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International J. of Healthcare and Biomedical Research, Volume: 2, Issue: 4, July 2014, Pages 117-121

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www.ijhbr.com ISSN: 2319-7072

Case Report:

Multiple juvenile fibroadenomas in a pre-pubertal girl

Dr. Kandukuri Mahesh kumar , Dr. Chintakindi Sravan , Dr. Swarupa Ravuri, Dr. Divyagna. ,

Dr. Ravikanth Soni , Dr. Konduru Omkareshwar

Department of Pathology , Malla Reddy Institute of Medical Sciences, Suraram, Hyderabad, India

Corresponding author : Dr. Kandukuri Mahesh Kumar

Abstract:

Fibro adenomas comprise most of the benign breast lumps among young females between the age group 20 and 35 years. Breast

masses or fibro adenomas are uncommon in childhood. The majority of them are related to inflammation (infection or abscess) or

benign tumors as fibro adenomas. Juvenile fibro adenoma is a rare clinical entity and forms 4% of the total fibro adenomas, and

giant juvenile or multiple fibro adenomas constitutes only 0.5% of all fibro adenomas. They usually present as well-

circumscribed, well encapsulated masses in the breast. Multiple fibro adenomas are not uncommon when they present in bilateral

breast. But the presence of more than four fibro adenomas in one breast is very rare. We present a case of multiple, unilateral

juvenile fibro adenomas (12 fibro adenomas in one breast) in a 10-year-old pre-pubertal girl. The diagnosis was done on fine

needle aspiration cytology and later on confirmed on histopathology. These tumors are almost always benign and should be

treated with breast conserving surgery.

Keywords: Juvenile Fibro adenomas, Multiple Fibro adenomas, Benign Breast Tumors, Breast Lump, Pre-pubertal girl.

INTRODUCTION

Fibro adenoma is the most common benign tumor of

female breast which implies a new growth

comprising of both fibrous and glandular tissue.

Fibro adenomas are common between age groups 20

and 35 years, but can occur at any age group within

reproductive period of life. Breast masses are

uncommon in children and adolescents. Breast

development is one of the first obvious signs of

puberty. Any variation in its normal progression

often deserves attention. Virginal hypertrophy, giant

fibro adenoma, and cystosarcoma phyllodes are the

important differential diagnoses to be considered

when one encounters a large breast mass in the

childhood and adolescence. Although the majority of

breast disorders in pediatric patients are benign. The

majority of them are associated with inflammation

due to infection or benign tumors like fibro

adenomas. Fibro adenomas usually present as an

encapsulated, mobile, rubbery, non-tender

mass/masses. Multiple fibro adenomas account for

0.5%–2% of all fibro adenomas and the exact

etiology is not known. If the mass is not diagnosed

early, it can cause psychological trauma to the

patient. In rare occasions, fibro adenomas can show

rapid proliferation and massive growth resulting in

multiple fibro adenomas or single giant fibro

adenoma. Giant fibro adenomas are more than 5 cm

in diameter and constitute less than 4% of all fibro

adenoma (1, 2).

CASE REPORT

A 10 year old pre-pubertal thin built girl presented

to the surgical out-patient department with

complaints of swelling in the left breast associated

with heaviness since 10 months. There was no pain

initially, but due to the growth of the swelling and


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heaviness patient experienced pain in the last 4

months. On examination, enlarged left breast (3 times

that of the right breast) with nipple, areola and skin

appear normal without any ulceration, but there were

engorged veins noticed on the left breast. Palpation of

the left breast revealed multiple well-defined, firm,

mobile swellings of size approximately 3.5 x 2 cm.

No other swellings noted neither in the axillary tail of

the left breast nor in the right breast. Apart from the

routine investigations patient was advised to undergo

ultrasound of the left breast and fine needle aspiration

cytology (FNAC).

Ultrasonography of the left breast revealed multiple

swellings – Features were suggestive of Multiple

Fibro adenomas.

Fine needle aspiration cytology (FNAC) -

Aspirations were done from three different swellings

of the left breast. Cytosmears show benign ductal

epithelial cells arranged in clusters and sheets with

few elongated myo-epithelial cells and bare nuclei in

the hemorrhagic background.

Features are suggestive of Multiple Fibro adenomas.

Patient was posted for lumpectomy of the multiple

fibro adenomas and the masses were sent for

Histopathological examination (HPE) to confirm the

diagnosis.

Gross findings

We have received 12 well-circumscribed, well

encapsulated, irregular, nodular to smooth gray white

masses. Largest mass measured 5 x 3.5 x 2 cm,

smallest mass measured 1 cm diameter. (Fig. 1).Cut

section of all the masses showed homogenous solid

gray white appearance with slit like spaces. (Fig. 2)

Microscopy

Multiple sections studied show benign ducts, glands

and stroma. Glands are lined by inner epithelial cell

layer and outer myo-epithelial layer. Some of the

glands are slit like. Stroma is fibro-myxoid and more

concentrated around the glands.

