In my time spent taking care of the general surgical outpatient clinic, fibroadenomas made up a large proportion of the complaints that I treated. When a young woman of child bearing age walked into the clinic, almost one in every 5 of them had the same problem. They had accidentally felt something moving around inside their breast while they were in the shower. While this might sound like a line from a horror movie, it is actually a lot more common than you think.
To understand this condition more easily, we need to have a look first at the structure of the breast. The main structural units are called lobules. The number of lobules varies widely and they are supported by fibrous tissue and ligaments known as Cooper’s ligaments. Each lobule empties via a short duct into a reservoir for milk or other abnormal discharges. This is called the ampulla. These ampulla open up into the nipple. The darker pigmented region around the nipple is called the areola. It contains numerous glands that secrete sweat and sebum.
Fibroadenomas belong to a group of benign breast diseases called ANDI (Aberrations of Normal Development and Involution) - a term coined up by the Cardiff Breast Clinic in the UK. Previous names of benign breast diseases used to unduly alarm patients and led to them being overtreated. ANDI, since it incorporates the word “normal” in its name, tells them that the symptoms experienced by the patient could be explained by natural changes that might occur in breast tissue. Other conditions included in this group are breast cysts and cyclical mastalgia (breast pain that occurs during specific times of the month, normally in relation to menstruation).
Fibroadenomas usually arise between the ages of 13 - 30 years old, although they can be present in older women too. It is normally due to an increase in the size of a single lobule. They are normally 1 - 3 cm in size but can grow to be much larger. If they are larger than 5 cm, they are known as giant fibroadenomas. They can be single or multiple. They are normally well-rounded in shape. They are normally not painful and therefore are sometimes only accidentally felt by the patient whilst bathing. There are no changes to the skin or nipple and the swelling may be mobile, hence the term "breast mouse".
What Should I Do If I Suspect I Have A Fibroadenoma?
Do not panic! This is the most important message. You should be referred to your nearest general surgery outpatient clinic by your family doctor or general practitioner for further assessment. When you are seen by the surgeon, you will undergo what is called triple assessment. This consists of a full history taking regarding previous illness and use of hormonal contraceptive pills. You will be asked regarding your menstrual history, the symptoms that you feel and the presence of other risk factors. Your surgeon will examine both of your breasts, not just the one where you felt the lump. History taking and physical examination is the first part of the triple assessment.
The second part of the assessment involves getting a radiological image. Since fibroadenomas are normally found in women under 30 years old, an ultrasound may be requested. In older women, a mammogram may be more useful.
The final part of the assessment is the need for cytological evidence. This means your surgeon will need a laboratory report confirming that the cells of the swelling are benign. There are two common ways to acquire the breast tissue cells. The first is via FNAC (fine needle aspiration cytology). This means a small fine needle will be passed into the swelling and cells will be sucked out to be sent to the laboratory for reading. The second method, a trucut biopsy, allows the laboratory to have a bigger sample of tissue. This may be necessary in cases where the clinical examination and radiological imaging do not tally, the swelling is large, the swelling appears to be cancerous on physical examination, etc.
Remember, triple assessment is not 100% accurate.
I Have Been Diagnosed To Have A Fibroadenoma. Should I Go For Surgery?
A fIbroadenoma can be left alone and observed. If the patient requests for it to be removed due to cosmetic reasons or anxiety, experiences too much or too frequent pain or it suddenly grows to become very large, then surgical removal may be planned. If the FNAC result comes back as suspicious or any of the 3 factors of the triple assessment do not tally with each other, you may also consider having it removed surgically.
Surgical removal for fibroadenomas does not involve removing the whole breast. Smaller fibroadenomas may be removed through small wounds on the edge of the areola or along the creases under the breast. These types of wounds normally heal well cosmetically. Removal of giant fibroadenomas may result in dimpling of the breast or asymmetry of the breast where the lump used to be. The final cosmetic result will depend on the size of the breast before the operation in relation to the size of the swelling. The operation is normally done under general anaesthetic.
The good news for those who have a “breast mouse” is that the operation to remove it is relatively simple and quick. In some hospitals, you may need to stay overnight for observation but in many hospitals nowadays, it can even be done as a day case and not require admission to the ward at all. The bad news is that even if you have it surgically removed, it does not mean it will not recur. Think carefully before you go requesting for surgery for cosmetic reasons! You may end up with a scar and need a second operation a few years later if a new swelling is felt.
October was the month of promoting self breast examination and breast cancer awareness. But, self breast examination should be performed monthly. It can be done in 5 steps:
1. Stand in front of the mirror with your hands in your hips and shoulders relaxed. Look for asymmetry of the breasts, unusual skin changes, discharge from the nipple and obvious swellings.
2. Lift up your arms and look for the same changes again.
3. Lie down with your right hand raised above your head. Use the finger pads of the left hand to examine the right breast for any lumps. You may use an up-and-down pattern or a circular pattern, as long as it is systematic and organised so that you do not miss any area of the breast. Make sure to also feel in your armpits and along the cleavage area.
4. Repeat the examination for the left breast.
5. Repeat the examination for both sides while standing up. This is easiest done in the shower.
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