ORIGINAL ARTICLE
Intermediate and Long-term Outcomes of Giant Fibroadenoma Excision in Adolescent and Young Adult Patients Felecia E. Cerrato, MPH,* Sandhya Pruthi, MD,†,‡ Judy C. Boughey, MD,§ Patricia S. Simmons, MD,†,¶,** Barbara Salje, MBChB,* Laura C. Nuzzi, BA,* Valerie Lemaine, MD, MPH,†† and Brian I. Labow, MD* *Department of Plastic and Oral Surgery and Adolescent Breast Clinic, Boston Children’s Hospital and Harvard Medical School, Boston, Massachusetts; †Breast Clinic, Mayo Clinic, Rochester, Minnesota; ‡Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota; §Department of Surgery, Mayo Clinic, Rochester, Minnesota; ¶Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota; **Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota; ††Division of Plastic Surgery, Mayo Clinic, Rochester, Minnesota
n
Abstract: Giant fibroadenomas (5 cm or greater) are benign breast masses that often present in adolescence and require surgical excision. Long-term outcomes, recurrence rates, and the need for additional reconstructive surgery in this population are unknown. Patients aged 11–25 years whose pathology reports indicated the presence of a giant fibroadenoma were eligible for this study. Medical records were reviewed for presentation, treatment, and outcomes. A subset of patients completed an investigator-designed long-term outcome survey to measure additional outcomes and the desire or need for subsequent reconstructive surgery. Forty-six patients with at least one giant fibroadenoma (mean size 7.4 2.8 cm) were identified. Most patients underwent excision with a periaroeolar incision (n = 31), and an enucleation technique (n = 41), and four patients underwent immediate breast reconstruction. Thirty-three patients had complete medical records with a mean follow-up time of 2.2 4.1 years and no complaints of asymmetry, additional breast deformities, or reconstructive surgery procedures documented. In addition, nine patients completed the investigator-designed survey with a mean follow-up time of 10.1 8.7 years (range 1.5–27.0). Three of these patients reported postoperative breast asymmetry and the desire to pursue reconstructive surgery. Aesthetic outcomes of giant fibroadenoma excision may be satisfactory for many patients without immediate reconstruction, but for others, the need for reconstructive surgery may arise during development. Providers should address this potential need prior to discussing treatment options and during postoperative follow-up. Caution should be exercised before recommending immediate reconstruction. n Key Words: adolescent, breast mass, excision, giant fibroadenoma
F
ibroadenomas are the most common benign breast masses in adolescents in both clinical and surgical series (1–4). Malignant breast disease is rare in this population (5). Nonsurgical management of masses that are consistent with fibroadenoma on physical examination and imaging is usually recommended. Giant fibroadenomas (5 cm or greater), though also benign, may be more clinically concerning because of
Address correspondence and reprint requests to: Brian I. Labow, MD, FACS, FAAP, Department of Plastic and Oral Surgery, Boston Children’s Hospital and Harvard Medical School, 300 Longwood Avenue, Hunnewell1, Boston, MA 02115, USA, or e-mail: [email protected] DOI: 10.1111/tbj.12394 © 2015 Wiley Periodicals, Inc., 1075-122X/15 The Breast Journal, Volume 21 Number 3, 2015 254–259
size, progressive growth, associated pain, and aesthetic concerns. For these indications, as well as to rule out other diagnoses such as phyllodes tumor, giant fibroadenomas are often removed by surgical excision. In some cases, giant fibroadenoma may contribute to macromastia or breast asymmetry, and a reduction mammaplasty may be performed in conjunction with excision (6,7). As giant fibroadenomas occur in the developing, adolescent patient, there are concerns that surgical resection may result in breast asymmetry, potentially impact future breast development and growth, or the need for subsequent reconstructive surgery. Guidelines for the timing of immediate or delayed breast recon-
Giant Fibroadenoma Excision Outcomes • 255
struction following giant fibroadenoma excision in adolescent patients are lacking, and the long-term outcomes after excision of giant fibroadenoma in adolescent patients are unknown. The purpose of this study was to obtain demographic, perioperative, and intermediate and long-term outcome data on young patients who underwent surgical resection of giant fibroadenoma by assessing the rate of recurrence and surgical outcomes in these patients and the need for immediate and/or subsequent reconstructive surgery. MATERIALS AND METHODS This study was approved by the Boston Children’s Hospital (BCH) Clinical Committee on Investigation and the Mayo Clinic Institutional Review Board. After obtaining approval, the Department of Pathology’s databases at the two participating institutions were queried for “breast mass,” “fibroadenoma,” and “giant fibroadenoma” between the years of 1986– 2010 for the Mayo Clinic and 2000–2010 for BCH. The Mayo Clinic used a wider range due to not being a pediatric-specific facility and to increase sample size. Patients were eligible for this study if they were 11–25 years of age at time of excision and had a pathologist-confirmed diagnosis of one or more fibroadenomas with at least one dimension 5 cm or greater. All eligible patients had presented for giant fibroadenoma treatment and had undergone excision of the giant fibroadenoma. Cases where fibroadenoma identification was incidental and not the reason for surgery were excluded. Relevant clinical information, including demographics, age at surgery, indications for surgery, procedure details, and intermediate outcomes, was collected from patient medical records. In addition to the retrospective component of the study, patients were contacted prospectively to assess long-term outcomes by mail and/or telephone up to two times to complete an investigator-designed survey that asked specific questions related to the diagnosis and treatment of giant fibroadenoma. This survey was designed due to the lack of available validated patient-reported outcomes questionnaires in this patient population. Informed consent was obtained from patients and parents of minors prior to survey administration. Participants were asked about family history of either breast cancer or fibroadenoma and if they had preoperative breast asymmetry, and if so, perceived cup size difference.
