Review Article

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The surgeon’s guide to fibroadenomas

Katherine Kopkash, Katharine Yao

Department of Surgery, NorthShore University HealthSystem, Evanston, IL, USA.

Contributions: (I) Conception and design: K Kopkash; (II) Administrative support: None; (III) Provision of study materials or patients: K Kopkash;
(IV) Collection and assembly of data: K Kopkash; (V) Data analysis and interpretation: K Kopkash; (VI) Manuscript writing: All authors; (VII) Final
approval of manuscript: All authors.
Correspondence to: Katherine Kopkash, MD. Clinical Associate Professor of Surgery, NorthShore University HealthSystem, University of Chicago
Pritzker School of Medicine, 2650 Ridge Avenue, Evanston, IL 60201, USA. Email: kkopkash@northshore.org.

Abstract: This review article takes a modern perspective on the assessment and management of
fibroadenomas (FA) from the viewpoint of the breast surgeon, using evidence-based guidelines. This
manuscript includes an overview of associated breast cancer risk with regards to FA and specific risk factors
for FA, which are questions often asked by patients. Attention is paid to the appropriate work-up of FA from
the clinical, imaging, and pathologic perspectives. There are multiple management options described for FA,
including surveillance, surgical excision, and alternative methods such as cryoablation and high frequency
ultrasound (US) ablation. The rationale and recommendations for each of these options is reviewed in detail,
with particular emphasis on the oncoplastic approach in regards to surgical excision. Finally, the review
article is summarized with concise recommendations to help guide the breast surgeon who is caring for a
patient with a FA. Common clinical scenarios with references are also included to help every breast surgeon
guide their patient in clinical-decision making in regards to FA. A table of clinical pearls and a table that
summarizes studies that guide FA management are included to ensure that evidence-based guidelines are
being emphasized and these can be used as a reference for physicians and patients.

Keywords: Fibroadenoma (FA); breast surgery; oncoplastic breast surgery

Received: 09 September 2020; Accepted: 11 November 2020; Published: 30 December 2020.

doi: 10.21037/abs-20-100
View this article at: http://dx.doi.org/10.21037/abs-20-100

Introduction Definitions and breast cancer risk

Fibroadenomas (FA) are the most common benign breast FAs usually grow as sharply circumscribed spherical nodules
lesion. The true incidence of FA is difficult to assess since and they are made up of epithelial and stromal components
many of these patients are followed by imaging or clinical (4,5). FA are characterized as proliferative breast lesions
exam in their primary care physician’s office. However, without atypia and they are associated with a slight
autopsy studies show approximately 20 percent of women increased risk of developing breast cancer in the future,
in adolescence to mid-20’s have FA (1). FA account for however there is some variation in risk based on subtype (6).
approximately half of all breast biopsies and are most The common subtypes of FA are juvenile, simple, complex,
commonly diagnosed in women between 15 and 35 years and giant.
old (2). The risk of FA decreases significantly with age after Juvenile FA occur in young women between ages 10 and
the peak incidence in the 20–30 age group (3). Many FA 18 and compromise 8% of all FAs; they present with an
patients are referred to breast surgery clinic. Therefore, accelerated growth pattern (7). At the time of diagnosis, up
as a modern breast surgeon, it is critically important to to 25% of juvenile FA patients will have multiple or bilateral
understand the appropriate work-up and management for tumors (8). Simple FA represent approximately 86% of
this type of patient. all FA’s and most often present as a palpable mass (9). The

© Annals of Breast Surgery. All rights reserved. Ann Breast Surg 2020;4:25 | http://dx.doi.org/10.21037/abs-20-100
Page 2 of 8 Annals of Breast Surgery, 2020

