Fibroadenoma treatment strategies | Journal of MEDICAL SCIENCES

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https://doi.org/10.53453/ms.2024.11.9

Fibroadenoma treatment strategies

Justė Kazlauskaitė

, Mindaugas Kvietkauskas

Faculty of Medicine of Vilnius University, Vilnius, Lithuania

Center of Abdominal and Oncological Surgery, Vilnius University Hospital Santaros Klinikos, Vilnius

University, Vilnius, Lithuania

Abstract

Background. Fibroadenoma is a very common benign tumor in young women. Surgery is the standard treatment

for fibroadenomas. However, cosmetic changes after breast surgery cause psychological problems that impair

patients' quality of life. For these reasons, nowadays it is very important to individualize the treatment of

fibroadenomas using nonsurgical treatment methods.

Aim: to review feasible treatment methods for fibroadenoma and indications, with a focus on recent

advancements.

Methods. A literature review was conducted in the PubMed database, using the keywords. "fibroadenoma",

"fibroadenoma treatment", "fibroadenoma advancements", and "fibroadenoma treatment management". The date

was from 2014 to 2024, and the study was limited to English-language publications (n = 47).

Results. Fibroadenomas, often managed with traditional surgical excision (500,000 surgeries/year worldwide),

can also be observed due to their low malignancy risk (0.002 - 0.0125 %). Observation is suitable for non-growing,

asymptomatic lumps, especially in patients under 35. Minimally invasive methods offer aesthetic and recovery

advantages over surgery, but surgical excision remains common for larger or symptomatic fibroadenomas.

Pharmacological treatments like Metformin show potential, but others, like Ormeloxifene, are less effective and

have significant side effects.

Conclusions. The treatment of fibroadenomas depends on the size, symptoms, and patient preference. Small,

nongrowing fibroadenomas usually require regular checkups, while larger, symptomatic, or growing tumors may

need surgical resection or minimally invasive procedures. Minimally invasive approaches offer advantages in

recovery, cosmetic outcome, and safety, and can save time, help avoid scars, and reduce surgical costs.

Keywords: fibroadenoma, fibroadenoma treatment, fibroadenoma advancements, fibroadenoma treatment

management.

Journal of Medical Sciences. 3 Nov, 2024 - Volume 12 | Issue 5. Electronic - ISSN: 2345-0592

Medical Sciences 2024 Vol. 12 (5), p. 82-90, https://doi.org/10.53453/ms.2024.11.9

1. Introduction

Fibroadenomas are benign breast tumors that are

common among women aged 14-35 years. About

10 % of women worldwide will have fibroadenomas

in their lifetime (1). As mentioned above,

fibroadenomas are most common in women and

very rare in men (2). Iatrogenic male fibroadenomas

occur due to prostate carcinoma treatment and in

male–to–male transgender people as a result of

estrogen therapy (3). Of all breast biopsies

fibroadenoma accounts for 30 to 75 % (4). The

pathogenesis of fibroadenoma is not well–known. It

is believed that fibroadenoma develops due to

changes in hormone levels, obesity and family

history (5). The connective tissues of the stroma and

epithelium of fibroadenoma contain estrogen and

progesterone receptors that can cause excessive

growth of breast tissue. MED12 (the mediator

complex subunit 12) gene also promotes the

formation of fibroadenomas (1). Fibroadenoma in

the family history can be an important risk factor for

the development of fibroadenoma (6). It is usually

unilateral, non-cancerous, and a painless breast

tumor that resolves itself in approximately 60 % of

all fibroadenoma cases and therefore is less common

in post-menopausal women (7). For this reason,

fibroadenomas are usually observed. Although the

likelihood of malignancy is low (0.002 to 0.0125 %)

(8), surgery is the standard treatment for

fibroadenoma. However, cosmetic changes after

breast surgery or permanent thoughts about the

malignancy in observation often lead to

psychological problems, which impair patients’

quality of life (9). This article aims to review

feasible treatment methods for fibroadenoma and

indications, with a focus on recent advancements.

