoma are married women, painless lump is the commonest presentation, incidence decreases with increase in number of live births.It is usually solitary, grows slowly, upper lateral quadrant commonly involved, incidence increases with history of premenstrual mastalgia.

Funding: Nil, Conflict of interest: None initiated.
Permission from IRB: Yes

References

1. Elston C. W and Ellis I. O. Fibroadenoma and related conditions. Systemic pathology, 3rd edition: P 147-183.

2. Purushothaman R, Rubby SA. Clinical study on fibroadenoma of the breast. IntSurg J 2016;3(4):1916-9.

3. Rangabashyam N, Gnanaprakasam D, Krishnaraj B, Manohar V, Vijayalakshmi SR. Spectrum of benign breast lesions in Madras. J R Coll SurgEdinb. 1983 Nov;28(6):369-73.

4. Cerrato F, Labow BI. Diagnosis and management of fibroadenomas in the adolescent breast. SeminPlast Surg. 2013 Feb;27(1):23-5. doi: 10.1055/s-0033-1343992. [PubMed]

5. Arno Kuijper, Ellen C.M. Mommers, Elsken van der Wall, Paul J. van Diest. Histopathology of Fibroadenoma of the Breast, American Journal of Clinical Pathology, Volume 115, Issue 5, 1 May 2001, Pages 736–742, https://doi.org/10.1309/F523-FMJV-W886-3J38.

6. Oluwole SF, Fadiran OA, Odesanmi WO. Diseases of the breast in Nigeria. Br J Surg. 1987 Jul;74(7):582-5.

7. Raju G.C, Jankey N and Naraynsingh V. Breast disease in young West Indian women: an analysis of 1051 consecutive cases. Postgraduate Medical Journal 1985; 61(721): 977-978.http://dx.doi.org/10.1136/pgmj.61.721.977. 

8. BewtraChhandra. Fibroadenoma in woman in Ghana. Pan Afr Med J.2009:2:11, published online 2009 July21. PMCID: PMC2984278

9. Nelson ZakiaCoriaty, Ray Roberta M, Gao Dao Li, and Thomas David B. Risk Factors for Fibroadenoma in a Cohort of Female Textile Workers in Shanghal in China. American Journal of Epidemiology 2002:156(7);599-605.DOI: 10.1093/aje/kwf094.

10. Carty N.J, Carter C, Rubin C, Ravichandran D, RoyleG.T, TaylorI. Management of fibroadenoma of the breast. Royal collSurg England 1995; 77(2):127-130.

11. WikinsonS,Anderson T.J, Rifkind E, Chetty U and Forrest A.P.M. Fibroadenoma of the breast; a follow-up of conservative management. Br.j.ofSurg 1989; vol. 76(4): 390-391.

12. Greenberg Ron, Skornick Yehuda and Kaplan Ofer. Management of Breast Fibroadenomas. J Gen Intern Med. 1998 September; 13(9): 640–645. doi:  10.1046/j.1525-1497.1998.cr188.x

13. Sainsbury JR, Nicholson S, Needham GK, Wadehra V, Farndon JR. Natural history of the benign breast lump. Br J Surg. 1988 Nov;75(11):1080-2. [PubMed]
14. Cant PJ, Madden MV, Close PM, Learmonth GM, Hacking EA, Dent DM. Case for conservative management of selected fibro-adenomas of the breast. Br J Surg. 1987 Sep;74(9):857-9.doi: 10.1002/bjs.1800740936. [PubMed]
15. A Vijaykumar, MB Ajitha, BS Shivaswamy, N Srinivasan. A Systematic Study on Fibroadenoma of the Breast.  Eur J Surg Sci 2012;3(3):80-85.

How to cite this article?

Hebsur N.I, Mulkipatil S.Y, Narayanaswamy R.R. A clinico pathological study of fibroadenoma of the breast. Surgical Update: Int J surg Orthopedics.2018;4(1):06-11. doi:10. 17511/ijoso.2018.i1.02.