majority of women with simple FA and no family history of Key history points that help differentiate this within
breast cancer are not at an increased risk of breast cancer in the broad differential of breast mass include duration of
the future (10,11). Complex FA are FA with associated cysts, symptoms and severity. If there is any fluctuation in size of
sclerosing adenosis, epithelial calcifications, or papillary the mass with the menstrual cycle, this mass is more likely
apocrine changes and they represent approximately 14% to be a cyst (22). A history of trauma or surgery to the
of FA (9,11). Breast cancer risk in patients with complex breast is often associated with fat necrosis (23). Associated
FA is increased if there are proliferative changes in the symptoms such as skin changes or nipple discharge decrease
surrounding breast tissue and complex FA alone is not the likelihood the mass is a FA. A focused history of prior
considered an independent risk factor (9). Giant FA are breast biopsies and surgeries as well as family history of
greater than 5 cm in size and comprise 0.5–2% of all FA (12). cancer will aid in assessing risk factors for FA.
There is rapid growth noted in giant FA and tissue diagnosis On clinical exam, key areas of focus are the lymph node
is necessary to rule out the possibility of a phyllodes basins (specifically cervical, supraclavicular, infraclavicular,
tumor (13). Due to the size of these lesions and the diagnostic and axillary) and breast exam. Careful visual exam of the
dilemma differentiating giant FA from a phyllodes tumor, patient’s breasts with the arms at the sides and raised above
surgical excision is the mainstay of treatment (14). the head help highlight cosmetic deformity caused by an
underlying breast mass. The lymph node exam should be
performed with the patient seated. The breast exam should
Risk factors for FA
be performed in both the seated and supine positions for
The exact etiology of FA is unknown. There is likely greatest accuracy (24). FA usually present as a well-defined
a hormonal component because FA are most common mobile mass in the breast without overlying skin changes
during the reproductive years and they also often enlarge or nipple discharge. Lymph node examination would be
during pregnancy or with estrogen therapies. Risk factors expected to be normal for these patients.
that increase a women’s risk for breast cancer also seem to
increase her risk for FA, including early menarche in some
Imaging assessment
reports (15). A family history of breast cancer has also been
shown to increase the risk of FA in certain women (16). Imaging assessment of a new breast mass is necessary in
A case-control study from China showed a significant essentially all patients because the mass may not exhibit
decreased risk of FA with increased intake of fruits and distinctive physical findings. It is preferable for imaging to
vegetables as well as oral contraceptive use (17). However, occur prior to biopsy as the biopsy changes may obscure
other studies have not demonstrated a linkage between the imaging interpretation. The American College of
FA and age at menarche, age at menopause, or hormonal Radiology Appropriateness Criteria® for palpable breast
therapy, including oral contraceptives (18). masses outlines that for a clinically detected palpable breast
mass, the patient’s age dictates the recommended first
imaging modality. If a patient is 40 or older, she should
Workup
start with diagnostic mammography. If she is younger than
Breast complaints compromise at least 3% of women’s visits 30, the first imaging option is a breast ultrasound (US). If
with their general practice physician and an increasing the patient is between 30 and 39, either US or diagnostic
number of these patients are referred to a specialized breast mammography are reasonable as initial imaging. Any highly
clinic (19,20). As a breast surgeon, the work-up of a new suspicious breast mass should be biopsied, regardless of
breast mass can be classified as clinical, imaging assessment, imaging findings (25).
and pathologic examination (21). Using all three of these US should be performed using a high-resolution, real-
processes in a complementary and coordinated fashion time, linear array scanner with a minimum frequency of
ensures that patients get the highest level of care without 10 MHz (25). The US should be directed to the palpable
unnecessary interventions. mass (26). On US, FA are most commonly described
as a hypoechoic mass with a circumscribed border (27).
Diagnostic mammogram usually consists of a craniocaudal
Clinical
(CC) and mediolateral oblique (MLO) view of each breast.
FA usually have the presenting symptom of a breast mass. A small radiopaque marker is placed on the skin overlying

© Annals of Breast Surgery. All rights reserved. Ann Breast Surg 2020;4:25 | http://dx.doi.org/10.21037/abs-20-100
Annals of Breast Surgery, 2020 Page 3 of 8

A B C

Figure 1 Fibroadenoma pathology. (A) FA with a pushing border between the lesion and the adjacent fatty tissue (hematoxylin and eosin,
2× magnification). (B) FA with hyalinized stroma (hematoxylin and eosin, 10× magnification). (C) FA with mildly hypercellular stroma
(hematoxylin and eosin, 10× magnification). FA, fibroadenoma.