2. Methods

A literature review was conducted in the Medline

(PubMed) database. The included data varied from

2014 to 2024. A detailed search, including the

keywords "fibroadenoma", "fibroadenoma treat-

ment", "fibroadenoma advancements", "fibroade-

noma treatment management" has revealed a total of

276 articles. Records titles and abstracts limited to

English language (n = 148). Full-text articles

assessed for eligibility (n = 47).

3. Results

3.1. Treatment Strategies

Even though nowadays there is a diversity of

fibroadenoma treatment options, the most common

ones are traditional methods, for example, surgical

excision (500,000 surgeries/year worldwide) and

observation (8). The other treatment options for

fibroadenoma are presented in Error! Reference

source not found. (8,10,11). The goals of

nonsurgical treatment of breast fibroadenoma are to

stop lesion growth and reduce palpable mass while

maintaining acceptable cosmetic results (12).

3.1.1. Observation

Removing the lump solves the problem, but surgery

is not always needed and may have bad cosmetic

outcomes as well as be a burden on the healthcare

system, especially when some of these lumps

disappear on their own (13). Fibroadenomas with no

symptoms that are not growing rapidly and cause no

cosmetic issues can be observed yearly by

performing an ultrasound. However, if the patient is

worried about observation and experiences anxiety

about malignancy despite the low risk (less than

1%), removal of asymptomatic fibroadenomas may

be considered. Indications for observation also

include patients younger than 35 years old,

sonographically typical fibroadenoma (14). It is

recommended to perform clinical palpation and

ultrasonography every 6 months. In patients whose

disease is stable should be observed for 2 years, the

observation interval may be extended to every 12

months (10).

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Table 1. Nonsurgical treatment and indications

Treatment methods

Indications

Percutaneous ultrasound-guided

cryoablation.

Visible on ultrasound. Confirmed histologically with core biopsy. Size

less than 4 cm. Lesion near the skin.

Vacuum-assisted breast biopsy.

Smaller than 2-3 cm.

Laser ablation.

Size less than 20 mm.

Percutaneous microwave

treatment.

Fibroadenomas > 2 cm. Adjacent to the areola.

Radiofrequency-assisted excision.

Multiple fibroadenoma.

High-intensity focused ultrasound.

Distance from the skin of ≤ 23 mm to the posterior, ≥ 5 mm from the

anterior border of the fibroadenoma, and ≥ 11mm from the focal point

of the ultrasound treatment. The chest wall must be >1 cm from the

posterior margin of the tumor.

Pharmacological methods.

Multiple fibroadenomas.

3.1.2. Surgical excision

Fibroadenoma size varies from 2 to 3 cm. Although,

masses can range from < 1 cm to greater than 10 cm.

The ones that are greater than 5 cm require surgical

excision. Usually, they are found in the upper-outer

quadrant of the breast (15). Surgical excision

indications are shown in Table 2 (16–18).

Fibroadenomas can be removed using either local or

general anesthesia (19). Surgical resections for

various benign breast tumors leave a significant

scar. The optimal incisions to minimize visible

scarring are inframammary and circumareolar. The

size and location of a fibroadenoma influence the

choice of incision site (Figure 1) (15). Radial and

directly extended incisions (Figure A, D) should not

be used in conservative breast surgery (20). Areolar

or periareolar incision (Figure B, C) is used for

fibroadenomas near the areola, offering good access

and cosmetic outcomes. Superior circumareolar

incision (Figure B) is used if the lump is further

away. Periareolar incision (Figure C) is suitable for

patients with an areolar diameter > 3.5-5 cm, mass-

to-areola distance < 5 cm, fibroadenoma < 3 cm, and

age < 35. Contraindications include small areola,

tumor > 5 cm, mass-to-areola distance > 6 cm,

suspected malignancy, and age > 35 (21). With the

periareolar technique, postoperative complications

occurred faster (22). An inframammary incision

(Figure E) is used if the lump is deep in the breast.