Study participants were then asked a series of questions related to postoperative outcomes, including: recurrence, incidence of additional fibroadenoma(s), and number of any subsequent excision procedures. Participants were asked if they currently experienced breast pain that they related to surgical management of the giant fibroadenoma(s), if they noted breast asymmetry following giant fibroadenoma excision, and if they had undergone, discussed or anticipated reconstructive breast surgery as a result of surgical management of their giant fibroadenoma. Participants were also asked if they were currently monitored by a physician for breast-related health issues and to record incidence of malignancy if they had been diagnosed with breast cancer. RESULTS Presentation A total of 46 eligible patients were identified across the two participating institutions (Table 1). White ethnicity was the most common (n = 19), followed by Black (n = 8), Hispanic/Latino (n = 5), and Asian (n = 1). Of note, 13 patients did not disclose their ethnicity or listed it as “other.” Nine patients had a family history of breast cancer. Indications for surgery included a persistent, palpable, solid mass of 5 cm or greater at its largest dimension upon examination and/ Table 1. Clinical Presentation and Treatment of Patients with Giant Fibroadenoma Age, years (mean, SD, range) Race/Ethnicity (n) White Black or African American Asian Hispanic/Latino Other/not disclosed Side of giant fibroadenoma presentation (n) Left Right Bilateral Longest dimension, cm (mean, SD, range) Ultrasound (n) Core needle biopsy (n) Type of incision (n) Incision over mass Periareolar Inframammary Wise pattern Excision technique (n) Enucleation Excision with small margin of normal breast tissue Reduction mammaplasty
16.1 2.7 (11.3–22.0) 19 8 1 5 13 19 27 0 7.4 2.8 (5.0–17.0) 32 4 8 31 6 1 41 4 1
256 • cerrato et al.
or ultrasound, either increasing in size or not resolving over a course of several months. Mean size of the largest dimension of giant fibroadenoma was 7.4 2.8 cm (range 5.0–17.0). Twentyseven presented with a giant fibroadenoma on the right side, 19 presented with a giant fibroadenoma on the left side, and there were no bilateral cases. One patient presented with two giant fibroadenomas on the right side, and two patients presented with one giant fibroadenoma and one fibroadenoma less than 5 cm in maximum diameter. One patient presented with one giant fibroadenoma and two fibroadenomas on the right side and one fibroadenoma on the left side. Thirty-two patients had an ultrasound prior to surgery. Core needle biopsy confirmed the diagnosis of giant fibroadenoma(s) in four patients. Procedure Details Mean age at first procedure was 16.1 2.7 years (range 11.3–22.0). The majority of patients underwent excision using a periareolar incision (n = 31). Inframammary incisions (n = 6) and incisions directly over the mass (either linear, curvilinear, or radial incisions) (n = 8) were also used. Most giant fibroadenomas were enucleated (n = 41), meaning that only the mass was excised during the procedure without additional margin of breast tissue. In four patients, the mass was excised along with a small margin of surrounding normal breast tissue. One patient underwent excision of a 17 cm giant fibroadenoma followed by breast reshaping using a Wise pattern reduction technique. One additional patient with a giant fibroadenoma of 6.4 cm had a saline implant placed during the excision procedure. Intermediate Surgical Outcomes Thirty-three patients had sufficient medical record information to determine intermediate outcomes with a mean follow-up time of 2.2 4.1 years. Ten patients had documented recurrence or incident fibroadenomas; three of these patients required additional excision procedures. No complaints of asymmetry, additional breast deformities, or reconstructive surgery procedures were recorded. Long-term Surgical Outcomes In addition, nine patients completed a short, investigator-designed long-term outcomes survey. For these
patients, mean age at excisional surgery was 16.8 2.5 (range 11.6–20.0) with a mean follow-up time of 10.1 8.7 years (range 1.5–27.0) (Table 2). Five patients indicated preoperative breast asymmetry due to the giant fibroadenoma, with three of these indicating a two cup size difference, one indicating a one cup size difference, and one patient not specifying the difference in size. No patients reported a recurrence of giant fibroadenoma. However, the patient that underwent excision followed by breast reshaping using a Wise pattern reduction technique reported that an additional excision procedure was required 4 years postoperatively. This same patient reported that she had an additional fibroadenoma 7 years postoperatively and underwent an additional excision. No details were available on self-reported recurrence and procedures. No patients reported breast pain. Postoperative breast asymmetry was reported in three patients, and two of these also reported preoperative asymmetry. The degree of breast asymmetry was described as a one cup size difference in two of these patients. In one of these patients, the side operated on for giant fibroadenoma was larger than the contralateral side. No patients reported having had subsequent reconstructive surgery after giant fibroadenoma excision, and only three indicated that the physician discussed the option of reconstruction with them before surgery. Those patients indicated that the reason for discussing Table 2. Survey Responses of Patients Underwent Giant Fibroadenoma Excision
Who
No (n)
Yes (n)
5 9
4 0
4 9 8
5 0 1
8
1
9
0
6
3
9
0
6
3
6
3
6
3
9
0
