Giant fibroadenoma of the breast treated with reduction mammoplasty and excision of lesion: A case report

INTRODUCTION

Fibroademonas are described as benign breast neoplasms that arise from the epithelium and stroma of the terminal-duct lobular unit.^[1] They are quite common and are very often found in premenopausal women in their 20–40 years but can be appreciated in women of any age. Most fibroadenomas present as a distinct, painless breast mass that is patient’s self-discovered and are usually <3 cm in size.^[2] The tumor may exceed to 5 cm and is labeled as giant fibroadenoma.^[3-5]

The usual clinical course for breast lumps consistent with fibroadenomas on physical examination and imaging is observation.^[4] Although benign, giant fibroadenomas are treated with surgical excision due to patient’s discomfort, back pain, progressive growth, and esthetic concerns.^[3] It may also be necessary to rule out other forms of malignancy, as both benign and malignant phyllodes tumors can mimic presentation of fibroadenomas.^[2,3]

The standard treatment of giant fibroadenomas is excision, but the extent of surgery is somehow controversial and ranges from excisional biopsy to reduction mammoplasty or even subcutaneous mastectomy.^[4,6] Simple excision is satisfactory for patients with smaller lesions; however, those with larger tumors can be left with a displeasing, loose, and ptotic breast and may require secondary surgery to address these issues.^[7]

CASE REPORT

We present a case of 29-year-old girl who noticed a discrete left-sided breast enlargement since October 2020. A surgical excision was performed, and the mass was diagnosed as a giant fibroadenoma. The etiology is believed to be an end-organ hypersensitivity to normal levels of estrogen. We report a case of giant fibroadenoma with final histopathology as fibroadenoma with no evidence of malignancy.

Pre-operative workup including mammographic studies showed a large well- circumscribed mixed density mass measuring 143 × 105 mm in the retroalveolar region and lower half of the left breast. Ring like benign calcification was identified in the mass too. Ultrasound scan showed a well-defined mixed echogenicity lesion having appearance of breast within breast in the upper half measuring 142*115 mm. No abnormal vascularity is seen with high frequency probe. No other solid or cystic lesions were identified. These features were most likely suggestive of Hamartoma.

Pre-operative markings were based on a breast reduction technique with Wise-pattern skin reduction. The left nipple was displaced laterally compared with the right, and skin excision was planned as a Wise incision with vertical limb under General anesthesia [Figure 1]. The lesion was resected and intact specimen including the lesion and minimal breast tissue and overlying skin with this exposure weighing 860G [Figure 2]. Skin over upper aspect of areola was deepithelialized and nipple-areola complex was mobilized from lateral edge to medial and superior aspect.

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Figure 1:

Tumor excision through a Wise incision.

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Figure 2:

Delivered specimen.

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DISCUSSION

In recent years, oncoplastic surgeries have become increasingly popular combining the principles of oncology and plastic surgery for best outcomes.^[8,9] Oncoplastic techniques account for tumor location and size, tumor to breast ratio, and the desires of the patient.^[10] Although giant fibroadenomas are benign lesions, the surgeon face reconstructive challenges similar to when a large malignant breast neoplasm is removed. There are two main principles in oncoplastics: volume displacement and volume replacement.^[9] In this case, a volume displacement technique was chosen.

CONCLUSION

At the completion of the procedure, the patient had excellent symmetry and the nipple had appropriate color and capillary refill [Figure 3]. Final pathology was benign and showed fibroadenoma. At 3-month follow-up, the surgical site demonstrated well-healed incisions with preserved symmetry and a viable, sensate nipple-areolar complex.

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Figure 3:

Post-operative day 02.

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