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A benign breast lump

This is a breast lump removed from a 25 year old woman.
1.  What is the likely pathology?
2.  How would you have investigated her preoperatively?

This lesion is a benign fibroadenoma. They are derived from breast lobules and have both a connective tissue and epithelial element. They should be regarded as aberrations of normal development rather than simple benign tumours. They have a polyclonal rather than monoclonal origin. The most important histological element is the connective tissue stroma. If this shows increased cellularity or cellular atypia then the diagnosis of either a locally invasive or metastatic phylloides tumour should be considered. This latter entity should be regarded as one end of the fibroadenoma disease spectrum. The following slide shows the histology of a typical fibroadenoma with a hypocellular stromal element and no cellular atypia

Clinically fibroademonas usually present in adolescence or early teens as a smooth or occasionally lobulated breast lump. This often aaptly termed a 'breast mouse'. They usually measure 2-3 cm in diameter. Approximately 10% are multiple. They rarely present after the menopause. In the elderly they occasionally present as a hard calcified mass with a typically uniform calcified appearance on mammography.  Diagnosis is by triple assessment - clinical evaluation, imaging and pathological assessment. In those <35 years imaging should be by ultrasound and in those > 35 years by standard two view mammography. Histopathological assessment should be by fine needle aspiration cytology (FNA). A C2 report will confirm the benign nature. If there is any doubt then a core or excision biopsy can be performed.

Until recently all breast lumps, and by implication all fibroadenomas, were surgically excised. The natural history of these lesions has recently been elucidated and has resulted in a change in management policy. Over a 2 year period approximately 20% slowly increase in size, 10% reduce in size, 20% completely resolve and 50% remain static. With knowledge of this natural history a conservative management policy can often be adopted. In those <35 years and with a triple assessment supporting the diagnosis then observation with regular review is acceptable. In those > 35 years and in younger patients requesting it, excision biopsy should be considered.

Recent papers

Dixon J M, Dobie V, Lamb J et al. Assessment of the acceptability of conservative management of fibroadenoma of the breast. Br J Surg 1996; 83: 264-265

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