FIBROADENOMA CASE PRESENTATION

ALDILYN J. SARAJAN MEDICAL CLERK ADZU-SOM

GENERAL OBJECTIVE:
To be able to present a comprehensive case on fibroadenoma

SPECIFIC OBJECTIVES
To be able to discuss a comprehensive Medical History and Physical Examination of fibroadenoma
To be able to discuss the anatomy and the pathophysiology concerned in fibroadenoma To be able to discuss the management of fibroadenoma

GENERAL DATA
Name: M.P.T Age: 22 years old Sex: Female Status: Single Religion: Roman Catholic Occupation: Student Address: Sinunuc, ZC

CHIEF COMPLAINT:

BREAST MASS

History of Present Illness:

8 months
PTC, noted painless breast mass, left, movable, no erythema, no nipple discharges

PTC, onset of on off pain associated with menstrual period

6 months

PTC, noted painless breast mass, right, gradually enlarging

4 months

Past Medical History

No previous hospitalization. No known allergies to food and drug. Non- asthmatic

Family History
(+) HPN maternal side (+) DM maternal side No other heredofamilial diseases

Personal and Social History

Patient is a student Non-smoker Non-alcoholic drinker

Review of Systems
General Survey: (-) recent weight loss or gain , (-) body malaise Skin: (-) pruritus (-)rashes Head: (-) dizziness, (-) headache Eyes: (-) blurring of vision

Ears: hearing is good, (-) tinnitus, (-) ear infection

Throat/Mouth: (-) sore throat, (-) dysphagia, (-) gum bleeding

Review of Systems
Neck: (-) pain, (-) stiffness Respiratory: (-) difficulty of breathing, (-) dyspnea on exertion, (-) hemoptysis, (-) recurrent cough Cardiovascular: (-) chest pain, (-) palpitations, (-) orthopnea, Gastrointestinal: (-) bowel changes, like LBM and constipation (-) changes in stool caliber

Review of Systems

Genito-urinary: (-) increased frequency of urination, (-) dysuria, (-) hematuria

Muscoloskeletal: (-) muscle pains, (-) joint pains, (-) stiffness

Physical Examination
General: awake, conscious, coherent, not in respiratory distress; afebrile, ambulatory. Vital signs: Temp : 36.9 oC PR : 93 beats per minute RR : 20 cycles per minute BP : 110/80mmHg Weight: 60 kgs

Physical Examination
Skin, Hair, Nails: Skin : warm and dry, palms are pinkish Hair : average texture Nails : without clubbing and cyanosis, normal capillary refill time HEENT: Head : Normocephalic, no lesions, atraumatic Eyes : Pink palpebral conjunctiva, anicteric sclera,PERRLA. External structures normal, without lesion or exudates.

Ears : Symmetric position. No discharges

Physical Examination
Nose : Symmetrical. Pink mucosa. No lesions. No nasal flaring, no congestion.
Throat & mouth: No lesions. Pink and moist oral mucosa. or

Neck : Neck supple, trachea midline, No masses lymphadenopathies. Thorax & Respiratory: Thorax symmetric with equal expansion. No lesions. No tenderness. (-) subcostal and suprasternal retractions. Clear breath sounds, (-) Rales and wheezes.

Physical Examination
Cardiovascular: Adynamic precordium. No murmurs or abnormal heart sounds. Abdomen: Flat, no scars, Normoactive bowel sounds, Soft, non-tender

Musculoskeletal & Extremities: No swelling. No clubbing, cyanosis or edema. Good peripheral pulses.

Clinical Impression: Acute Appendicitis

Basis: Initial history of epigastric pain shifting to RLQ with associated anorexia and vomiting, PE findings of guarding, RLQ direct and rebound tenderness, rovsing sign

Functional Anatomy
Glandular lobules drained by 15-20 lactiferous ducts

Lactiferous ducts converge & open onto nipple Areola surrounds nipple & conceals sebaceous glands
(Nipple-areola complex)

(i.e., produce lubrication for nipple)

4 Quadrants of the Breast

Upper outer (superolateral) quadrant

Upper Inner (superomedial) quadrant

Lower outer (inferolateral) quadrant Lower inner (inferomedial) quadrant

Blood Supply
a) Perforating branches of internal mammary a. b) Lateral branches of the posterior intercostal a. c) Branches of the axillary a.: higher thoracic, lateral thoracic, and pectoral branches of the thoracoacromial artery

Venous drainage follows the course of the arteries. Venous plexus of Batsons - extend from the base of the skull to sacrum - may provide route for breast metastases to vertebrae, skull, pelvic, and CNS.

Innervations Cutaneous innervation

Lateral cutaneous branches of 3rd-6th intercostal nerves provide sensory innervation of the breast and anterolateral chest wall Ant. branches of the supraclavicular nerve supply some area over the upper portion of the breast Intercostobrachial nerve is a lateral cutaneous branch of 2nd intercostal nerve. Supplies the medial aspect of upper arm.

Innervations Medial Pectoral Nerve

Branch of med. Cord of brachial plexus
Derived from ventral rami of C8-T1 Pierces pectoralis minor to enter pec. major

Supplies pec. minor & part of pec. major

Medial Pectoral Nerve

Branch of lat. cord of brachial plexus Derived from ventral rami of C5-C7 Runs above pec. minor to enter pec. major Supplies remainder of pec. major

Innervations Long Thoracic Nerve

Derived from ventral rami of C5-C7 Supplies serratus anterior superficially Resection during mastectomy results in winged scapula

Lymph Drainage Axillary vein (Lateral group)

4-6 nodes Lie medial or posterior to the vein Receive most lymph drainage from upper extremity

External mammary ( anterior or pectoral group)

5-6 nodes Lie along the lower border of pectoralis minor Receive most lymph drainage from lateral aspect of the breast

Lymph Drainage
Scapular group (posterior or subscapular)
5-7 nodes

Lie along the posterior wall of the axilla

Receive most lymph drainage from lower posterior neck, posterior trunk, and posterior shoulder.