This incision provides optimal tissue visualization

and hides scars in the lower breast crease. It poses a

low risk of breastfeeding issues and is suitable for

fibroadenomas in the lower inner to lower outer

breast quadrant (23). Axillary incision (Figure F):is

used if the fibroadenoma is near the armpit. The

surgeon may use an axillary incision to access it,

resulting in less visible scarring on the breast but

leaving a scar in the armpit (24). The choice of

incision type depends on various factors, such as

fibroadenoma location, size, the patient's

preferences, or the surgeon's expertise. Nowadays,

the requirements for a beautiful post-operative

breast appearance are higher (25). It's essential to

discuss these options with the surgeon to determine

the most suitable approach for a specific case.

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Figure 1. Incisions for removing lumps from the

breast. A - superolaterial radial incision, B -

superior circumareolar incision, C - periareolar

incision, D - inferolateral radial incision. E -

inframammary fold incision, F - axillary incision, G

- other incision.

3.1.3. Percutaneous ultrasound-guided

cryoablation

Cryoablation uses the cytotoxic effects of cold to

create tumor necrosis (26). Cryoablation is a safe

and effective nonsurgical treatment for breast

fibroadenomas, with optimal response in tumors

smaller than 2 cm. Ultrasound follow-up is

recommended every 6 months for 2 years (27).

Cryoablation causes little discomfort after the

procedure and does not result in deformity. The

results show that 75 % of lesions are no longer

palpable after treatment at 1-year follow-up (16).

3.1.4. Vacuum-assisted percutaneous therapeutic

excisional biopsy

Vacuum-assisted breast biopsy (VAB) is effective at

excising smaller fibroadenomas (less than 15 mm),

but it is less successful with larger lesions (28).

Complete excision effectiveness has been reported

to be in a range from 70 to 100 % (29). Clinicians

and patients favor VAB for its efficacy in lesion

removal, improved cosmetic outcomes, and

suitability as a day-care procedure (30).

3.1.5. Percutaneous interstitial laser ablation

Percutaneous interstitial laser ablation (ILA) uses a

portable diode laser to generate heat in tissues. The

photothermal effect can be followed by magnetic

resonance thermometry or by internal and accessory

temperature monitors placed into the tissue (31).

ILA relies on imaging for guidance, prioritizing

demarcated lesions no larger than 20 mm (32).

Major side effects include skin burns, and the most

serious complication is pneumothorax (33). The

treatment is done under local anesthesia with

minimal pain and discomfort. It is aesthetically

superior to lumpectomy (32).

3.1.6. Percutaneous microwave treatment

Percutaneous microwave treatment (MWA) is a

promising thermal ablation technique (34). MWA

offers better cosmetic results, less pain, and fewer

complications, but surgery is still better because the

recurrence rate is lower (35). Some studies showed

that MVA is a very efficient treatment for

fibroadenomas > 2 cm, without damage to normal

tissue (36). The results of a study of 122 patients

showed that cosmetic results after treatment with

MWA were excellent (90.2 % ) (34).

3.1.7. Radiofrequency-assisted excision

Radiofrequency-assisted excision (RFA) uses low-

frequency radio waves and causes localized

coagulative tissue necrosis (26). RFA works by

heating water molecules and causing coagulation.

The treatment goal for RFA is to ablate the whole

lesion plus a 1 cm tissue rim to between 50–100° C

for 9 minutes (31). The procedure is well tolerated

by patients and is associated with minimal

complications (37). RFA has advantages in the

treatment of multiple fibroadenomas. Conducted

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studies show that RFA can become the most suitable

method for treating fibroadenomas due to such

advantages as a high rate of complete ablation, little

damage to the surrounding tissues, quick recovery

after the procedure, and a cosmetic result that

satisfies patients (8,38).

3.1.8. High-intensity focused ultrasound

High-intensity focused ultrasound (HIFU) is an

ablation technique that uses an ultrasound beam to

pass through the tissue as a high-frequency pressure

wave that passes through the tissue causing protein

denaturation and necrosis. Surrounding tissues are

preserved (39). HIFU surgery is an effective and

safe noninvasive alternative technique for the

treatment of breast fibroadenoma (40). According to

the studies, although the HIFU method is safe, but

in some cases, coagulation necrosis of cells was

found after this treatment (41). The efficacy and

safety of HIFU therapy for breast fibroadenomas

larger than 3 cm are unclear (42). Recurrence occurs

in approximately 4 % of cases treated this way and

is more likely in patients with multiple lesions,

larger lesions, and hematoma at surgery. HIFU has

shown promising results (16).