Impression- Multiple Fibro adenomas of left breast-

Pericanalicular type.

FIGURE 1 FIGURE 2

FIGURE 1- Photograph showing gross appearance of Multiple Fibro adenomas which are irregular, nodular,

well circumscribed, encapsulated.

FIGURE 2 – Photograph showing cut section of the largest fibro adenoma which is homogenous gray white

appearance with slit like spaces.


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DISCUSSION

Breast fibro adenomas are the most common solid

lesions found in young women. They typically

present as firm, mobile, painless, easily palpable

breast nodules. They occur in any part of

reproductive life of female but more common

between the age groups 20 and 35 years. The

nomenclature of fibro adenoma in younger women is

confusing and a plethora of names exists to designate

the lesion such as age related term juvenile fibro

adenoma and size related term giant or massive fibro

adenoma(3). According to Stanford School of

Medicine, juvenile fibro adenoma of breast is defined

as circumscribed, often large, breast mass occurring

in adolescent females with stromal and epithelial

hypercellularity but lacking leaf like growth pattern

of phyllodes tumors. Most of the patient’s age ranges

between 10-20 years with a mean age of 15 years.

Juvenile fibro adenoma may be multiple. Exact

etiology of juvenile fibro adenoma is not known;

hormonal influences are thought to be contributing

factors. Excessive estrogen stimulation and/ or

receptor sensitivity or reduced levels of estrogen

antagonist during puberty have been implicated in

pathogenesis (4, 5). A wide variety of breast conditions

such as phyllodes tumor, virginal hypertrophy,

lipomas, hamartoma, cyst, abscess and carcinoma can

result in solitary or multiple giant masses (6). It is

important to distinguish these pathological entities

preoperatively as the treatment modalities and the

prognosis differ quite significantly in these various

conditions. Some of the lesions were treated by

mastectomy, but most of the lesions require only

local excision, aspiration, or conservative

management. Virginal hypertrophy is rapid and

distressing enlargement of one or both breast, but is

often asymmetrical. It is treated by reduction

mammoplasty. Giant lipomas can cause unilateral

breast hypertrophy and presents as soft mobile mass

on palpation. Breast abscesses during puberty cause

sudden and rapid growth in the breast with pain and

erythema. Malignant tumors of the breast are rare in

children and adolescence. Preoperative cytological

examination is essential as cytological diagnosis of

phyllodes tumor remains difficult with a significant

overlap with fibro adenomas. The cytological smears

FIGURE 3 FIGURE 4

FIGURE 3 & 4 (40 X View) – Microscopy of fibro adenomas showing benign ducts and glands.

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of malignant phyllodes tumor is quite easy and well

established, but the differential diagnosis between

fibro adenomas and benign or borderline phyllodes

tumor is overlapping at times.

The intervention to be done to the breast changes

according to the size of the lesion and its localization.

If the lesion is small, it can be treated by simple

enucleation from an areolar incision (7). A skin

sparing mastectomy and reconstruction with

prosthesis are eligible choices when the tumor is not

gigantic (8). When there are gigantic tumors causing

structural deformities, it becomes necessary to

reshape the breast by excising excessive skin (9, 10).

When performing excision, the symmetric

appearance between each breast should be protected.

It is essential to know that juvenile fibro adenoma

may recur after complete excision, and the chance of

recurrence become less after third decade. Isolated

case reports of unilateral juvenile fibro adenoma and

multiple giant fibro adenoma in single breast were

reported in the past (4, 7, 11, 12). The patients were

treated by removal of fibro adenoma with

preservation of breast tissue, nipple and areola.

CONCLUSION

The diagnosis and management of large breast

tumors in the pre-pubertal age group is challenging

for pathologist and surgeon. In the diagnostic work-

up, sonography and fine-needle aspiration are used

after physical examination. In the majority of the

cases, these tumors are benign and should be treated

with breast sparing surgery.

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Young Female: A Cytological Dilemma. The Internet Journal of Third World Medicine 2008; 6:2.

4) Musio E, Mozingo D, Otchy DP. Multiple giant fibroadenoma. American Surgeon 1991; 57(7):438-41.

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reconstruction. J Plast Reconstr Aesthet Surg. 2007;60(10):1156-7.

9) Yamamoto, Y., and Sugihara, T. Application of reduction mammoplasty in treatment of giant breast

tumour. Br. J. Plast. Surg. 51: 109, 1998.

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11) Mukhopadhyay M, Patra R, Mondal S, Ghosh A, Ray AK. Bilateral giant juvenile fibroadenoma of breasts.

J Indian Assoc Pediatr Surg. 2009; 14(2):68-69.

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