Central group
3-4 nodes Embedded in the fat of axilla, lying immediately posterior to pectoralis minor Receive lymph drainage: axillary vein, external mammary and scapular groups, and directly from the breast

Lymph Drainage
Subclavicular group
12 sets of nodes

Lie posterior and superior to the upper border of

pectoralis minor Receive drainage from all other groups.

Interpectoral group (Rotters node)

1-4 nodes Interposed bet. P. minor and P. major Receive lymph drainage: directly from the breast

Axillary lymph node groups

LEVEL I
Lateral or below the lower border of pectoralis minor Axillary vein, external mammary, and scapular groups

LEVEL II
Superficial or deep to the pectoralis minor Central , and interpectoral groups

Axillary lymph node groups

LEVEL III
Medial to or above the upper border of pectoralis minor Subclavicular group

CLINICAL SIGNIFICANCE OF THE LYMPHATIC DRAINAGE OF THE BREAST

Cancer cells tend to spread along lymph passages Typical spread is supr./laterally to axillary lymph nodes More than 75% of drainage via axillary lymph nodes Most remaining drainage is medially to parasternal nodes Unilateral lymphatic blockage may occur Lymph (with cancer cells) can then drain to opposite side

PHYSIOLOGY: DEVELOPMENT AND FUNCTION HORMONES

Estrogen - initiates ductal development Progesterone - responsible for differentiation of epithelium and for lobular development. Prolactin - is the primary hormonal stimulus for lactogenesis in late pregnancy and the postpartum period. It upregulates hormone receptors and stimulates epithelial development.

PHYSIOLOGY: DEVELOPMENT AND FUNCTION HORMONES

GnRH a hypothalamic hormone that regulates the secretion of LH and FSH from the basophilic cells of ant. pituitary LH and FSH regulates the release of estrogen and progesterone from the ovaries

PHYSIOLOGY: DEVELOPMENT AND FUNCTION HORMONES

Common benign disorder of the breast

SALIENT FEATURES
Fibroadenomas are seen predominantly in younger women aged 15 to 25 years Fibroadenomas usually grow to 1 or 2 cm in diameter and then are stable but may grow to a larger size Small fibroadenomas ( 1 cm in size) are considered normal, whereas larger fibroadenomas ( 3 cm) are disorders and giant fibroadenomas (>3 cm) are disease. Lumps may be: movable, firm, painless, and rubbery with smooth and well define border

SYMPTOMS

Lumps may be: movable, firm, painless, and rubbery

Small fibroadenomas ( 1 cm in size) are considered normal, whereas larger fibroadenomas ( 3 cm) are disorders and giant fibroadenomas (>3 cm) are disease.

Classification of Benign Disorder of the Breast

Nonproliferative disorders of the breast
Cysts and apocrine metaplasia Duct ectasia Mild ductal epithelial hyperplasia Calcifications Fibroadenoma and related lesions

Proliferative breast disorders without atypia

Sclerosing adenosis Radial and complex sclerosing lesions Ductal epithelial hyperplasia Intraductal papillomas

Atypical proliferative lesions

Atypical lobular hyperplasia Atypical ductal hyperplasia

PATHOLOGY

Fibroadenoma have abundant stroma with histologically normal cellular elements They show hormonal dependence similar to that of normal breast lobules in that they lactate during pregnancy and involute in the postmenopausal period.

ABBERATION OF NORMAL DEVELOPMENT INVOLUTION (ANDI)

ANDI CLASSIFICATION OF BENIGN BREAST DISORDER Normal Disorder Disease Fibroadenoma Giant Fibroadenoma Early reproductive years Lobular development (age 15-25) Stromal development Adolescent Gigantomastia hypertrophy

Nipple eversion
Later reproductive years (age 25-40) Cyclical changes of menstruation Epithelial hyperplasia of pregnancy Involution (age 35-55) Lobular involution

Nipple inversion
Cyclical mastalgia

Subareolar abscess Mammary duct fistula Incapacitating mastalgia

Bloody nipple discharge

Macrocysts Sclerosing lesions

Duct involution Dilatation Sclerosis Epithelial turnover

Duct ectasia Nipple retraction Epithelial hyperplasia

Periductal mastitis Epithelial hyperplasia with atypia

Cancer Risk Associated with Benign Breast Disorders and In Situ Carcinoma
Abnormality Nonproliferative lesions of the breast Sclerosing adenosis Intraductal papilloma Florid hyperplasia Atypical lobular hyperplasia Atypical ductal hyperplasia Ductal involvement by cell of atypical ductal hyperplasia Lobular Carcinoma in situ Ductal carcinoma in situ Relative risk No increased risk No increased risk No Increased risk 1.5 to 2 fold 4 fold 4 fold 7 fold 10 fold 10 fold

MANAGEMENT

Removal of all fibroadenomas has been advocated irrespective of patient age Careful ultrasound examination with core-needle biopsy will provide for an accurate diagnosis Cryoablation is an approved treatment for fibroadenomas of the breast.