1. I have a family history of breast cancer 2. I have a family history of fibroadenoma/giant fibroadenoma/breast mass 3. Prior to fibroadenoma surgery, I had breast asymmetry 4. I have had a recurrence of the fibroadenoma 5. I have had additional excision procedures at an outside institution to remove the fibroadenoma 6. I have developed 1 or more additional fibroadenoma(s) since being treated 7. I currently have breast pain due to the diagnosis and treatment of fibroadenoma 8. I have breast asymmetry that I feel is due to the treatment of fibroadenoma 9. I have had reconstructive breast surgery due to the treatment of fibroadenoma 10. My physician has discussed the option of reconstructive breast surgery with me 11. I would like to have reconstructive breast surgery in the future 12. I am currently monitored by a physician for breast-related health issues 13. I have been diagnosed with breast cancer
Giant Fibroadenoma Excision Outcomes • 257
surgery was to correct associated breast asymmetry that may have been a result of giant fibroadenoma excision. The same three patients responded that they would like to pursue reconstructive surgery in the future to correct asymmetry. Only three of the survey responders indicated being followed regularly by a physician for breast-related health issues. No patients indicated having been diagnosed with breast cancer. DISCUSSION Unlike smaller fibroadenomas more commonly observed in adolescents or young adults, giant fibroadenomas are excised for a variety of indications (6,7). Concerns related to giant fibroadenoma excision in adolescent or young adult patients include the consequences of surgical intervention in the developing breast and the potential for secondary deformity such as breast asymmetry, which may necessitate reconstructive surgery. Outcomes data in this population are lacking and the rate of secondary deformity and/ or need for reconstructive surgery is unknown. We report a series of 46 adolescent and young adult patients who underwent giant fibroadenoma excision with intermediate outcome data on 33 patients (mean follow-up time of 2.2 4.1 years) and long-term outcome data on nine patients (mean follow-up time of 10.1 8.7 years). Of these nine patients, three indicated they wish to pursue reconstructive surgery due to resulting breast asymmetry, but none had undergone such procedures. The majority of patients underwent tumor excision by enucleation and did not undergo any breast reconstruction at the time of initial surgery, and our results suggest that for some patients the desire for reconstructive surgery may arise as the adolescent patient matures. However, there was no indication of asymmetry or additional reconstructive surgery in the medical records of patients who did not complete the survey, suggesting that aesthetic outcomes may be satisfactory for many patients without immediate reconstruction. Providers should address this potential need prior to discussing treatment options and during follow-up. Specific guidelines for the treatment of giant fibroadenoma, as for breast masses in general, in adolescent patients are lacking. As fibroadenomas are benign, conservative management is generally recommended in young patients (6). However, giant fibroadenomas, especially those that are symptomatic or progressively enlarge, may raise concerns about breast
development, appearance or malignancy. In our study, patients presented with a large breast mass, underwent an examination by the treating physician, and in most cases, ultrasounds were performed that all were consistent with giant fibroadenoma. Although most patients received ultrasounds, 30% did not have an ultrasound or report that could be identified from the medical record. Although some patients may have received sonograms at outside institutions that were not documented in the medical record, this may also represent a true underutilization of sonography as a safe, quick, and effective diagnostic tool. Core needle biopsy was performed in four patients; however, this diagnostic procedure is generally not required as the tissue diagnosis in these patients rarely influences the recommendation for surgical excision. It may be of value to exclude phyllodes tumor or malignancy, if there is a clinical concern (6,8). Most giant fibroadenomas in our series were excised via periareolar incisions and enucleation, though in a subset of patients, a small margin of normal breast tissue was removed as well. Of those patients, one completed the investigator-designed survey and did not indicate any postoperative asymmetry or desire to pursue reconstructive surgery. However, it was noted that this patient underwent reconstruction at the time of initial excision, though details of this reconstruction were not available. Most patients who completed the survey did not indicate any postoperative asymmetry or desire to pursue reconstructive surgery. Previous reports of outcomes of giant fibroadenoma excision in adolescent patients and evolving surgical techniques have led to various conclusions about the timing and necessity of breast reconstruction. One group used a tissue expander by inserting it into the resulting defect immediately following giant fibroadenoma excision in two adolescent patients; the authors believe this helped facilitate skin reduction and natural recovery of the breast with follow-up times of 4– 5 years (9). Immediate dermoglandular preserving mastopexy after giant fibroadenoma excision in two adolescent patients resulted in aesthetic improvement and no additional surgical corrections were needed, but follow-up times for each patient were 2 months and 1 year, respectively (10). Another report suggests that enucleation and immediate reconstruction by a modified McKissock vertical bipedicle reduction results in symmetric breasts and reduces the need for further surgery; follow-up time was 3 years (11).
258 • cerrato et al.