the mass to aid in the ability to obtain spot compression cells (32) (Figure 1). Percutaneous core needle biopsy is
or magnification views (25). Mammogram demonstrates recommended over a fine needle aspiration as it is more
an oval or round mass with a circumscribed margin (28). accurate in differentiating between a FA and a phyllodes
Calcifications are occasionally seen associated with an tumor (33).
involuting FA, often in post-menopausal women, and are
usually coarse and “popcorn-like” (7). Breast magnetic
Management options
resonance imaging (MRI) is occasionally used in the work-
up of FA, especially if there are multiple breast masses Once the breast surgeon has diagnosed an FA in their
and biopsy of all the findings would be difficult (29). The patient, the next step is discussing a management strategy;
appearance of FA on MRI varies based on the hyalinization surveillance, surgical excision, or alternative management
of the lesion. T2 hypointensity is seen with sclerotic or (Table 1).
hyalinized FA while T2 hyperintensity is seen with cellular
FA. FA also show varied enhancement patterns however
Surveillance
typical FA show rapid initial and persistent delayed phases,
also called type 1 enhancement kinetics (30). Observation alone is reasonable in pediatric FA that are
asymptomatic (34). In adult patients, the American Society of
Breast Surgeons Choosing Wisely® campaign recommends
Pathologic examination
against routinely excising biopsy-proven FA that are
Clinical concern and imaging characteristics determine the <2 cm (35). The American College of Radiology
need for pathologic examination in suspected FA. Younger Appropriateness Criteria® for palpable breast masses even
patients, under age 40, with a Breast Imaging-Reporting states that short term imaging follow-up (such as every
and Data System (BIRADS) 3 lesion can often be safely 6 months for 2 years) is a reasonable alternative to biopsy
followed with careful surveillance. Women over age 40 for solid masses with probably benign features suggesting
with palpable breast masses, even with benign features FA (36).
on imaging, and all women with a BIRADS 4 or higher
finding should be considered for biopsy (31). The ideal
Surgical excision
approach is a percutaneous core biopsy. FA classically have
an evenly distributed glandular and stromal elements ratio Defining which patients require surgery for biopsy proven
and the borders of the lesion are usually circumscribed FA can be difficult and it requires the breast surgeon to take
and pushing, without infiltrating the surrounding tissue. an individualized case-based approach. Some earlier data
The stroma is typically low in cellularity and does not have drove a more aggressive stance, recommending surgical
significant nuclear atypia. The epithelial component shows excision for patients >35 years old, immobile or poorly
an intact myoepithelial layer supporting ductal epithelial circumscribed masses, and FA size greater than 2.5 cm (38).

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Page 4 of 8 Annals of Breast Surgery, 2020

Table 1 Fibroadenoma management options

Number of Average
Author Type of study Key point(s)
subjects patient age

Surveillance

McLaughlin (34) Retrospective chart 196 15 Observation is appropriate for asymptomatic breast masses in
review children

Rao (35) Evidence based N/A N/A No routine excision of <2 cm FA

guidelines

Harvey (36) Evidence based N/A N/A Short term imaging follow up for benign appearing masses
guidelines

Surgical excision

Dialani (37) Retrospective review 378 Not reported Even FA that are enlarging on imaging are highly unlikely to be
malignant

Hubbard (38) Retrospective review 723 32 Surgery for FA if patient >35 years old, FA >2.5 cm, or poorly
circumscribed mass

Alternative management

Kaufman (39) Prospective 47 34 At 12 months of follow-up following cryoablation, 75% of FA

nonrandomized trial were non-palpable

Li (40) Retrospective review 1,578 35 3% recurrence risk, associated with larger lesion size, using
vacuum-assisted percutaneous excision

Kovatcheva (41) Prospective 42 32 US guided HIFU shows a 72.5% mean volume reduction of the
nonrandomized trial FA at 12-month follow-up
FA, fibroadenoma; US, ultrasound; HIFU, high-intensity focused ultrasound.

If a biopsy proven FA is enlarging on imaging or clinical with an excellent aesthetic result as long as surrounding
follow-up, there is still a very low risk of malignancy (42). breast parenchyma is not resected with the FA (Figure 2B).
For biopsy proven FA, surgical excision is should be However, if there are concerns for long-term cosmetic
considered if there is associated atypia, unusual pathologic outcomes, reconstructive plastic surgery should be consulted
features, or symptomatic/cosmetic concerns (37). and a combination procedure can be considered (46).
The surgical removal of a biopsy proven FA is considered
an excisional biopsy, which the American Medical
Alternative management
Association assigns Current Procedural Terminology
(CPT) code 19120 for billing purposes. This surgery can Alternatives to surgical excision exist but they should only
often be done using sedation and local anesthesia however be considered in patients with a core biopsy proven FA.
occasionally requires general anesthesia, especially with US guided cryoablation is one alternative for FA that has
larger lesions. Perioperative antibiotics are not required for shown significant decrease in lesion size after treatment,
these cases (43). For a palpable lesion without a radiologic with 75% of lesions being non-palpable at 1 year of
marker, it is important for the patient and the surgeon follow-up (39). US guided vacuum-assisted percutaneous
to agree on the mass being removed and circle it on the excision can also be performed for FA, with good patient
skin pre-operatively, to avoid any confusion (Figure 2A). satisfaction. Recurrence occurs approximately 4% of the
Aesthetic scar placement, one of the basic building blocks of time with this modality and is more likely in patients with
oncoplastic breast surgery, is recommended to maximize the multiple lesions, a larger lesion size, and a hematoma at the
cosmetic outcomes (44). A biopsy proven FA can be safely time of the procedure (40). There are preliminary studies
enucleated and margins are not recommended (45). Even using percutaneous US ablation for FA, such as high-
very large FA can often be enucleated and leave the patient intensity focused ultrasound (HIFU), that have shown