3.1.9. Pharmacological methods

Although fibroadenomas are relatively benign, they

can cause significant psychological distress. Patients

often worry about misdiagnosis, potential

malignancy, and fear when touching the lump,

which are common concerns with conservative

treatment (43). Metformin, an anti-hyperglycemic

agent, is being studied for various medical

conditions. Metformin exhibits effects on breast

cancer cells. Given fibroadenoma's estrogen-

dependent and proliferative nature, along with

Metformin's low incidence of side effects,

metformin might have therapeutic potential for

treating fibroadenoma (44). Ormeloxifene is a new

nonsteroidal drug that produces estrogen agonist and

strong antagonist activity and is used to treat

fibroadenoma. However multiple studies have

reported that Ormeloxifene was not effective in

fibroadenoma treatment and had side effects, such as

hot flashes, irregular menstruation, headaches,

depression, thromboembolic events, eye disease, leg

cramps, endometrial hyperplasia, and more (45).

3.2. Evaluation of treatment methods for

fibroadenoma

Recent systematic reviews indicate that minimally

invasive methods for breast treatment offer

significant advantages over traditional surgery in

terms of patient recovery, aesthetic outcomes, and

overall safety. Ardila C. M. et al. found that these

techniques result in better aesthetic results, less

postoperative morbidity, and improved clinical

outcomes compared to conventional surgery (46).

According to Zhang W. et al. study, the MWA

technique is found to be an effective, safe, and

promising alternative to traditional surgical methods

(47). In most cases, fibroadenomas require no

intervention as they naturally diminish with time (1).

However, for some reasons explained in Table 2,

surgery might be advisable. Despite this, many

women opt against surgery due to the benign nature

of these lesions, which pose no enduring risk of

malignancy. Usually, women do not feel

comfortable being observed for psychological

reasons. Surgical procedures can rarely result in

complications, such as wound infections, scar

formation, and breast deformity. According to Peek

et al., minimally invasive, time-consuming ablative

techniques are MWA, cryoablation and HIFU.

Minimally invasive and time-efficient are LA and

RFA (39). Minimally invasive methods of treating

fibroadenomas vary greatly depending on the

equipment available at the hospital. It is difficult to

evaluate the effectiveness of each of them.

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Comparative studies are needed to compare ablation

methods and determine which one is most

promising. However, ongoing research into the

causes of fibroadenomas may reveal new

therapeutic targets that could be used in drug

development. And finally, the most important part -

patient involvement in treatment. Applying the

analyzed treatment methods in practice can offer the

patient more treatment alternatives.

Table 2. Surgical excision indications

Surgical excision indications

Mass greater than 5 cm.

Rapid grow.

Nonmobile, hard, enlarging, tender (can be

smaller than 5 cm).

Fixed to the overlying skin or nipple areolar

complex.

Associated with axillary or supraclavicular

lymphadenopathy.

The patient is experiencing anxiety because of

the mass.

Breast asymmetry.

4. Conclusion

According to this review of the literature, the

treatment of fibroadenomas depends on the

indications, psychological patient status and

preferences of the patient. For small, stable

fibroadenomas, regular surveillance is usually

sufficient, but if the tumor is large or symptoms are

severe, surgical resection or minimally invasive

procedures such as ultrasound biopsy or laser

ablation may be necessary. Compared to traditional

surgical methods, minimally invasive fibroadenoma

resection methods are better due to faster recovery

of patients, smaller postoperative scars and

complications, and better psychological well-being

of patients. It is necessary to pay attention to medical

treatment, because of the possibility to save time,

avoid postoperative scars, and reduce the costs of

surgical operations.

Conflict of Interest

The authors have declared that no competing

interests exist.

Funding

The authors have no funding to report.

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