Another report of four adolescent patients who underwent inframammary excision without reconstruction with follow-up times ranging from 1 month to 8 years did not indicate recurrence or need for additional surgery. Although the authors conclude that this technique has the ideal cosmetic results and that reconstruction, if needed, should be addressed after a prolonged period of time after excision, they acknowledge that there was no comparative data (12). In addition, Gobbi et al. describe two adolescent patients whose giant fibroadenomas were removed using elliptical and circumaeroeolar incisions without reconstruction, and the authors report satisfactory cosmetic results 10 months postoperatively (13). It should be noted that all reports of satisfactory cosmetic outcomes in the above reports were assessed by the surgeon(s) and no objective assessments were made. Furthermore, these are all small case series with no comparison groups; therefore, conclusions about the timing or need for reconstructive surgery are subjective. In some cases, very large giant fibroadenomas resulting in substantial breast asymmetry or macromastia on presentation may drive immediate reconstruction. This is presumably more likely in patients who have visible skin attenuation (striae) or who have completed breast development. Alternatively, in younger patients with good skin appearance, the breast parenchyma may expand to fill a resulting defect and resolve any deformities over the course of development (13,14). There is also the issue of recurrence or additional incident masses, which may warrant the need for additional excision procedures. In this study, three of nine participants indicated postoperative breast asymmetry. Interestingly, one patient who had undergone excision at age 11 years reported that by age 21, the breast that had been operated on grew to be larger than the contralateral breast. This speaks to the challenges of predicting the natural history of a developing breast following excision of a giant fibroadenoma, and the potential pitfalls of immediate reconstruction in this population. It should be noted that three patients completing our survey felt that they have significant breast asymmetry and would like to pursue reconstructive surgery. None of those patients underwent reconstruction during excision. Of the two patients who did undergo reconstruction during initial excision, one completed the investigator-designed survey and this patient, who was 19 years old at the time of excision, did not indicate postoperative breast
asymmetry or the desire to pursue reconstructive surgery. Some patients did have a recurrence or additional fibroadenomas (n = 10), but only three had additional excision procedures, as most of the masses resolved on their own or surgical excision was not recommended. However, there was no mention of asymmetry or other secondary deformities in the available medical records of those patients who did not complete the survey. Our results suggest that the need for breast reconstruction following excision of giant fibroadenomas does exist and should be discussed prior to excision. If a patient presents with a giant fibroadenoma, attenuated skin and has completed breast development, an argument can be made for immediate reconstruction at the time of initial excision. However, most of the patients who responded to our survey did not have postoperative asymmetry or a desire to pursue reconstructive surgery. Of the patients who did not respond to the survey, though some of these patients had recurrence or additional fibroadenoma(s), medical records did not indicate a resulting deformity, asymmetry, or need to pursue additional reconstructive breast surgery. We conclude that the majority of patients undergoing enucleation of giant fibroadenomas will have a good aesthetic result without the need for additional reconstruction. Furthermore, caution should be exercised in recommending immediate reconstruction to all patients undergoing excision of giant fibroadenomas; this may be especially true in younger patients with growth potential remaining in the affected breast. There were several limitations to this study. Longterm outcome survey response rate was low, as most patients were lost to follow-up. It must also be considered that patients who were very satisfied with surgical outcomes were more likely to participate, and thus long-term outcomes data may not be representative of the total patient population. Similarly, those patients who were very dissatisfied may have declined to participate and sought treatment elsewhere. For some patients, follow-up times may have been too short to notice resulting breast asymmetry or it may not have been recorded in the medical record. Patients who completed the long-term outcome survey did so subjectively and no standardized measurements of postoperative breast asymmetry were obtained. Larger series with objective measurements of postoperative differences in breast size would provide more standardized data to make recommendations for the timing of
Giant Fibroadenoma Excision Outcomes • 259
breast reconstruction following giant fibroadenoma excision. The relatively short mean follow-up time for long-term outcomes prevented data collection regarding breast feeding. In addition, data regarding sensation after surgery were not available. Excision of giant fibroadenoma in adolescent and young adult patients may raise concerns about the effects of surgical intervention in a developing breast. While some patients may have resulting breast asymmetry, our data appear to indicate that most patients who undergo excision by enucleation will have satisfactory aesthetic results. The potential need for reconstructive surgery should be discussed with patients prior to excision. In younger patients who will continue to develop, caution should be exercised before recommending immediate reconstruction, and patients should be monitored postoperatively to assess secondary deformity and then decide regarding the need for reconstructive surgery. REFERENCES 1. Greenberg R, Skornick Y, Kaplan O. Management of breast fibroadenomas. J Gen Intern Med 1998;13:640–5. 2. Neinstein LS, Atkinson J, Diament M. Prevalence and longitudinal study of breast masses in adolescents. J Adolesc Health 1993;14:277–81.
3. Simmons PS, Wold LE. Surgically treated breast disease in adolescent females: a retrospective review of 185 cases. Adolesc Pediatr Gynecol 1989;2:95–8. 4. Santen RJ, Mansel R. Benign breast disorders. N Engl J Med 2005;353:275–85. 5. Simmons PS, Jayasinghe YL, Wold LE, Melton LJ 3rd. Breast carcinoma in young women. Obstet Gynecol 2011;118:529–36. 6. Jayasinghe Y, Simmons PS. Fibroadenomas in adolescence. Curr Opin Obstet Gynecol 2009;21:402–6. 7. Divasta AD, Weldon C, Labow BI. Chapter 22: the breast: examination and lesions. In: Emans SJH, Laufer MR, eds. Pediatric and Adolescent Gynecology, 6th edn. Philadelphia, PA: Lippincott, Williams & Wilkins, 2012:405. 8. Smith GE, Burrows P. Ultrasound diagnosis of fibroadenoma - is biopsy always necessary? Clin Radiol 2008;63:511–5; discussion 516-7. 9. Kamei Y, Torii S. Natural skin reduction and breast recovery using a tissue expander after enucleation of a giant breast tumour. Scand J Plast Reconstr Surg Hand Surg 2000;34:383–5. 10. Chepla KJ, Armijo BS, Ponsky TA, Soltanian HT. Benefits of immediate dermoglandular preserving reconstruction following giant fibroadenoma excision in two patients. J Plast Reconstr Aesthet Surg 2011;64:e244–7. 11. Chang DS, McGrath MH. Management of benign tumors of the adolescent breast. Plast Reconstr Surg 2007;120:13e–9e. 12. Biggers BD, Lamont JP, Etufugh CN, Knox SK. Inframammary approach for removal of giant juvenile fibroadenomas. J Am Coll Surg 2009;208:e1–4. 13. Gobbi D, Dall’Igna P, Alaggio R, Nitti D, Cecchetto G. Giant fibroadenoma of the breast in adolescents: report of 2 cases. J Pediatr Surg 2009;44:e39–41. 14. Jacob MM. Application of reduction mammaplasty in treatment of giant breast tumour. Br J Plast Surg 2000;53:265–6.