© Annals of Breast Surgery. All rights reserved. Ann Breast Surg 2020;4:25 | http://dx.doi.org/10.21037/abs-20-100
Annals of Breast Surgery, 2020 Page 5 of 8

A B

Figure 2 (A) Pre-operative and (B) 2-week post-operative images of a 34-year-old patient undergoing an excisional biopsy for a symptomatic
FA of the right breast using aesthetic scar placement in the periareolar position. FA, fibroadenoma.

Table 2 Fibroadenoma clinical pearls Common clinical scenarios

Initial imaging: ultrasound (mammogram if over 40 years old)
(I) A 14-year-old female is referred to you by her
Biopsy modality: core biopsy pediatrician who found a small, mobile, 1.5 cm mass
Asymptomatic FA management: observation in the patient’s left breast on clinical exam. This is
Symptomatic FA management: surgical excision not bothering the patient. How would you manage
this? Careful physical exam followed by ultrasound.
FA management with concern for malignancy: surgical excision
If US shows imaging characteristics classic for FA,
FA, fibroadenoma.
serial US every 6 months for 2 years and observation.
If US shows concerning characteristics, perform core
biopsy. If the pathology is FA, clinical surveillance is
promising results. One European multicenter study using
reasonable (47).
HIFU showed a 72.5% volume reduction of the lesion at
(II) A 26-year-old patient comes to your clinic with a
1 year follow-up of the procedure, with minimal transient
rapidly enlarging 3.5 cm mass in her right breast that
side effects (41). Clinical follow-up by the performing
physician is recommended in these patients due to the lack is visible in her swimsuit and causing her distress.
of long-term data on these emerging technologies. What do you recommend? Physical exam to confirm
this is the only breast abnormality and then US. Due
to the size and rapid enlargement of the mass, core
Recommendations biopsy is necessary to rule out malignancy. Surgical
FA is an extremely common benign breast lesion affecting excision should be considered due to the symptomatic
younger women. The ideal approach for a patient with nature and rapid growth pattern of this lesion even if
a breast mass suggestive of FA is to image with US only FA is diagnosed on core biopsy, as the imaging
+/− mammogram, confirm the lesion is an FA using and pathologic distinctions of phyllodes tumor and FA
percutaneous core biopsy, and conservative follow-up in the are nuanced (32).
future. If the FA is causing concern for the patient or the (III) A 45-year-old female presents with a screening
physician has suspicion for malignancy, surgical excision mammogram finding of a 2.7 cm mass, the radiologist
is reasonable and should be performed in an oncoplastic reports it has characteristics indicating it is likely a
fashion to maximize long-term aesthetic outcomes (Table 2). FA. She has no symptoms and a normal physical exam.

© Annals of Breast Surgery. All rights reserved. Ann Breast Surg 2020;4:25 | http://dx.doi.org/10.21037/abs-20-100
Page 6 of 8 Annals of Breast Surgery, 2020

What are your next steps? Diagnostic mammogram Attribution-NonCommercial-NoDerivs 4.0 International
and US followed by an US guided core biopsy. The License (CC BY-NC-ND 4.0), which permits the non-
core biopsy shows a “fibroadenoma with associated commercial replication and distribution of the article with
atypia and radial scar”. Surgical excision, with imaging the strict proviso that no changes or edits are made and the
localization prior to surgery, is recommended due to original work is properly cited (including links to both the
the patient’s age, the lesion size, and the associated formal publication through the relevant DOI and the license).
atypia (37,38). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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doi: 10.21037/abs-20-100
Cite this article as: Kopkash K, Yao K. The surgeon’s guide to
fibroadenomas. Ann Breast Surg 2020;4:25.

© Annals of Breast Surgery. All rights reserved. Ann Breast Surg 2020;4:25 | http://dx.doi.org/10.21037/abs-20-100