Copyright of Breast Journal is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Intermediate and Long-term Outcomes of Giant Fibroadenoma Excision in Adolescent and Young Adult Patients Felecia E. Cerrato, MPH,* Sandhya Pruthi, MD,†,‡ Judy C. Boughey, MD,§ Patricia S. Simmons, MD,†,¶,** Barbara Salje, MBChB,* Laura C. Nuzzi, BA,* Valerie Lemaine, MD, MPH,†† and Brian I. Labow, MD* *Department of Plastic and Oral Surgery and Adolescent Breast Clinic, Boston Children’s Hospital and Harvard Medical School, Boston, Massachusetts; †Breast Clinic, Mayo Clinic, Rochester, Minnesota; ‡Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota; §Department of Surgery, Mayo Clinic, Rochester, Minnesota; ¶Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota; **Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota; ††Division of Plastic Surgery, Mayo Clinic, Rochester, Minnesota
n
Abstract: Giant fibroadenomas (5 cm or greater) are benign breast masses that often present in adolescence and require surgical excision. Long-term outcomes, recurrence rates, and the need for additional reconstructive surgery in this population are unknown. Patients aged 11–25 years whose pathology reports indicated the presence of a giant fibroadenoma were eligible for this study. Medical records were reviewed for presentation, treatment, and outcomes. A subset of patients completed an investigator-designed long-term outcome survey to measure additional outcomes and the desire or need for subsequent reconstructive surgery. Forty-six patients with at least one giant fibroadenoma (mean size 7.4 2.8 cm) were identified. Most patients underwent excision with a periaroeolar incision (n = 31), and an enucleation technique (n = 41), and four patients underwent immediate breast reconstruction. Thirty-three patients had complete medical records with a mean follow-up time of 2.2 4.1 years and no complaints of asymmetry, additional breast deformities, or reconstructive surgery procedures documented. In addition, nine patients completed the investigator-designed survey with a mean follow-up time of 10.1 8.7 years (range 1.5–27.0). Three of these patients reported postoperative breast asymmetry and the desire to pursue reconstructive surgery. Aesthetic outcomes of giant fibroadenoma excision may be satisfactory for many patients without immediate reconstruction, but for others, the need for reconstructive surgery may arise during development. Providers should address this potential need prior to discussing treatment options and during postoperative follow-up. Caution should be exercised before recommending immediate reconstruction. n Key Words: adolescent, breast mass, excision, giant fibroadenoma
F
ibroadenomas are the most common benign breast masses in adolescents in both clinical and surgical series (1–4). Malignant breast disease is rare in this population (5). Nonsurgical management of masses that are consistent with fibroadenoma on physical examination and imaging is usually recommended. Giant fibroadenomas (5 cm or greater), though also benign, may be more clinically concerning because of
Address correspondence and reprint requests to: Brian I. Labow, MD, FACS, FAAP, Department of Plastic and Oral Surgery, Boston Children’s Hospital and Harvard Medical School, 300 Longwood Avenue, Hunnewell1, Boston, MA 02115, USA, or e-mail: [email protected] DOI: 10.1111/tbj.12394 © 2015 Wiley Periodicals, Inc., 1075-122X/15 The Breast Journal, Volume 21 Number 3, 2015 254–259
size, progressive growth, associated pain, and aesthetic concerns. For these indications, as well as to rule out other diagnoses such as phyllodes tumor, giant fibroadenomas are often removed by surgical excision. In some cases, giant fibroadenoma may contribute to macromastia or breast asymmetry, and a reduction mammaplasty may be performed in conjunction with excision (6,7). As giant fibroadenomas occur in the developing, adolescent patient, there are concerns that surgical resection may result in breast asymmetry, potentially impact future breast development and growth, or the need for subsequent reconstructive surgery. Guidelines for the timing of immediate or delayed breast recon-
Giant Fibroadenoma Excision Outcomes • 255
struction following giant fibroadenoma excision in adolescent patients are lacking, and the long-term outcomes after excision of giant fibroadenoma in adolescent patients are unknown. The purpose of this study was to obtain demographic, perioperative, and intermediate and long-term outcome data on young patients who underwent surgical resection of giant fibroadenoma by assessing the rate of recurrence and surgical outcomes in these patients and the need for immediate and/or subsequent reconstructive surgery. MATERIALS AND METHODS This study was approved by the Boston Children’s Hospital (BCH) Clinical Committee on Investigation and the Mayo Clinic Institutional Review Board. After obtaining approval, the Department of Pathology’s databases at the two participating institutions were queried for “breast mass,” “fibroadenoma,” and “giant fibroadenoma” between the years of 1986– 2010 for the Mayo Clinic and 2000–2010 for BCH. The Mayo Clinic used a wider range due to not being a pediatric-specific facility and to increase sample size. Patients were eligible for this study if they were 11–25 years of age at time of excision and had a pathologist-confirmed diagnosis of one or more fibroadenomas with at least one dimension 5 cm or greater. All eligible patients had presented for giant fibroadenoma treatment and had undergone excision of the giant fibroadenoma. Cases where fibroadenoma identification was incidental and not the reason for surgery were excluded. Relevant clinical information, including demographics, age at surgery, indications for surgery, procedure details, and intermediate outcomes, was collected from patient medical records. In addition to the retrospective component of the study, patients were contacted prospectively to assess long-term outcomes by mail and/or telephone up to two times to complete an investigator-designed survey that asked specific questions related to the diagnosis and treatment of giant fibroadenoma. This survey was designed due to the lack of available validated patient-reported outcomes questionnaires in this patient population. Informed consent was obtained from patients and parents of minors prior to survey administration. Participants were asked about family history of either breast cancer or fibroadenoma and if they had preoperative breast asymmetry, and if so, perceived cup size difference.
Study participants were then asked a series of questions related to postoperative outcomes, including: recurrence, incidence of additional fibroadenoma(s), and number of any subsequent excision procedures. Participants were asked if they currently experienced breast pain that they related to surgical management of the giant fibroadenoma(s), if they noted breast asymmetry following giant fibroadenoma excision, and if they had undergone, discussed or anticipated reconstructive breast surgery as a result of surgical management of their giant fibroadenoma. Participants were also asked if they were currently monitored by a physician for breast-related health issues and to record incidence of malignancy if they had been diagnosed with breast cancer. RESULTS Presentation A total of 46 eligible patients were identified across the two participating institutions (Table 1). White ethnicity was the most common (n = 19), followed by Black (n = 8), Hispanic/Latino (n = 5), and Asian (n = 1). Of note, 13 patients did not disclose their ethnicity or listed it as “other.” Nine patients had a family history of breast cancer. Indications for surgery included a persistent, palpable, solid mass of 5 cm or greater at its largest dimension upon examination and/ Table 1. Clinical Presentation and Treatment of Patients with Giant Fibroadenoma Age, years (mean, SD, range) Race/Ethnicity (n) White Black or African American Asian Hispanic/Latino Other/not disclosed Side of giant fibroadenoma presentation (n) Left Right Bilateral Longest dimension, cm (mean, SD, range) Ultrasound (n) Core needle biopsy (n) Type of incision (n) Incision over mass Periareolar Inframammary Wise pattern Excision technique (n) Enucleation Excision with small margin of normal breast tissue Reduction mammaplasty
16.1 2.7 (11.3–22.0) 19 8 1 5 13 19 27 0 7.4 2.8 (5.0–17.0) 32 4 8 31 6 1 41 4 1
256 • cerrato et al.
or ultrasound, either increasing in size or not resolving over a course of several months. Mean size of the largest dimension of giant fibroadenoma was 7.4 2.8 cm (range 5.0–17.0). Twentyseven presented with a giant fibroadenoma on the right side, 19 presented with a giant fibroadenoma on the left side, and there were no bilateral cases. One patient presented with two giant fibroadenomas on the right side, and two patients presented with one giant fibroadenoma and one fibroadenoma less than 5 cm in maximum diameter. One patient presented with one giant fibroadenoma and two fibroadenomas on the right side and one fibroadenoma on the left side. Thirty-two patients had an ultrasound prior to surgery. Core needle biopsy confirmed the diagnosis of giant fibroadenoma(s) in four patients. Procedure Details Mean age at first procedure was 16.1 2.7 years (range 11.3–22.0). The majority of patients underwent excision using a periareolar incision (n = 31). Inframammary incisions (n = 6) and incisions directly over the mass (either linear, curvilinear, or radial incisions) (n = 8) were also used. Most giant fibroadenomas were enucleated (n = 41), meaning that only the mass was excised during the procedure without additional margin of breast tissue. In four patients, the mass was excised along with a small margin of surrounding normal breast tissue. One patient underwent excision of a 17 cm giant fibroadenoma followed by breast reshaping using a Wise pattern reduction technique. One additional patient with a giant fibroadenoma of 6.4 cm had a saline implant placed during the excision procedure. Intermediate Surgical Outcomes Thirty-three patients had sufficient medical record information to determine intermediate outcomes with a mean follow-up time of 2.2 4.1 years. Ten patients had documented recurrence or incident fibroadenomas; three of these patients required additional excision procedures. No complaints of asymmetry, additional breast deformities, or reconstructive surgery procedures were recorded. Long-term Surgical Outcomes In addition, nine patients completed a short, investigator-designed long-term outcomes survey. For these
patients, mean age at excisional surgery was 16.8 2.5 (range 11.6–20.0) with a mean follow-up time of 10.1 8.7 years (range 1.5–27.0) (Table 2). Five patients indicated preoperative breast asymmetry due to the giant fibroadenoma, with three of these indicating a two cup size difference, one indicating a one cup size difference, and one patient not specifying the difference in size. No patients reported a recurrence of giant fibroadenoma. However, the patient that underwent excision followed by breast reshaping using a Wise pattern reduction technique reported that an additional excision procedure was required 4 years postoperatively. This same patient reported that she had an additional fibroadenoma 7 years postoperatively and underwent an additional excision. No details were available on self-reported recurrence and procedures. No patients reported breast pain. Postoperative breast asymmetry was reported in three patients, and two of these also reported preoperative asymmetry. The degree of breast asymmetry was described as a one cup size difference in two of these patients. In one of these patients, the side operated on for giant fibroadenoma was larger than the contralateral side. No patients reported having had subsequent reconstructive surgery after giant fibroadenoma excision, and only three indicated that the physician discussed the option of reconstruction with them before surgery. Those patients indicated that the reason for discussing Table 2. Survey Responses of Patients Underwent Giant Fibroadenoma Excision
Who
No (n)
Yes (n)
5 9
4 0
4 9 8
5 0 1
8
1
9
0
6
3
9
0
6
3
6
3
6
3
9
0
1. I have a family history of breast cancer 2. I have a family history of fibroadenoma/giant fibroadenoma/breast mass 3. Prior to fibroadenoma surgery, I had breast asymmetry 4. I have had a recurrence of the fibroadenoma 5. I have had additional excision procedures at an outside institution to remove the fibroadenoma 6. I have developed 1 or more additional fibroadenoma(s) since being treated 7. I currently have breast pain due to the diagnosis and treatment of fibroadenoma 8. I have breast asymmetry that I feel is due to the treatment of fibroadenoma 9. I have had reconstructive breast surgery due to the treatment of fibroadenoma 10. My physician has discussed the option of reconstructive breast surgery with me 11. I would like to have reconstructive breast surgery in the future 12. I am currently monitored by a physician for breast-related health issues 13. I have been diagnosed with breast cancer
Giant Fibroadenoma Excision Outcomes • 257
surgery was to correct associated breast asymmetry that may have been a result of giant fibroadenoma excision. The same three patients responded that they would like to pursue reconstructive surgery in the future to correct asymmetry. Only three of the survey responders indicated being followed regularly by a physician for breast-related health issues. No patients indicated having been diagnosed with breast cancer. DISCUSSION Unlike smaller fibroadenomas more commonly observed in adolescents or young adults, giant fibroadenomas are excised for a variety of indications (6,7). Concerns related to giant fibroadenoma excision in adolescent or young adult patients include the consequences of surgical intervention in the developing breast and the potential for secondary deformity such as breast asymmetry, which may necessitate reconstructive surgery. Outcomes data in this population are lacking and the rate of secondary deformity and/ or need for reconstructive surgery is unknown. We report a series of 46 adolescent and young adult patients who underwent giant fibroadenoma excision with intermediate outcome data on 33 patients (mean follow-up time of 2.2 4.1 years) and long-term outcome data on nine patients (mean follow-up time of 10.1 8.7 years). Of these nine patients, three indicated they wish to pursue reconstructive surgery due to resulting breast asymmetry, but none had undergone such procedures. The majority of patients underwent tumor excision by enucleation and did not undergo any breast reconstruction at the time of initial surgery, and our results suggest that for some patients the desire for reconstructive surgery may arise as the adolescent patient matures. However, there was no indication of asymmetry or additional reconstructive surgery in the medical records of patients who did not complete the survey, suggesting that aesthetic outcomes may be satisfactory for many patients without immediate reconstruction. Providers should address this potential need prior to discussing treatment options and during follow-up. Specific guidelines for the treatment of giant fibroadenoma, as for breast masses in general, in adolescent patients are lacking. As fibroadenomas are benign, conservative management is generally recommended in young patients (6). However, giant fibroadenomas, especially those that are symptomatic or progressively enlarge, may raise concerns about breast
development, appearance or malignancy. In our study, patients presented with a large breast mass, underwent an examination by the treating physician, and in most cases, ultrasounds were performed that all were consistent with giant fibroadenoma. Although most patients received ultrasounds, 30% did not have an ultrasound or report that could be identified from the medical record. Although some patients may have received sonograms at outside institutions that were not documented in the medical record, this may also represent a true underutilization of sonography as a safe, quick, and effective diagnostic tool. Core needle biopsy was performed in four patients; however, this diagnostic procedure is generally not required as the tissue diagnosis in these patients rarely influences the recommendation for surgical excision. It may be of value to exclude phyllodes tumor or malignancy, if there is a clinical concern (6,8). Most giant fibroadenomas in our series were excised via periareolar incisions and enucleation, though in a subset of patients, a small margin of normal breast tissue was removed as well. Of those patients, one completed the investigator-designed survey and did not indicate any postoperative asymmetry or desire to pursue reconstructive surgery. However, it was noted that this patient underwent reconstruction at the time of initial excision, though details of this reconstruction were not available. Most patients who completed the survey did not indicate any postoperative asymmetry or desire to pursue reconstructive surgery. Previous reports of outcomes of giant fibroadenoma excision in adolescent patients and evolving surgical techniques have led to various conclusions about the timing and necessity of breast reconstruction. One group used a tissue expander by inserting it into the resulting defect immediately following giant fibroadenoma excision in two adolescent patients; the authors believe this helped facilitate skin reduction and natural recovery of the breast with follow-up times of 4– 5 years (9). Immediate dermoglandular preserving mastopexy after giant fibroadenoma excision in two adolescent patients resulted in aesthetic improvement and no additional surgical corrections were needed, but follow-up times for each patient were 2 months and 1 year, respectively (10). Another report suggests that enucleation and immediate reconstruction by a modified McKissock vertical bipedicle reduction results in symmetric breasts and reduces the need for further surgery; follow-up time was 3 years (11).
258 • cerrato et al.
Another report of four adolescent patients who underwent inframammary excision without reconstruction with follow-up times ranging from 1 month to 8 years did not indicate recurrence or need for additional surgery. Although the authors conclude that this technique has the ideal cosmetic results and that reconstruction, if needed, should be addressed after a prolonged period of time after excision, they acknowledge that there was no comparative data (12). In addition, Gobbi et al. describe two adolescent patients whose giant fibroadenomas were removed using elliptical and circumaeroeolar incisions without reconstruction, and the authors report satisfactory cosmetic results 10 months postoperatively (13). It should be noted that all reports of satisfactory cosmetic outcomes in the above reports were assessed by the surgeon(s) and no objective assessments were made. Furthermore, these are all small case series with no comparison groups; therefore, conclusions about the timing or need for reconstructive surgery are subjective. In some cases, very large giant fibroadenomas resulting in substantial breast asymmetry or macromastia on presentation may drive immediate reconstruction. This is presumably more likely in patients who have visible skin attenuation (striae) or who have completed breast development. Alternatively, in younger patients with good skin appearance, the breast parenchyma may expand to fill a resulting defect and resolve any deformities over the course of development (13,14). There is also the issue of recurrence or additional incident masses, which may warrant the need for additional excision procedures. In this study, three of nine participants indicated postoperative breast asymmetry. Interestingly, one patient who had undergone excision at age 11 years reported that by age 21, the breast that had been operated on grew to be larger than the contralateral breast. This speaks to the challenges of predicting the natural history of a developing breast following excision of a giant fibroadenoma, and the potential pitfalls of immediate reconstruction in this population. It should be noted that three patients completing our survey felt that they have significant breast asymmetry and would like to pursue reconstructive surgery. None of those patients underwent reconstruction during excision. Of the two patients who did undergo reconstruction during initial excision, one completed the investigator-designed survey and this patient, who was 19 years old at the time of excision, did not indicate postoperative breast
asymmetry or the desire to pursue reconstructive surgery. Some patients did have a recurrence or additional fibroadenomas (n = 10), but only three had additional excision procedures, as most of the masses resolved on their own or surgical excision was not recommended. However, there was no mention of asymmetry or other secondary deformities in the available medical records of those patients who did not complete the survey. Our results suggest that the need for breast reconstruction following excision of giant fibroadenomas does exist and should be discussed prior to excision. If a patient presents with a giant fibroadenoma, attenuated skin and has completed breast development, an argument can be made for immediate reconstruction at the time of initial excision. However, most of the patients who responded to our survey did not have postoperative asymmetry or a desire to pursue reconstructive surgery. Of the patients who did not respond to the survey, though some of these patients had recurrence or additional fibroadenoma(s), medical records did not indicate a resulting deformity, asymmetry, or need to pursue additional reconstructive breast surgery. We conclude that the majority of patients undergoing enucleation of giant fibroadenomas will have a good aesthetic result without the need for additional reconstruction. Furthermore, caution should be exercised in recommending immediate reconstruction to all patients undergoing excision of giant fibroadenomas; this may be especially true in younger patients with growth potential remaining in the affected breast. There were several limitations to this study. Longterm outcome survey response rate was low, as most patients were lost to follow-up. It must also be considered that patients who were very satisfied with surgical outcomes were more likely to participate, and thus long-term outcomes data may not be representative of the total patient population. Similarly, those patients who were very dissatisfied may have declined to participate and sought treatment elsewhere. For some patients, follow-up times may have been too short to notice resulting breast asymmetry or it may not have been recorded in the medical record. Patients who completed the long-term outcome survey did so subjectively and no standardized measurements of postoperative breast asymmetry were obtained. Larger series with objective measurements of postoperative differences in breast size would provide more standardized data to make recommendations for the timing of
Giant Fibroadenoma Excision Outcomes • 259
breast reconstruction following giant fibroadenoma excision. The relatively short mean follow-up time for long-term outcomes prevented data collection regarding breast feeding. In addition, data regarding sensation after surgery were not available. Excision of giant fibroadenoma in adolescent and young adult patients may raise concerns about the effects of surgical intervention in a developing breast. While some patients may have resulting breast asymmetry, our data appear to indicate that most patients who undergo excision by enucleation will have satisfactory aesthetic results. The potential need for reconstructive surgery should be discussed with patients prior to excision. In younger patients who will continue to develop, caution should be exercised before recommending immediate reconstruction, and patients should be monitored postoperatively to assess secondary deformity and then decide regarding the need for reconstructive surgery. REFERENCES 1. Greenberg R, Skornick Y, Kaplan O. Management of breast fibroadenomas. J Gen Intern Med 1998;13:640–5. 2. Neinstein LS, Atkinson J, Diament M. Prevalence and longitudinal study of breast masses in adolescents. J Adolesc Health 1993;14:277–81.
3. Simmons PS, Wold LE. Surgically treated breast disease in adolescent females: a retrospective review of 185 cases. Adolesc Pediatr Gynecol 1989;2:95–8. 4. Santen RJ, Mansel R. Benign breast disorders. N Engl J Med 2005;353:275–85. 5. Simmons PS, Jayasinghe YL, Wold LE, Melton LJ 3rd. Breast carcinoma in young women. Obstet Gynecol 2011;118:529–36. 6. Jayasinghe Y, Simmons PS. Fibroadenomas in adolescence. Curr Opin Obstet Gynecol 2009;21:402–6. 7. Divasta AD, Weldon C, Labow BI. Chapter 22: the breast: examination and lesions. In: Emans SJH, Laufer MR, eds. Pediatric and Adolescent Gynecology, 6th edn. Philadelphia, PA: Lippincott, Williams & Wilkins, 2012:405. 8. Smith GE, Burrows P. Ultrasound diagnosis of fibroadenoma - is biopsy always necessary? Clin Radiol 2008;63:511–5; discussion 516-7. 9. Kamei Y, Torii S. Natural skin reduction and breast recovery using a tissue expander after enucleation of a giant breast tumour. Scand J Plast Reconstr Surg Hand Surg 2000;34:383–5. 10. Chepla KJ, Armijo BS, Ponsky TA, Soltanian HT. Benefits of immediate dermoglandular preserving reconstruction following giant fibroadenoma excision in two patients. J Plast Reconstr Aesthet Surg 2011;64:e244–7. 11. Chang DS, McGrath MH. Management of benign tumors of the adolescent breast. Plast Reconstr Surg 2007;120:13e–9e. 12. Biggers BD, Lamont JP, Etufugh CN, Knox SK. Inframammary approach for removal of giant juvenile fibroadenomas. J Am Coll Surg 2009;208:e1–4. 13. Gobbi D, Dall’Igna P, Alaggio R, Nitti D, Cecchetto G. Giant fibroadenoma of the breast in adolescents: report of 2 cases. J Pediatr Surg 2009;44:e39–41. 14. Jacob MM. Application of reduction mammaplasty in treatment of giant breast tumour. Br J Plast Surg 2000;53:265–6.
Copyright of Breast Journal is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
