Abstract
Background: Fibroadenomas are hyperplasia arising from the terminal ductulo-lobular unit and adjacent tissue of the breast. As single fibroadenoma, even giant ones are easily manageable, however multiple fibroadenomas pose a particular challenge. Case Report: In 1971, Liacyr Ribeiro described his new technique for reduction mammaplasty. Four years later, the first 20 cases were published. This technique was introduced by Rezai in oncoplastic surgery. With free hand design, preoperative marking is performed- and the inferior pedicle modulated. Results: Selective resection of more than seventy fibroadenomas was performed on two patients. The technique allowed a modelling of the breast like a mastopexy through the inferior pedicle. Conclusion: Multiple fibroadenomas of the breast are safely removable with the Ribeiro technique modified by Rezai.
Fibroadenoma is a common cause of discrete breast lumps in young women (1) and occurs in 25% of asymptomatic women (2). The size varies but is on average between 1 and 3 cm (3). Giant fibroadenomas are reported frequently in the literature and the surgical approach varies from local wide excision to mastectomy (4-10).
Thirty years ago, Egger and Muller described 412 women with fibroadenoma, of whom 7.1% had considerable epithelial proliferation and 1.7% carcinoma in situ or carcinoma. With increasing age, the risk of carcinomatous degeneration in fibroadenomas rises to 17% (11). This necessitates excision of all such tumours. Fibroadenoma with hyperplasia and atypia confers a higher risk for breast cancer (2).
Although fibroadenoma is associated with other pathological entities in 50% of cases (12), the risk is still considered low (13).
Wide local excision has been proposed for the treatment of benign lesions (14).
In cases of multiple unilateral fibroadenomas, circumareolar incision seems to be adequate (15). Complete excision is recommended. Not all women are candidates for conservative treatment (16). Reduction mammaplasty is described in cases of asymmetry (14, 17-20).
The aim of this paper is to describe the usefulness of the Ribeiro technique modified by Rezai in the treatment of bilateral multiple fibroadenomas (21-23)
Case Report
In 1971, Ribeiro described his dermo-lipo-glandular flap and presented his new technique for reduction mammaplasty in 1975 (21). Thirty years later, with more than two thousand patients having been treated, the technique was combined with different incisions and for several indications (22). The modified technique by Rezai was used in January 2002 and in August 2004 to treat multiple bilateral fibroadenomas in two patients aged 28 and 18 years (23, 24). The first patient, multiparous, presented with palpable masses in both breasts as shown in Figure 3. The second patient was a nulliparous (Figure 1). No patient had operative antecedent in their medical history. With the patient in an upright position, the midbreast line was determined. The new nipple position was designated on a point on this midbreast line. The angle of the upper V was determined. By approximating a lateral and medial point and raising the lower quadrants, the proposed new breast can be evaluated in volume and shape. Straight lines joined the lowest points of the V with the inframammary line. De-epithelisation was performed within this area.
Results
From the four breasts of these two patients, more than seventy fibroadenomas were excised. Figure 1 shows an MRI slide with nine (a) and twelve (b) detectable fibroadenomas in both breasts. Figure 2 shows 16 fibroadenomas of different size removed from the left breast. In August 2008, the younger patient required an excision of one fibroadenoma >2 cm. The old mammaplasty scar was used and the cosmetic results after four years are quite satisfactory (Figure 3).
MRI slides of fibroadenomas of different sizes in one patient.
Discussion
The surgical treatment of choice of fibroadenoma is breast conserving. Gordon et al. reported changes in volumes in 1070 consecutive patients with breast lesions diagnosed as fibroadenoma at fine-needle aspiration. Change in volume per month was approximately 16% and 13% for patients younger than 50 years and older than 50 years respectively. The 95th percentile mean change in dimension at a 6-month interval for both was 20%. They concluded that fibroadenomas may be safely followed up if volume growth rate is less than 16% in those younger than 50 years and less than 13% per month in those 50 years or older. Acceptable mean change in dimension for a 6-month interval is 20% for all ages (25). Non-operative management of fibroadenomas seems to be safe (1, 26). In a retrospective summary Edwards and co-workers reported cryoablation of 310 fibroadenomas. At 12 months post procedure, the remaining fibroadenoma progressively involuted (27). Volume-dependent local excision of multiple fibroadenomas, even giant fibroadenomas, can be safely carried out (9, 15, 28). Reduction mammaplasty is mostly reported on giant fibroadenomas (6, 14, 17). Lee and co-workers treated an 11-year-old girl with multiple bilateral fibroadenomas with a central pedicle breast reduction. All masses were complete excised, resulting in a reduction of 1,750 g from the right breast and 1,900 g from the left breast. The patient reported no recurrent enlargement of her breasts 5 years after surgery (18).
We treated our patients using the inferior pedicle as described by Ribeiro and Rezai (22, 23). It allowed excision in any part of the breast and remodelling. The younger patient had a second intervention two years later due to a fibroadenoma. After 5 years, the cosmetic results are stable.
In conclusion, multiple fibroadenomas of the breast are safely removable with the Ribeiro technique modified by Rezai.
Excised fibroadenomas on the template of the left breast.
Preoperative (a, c) and postoperative (b, d) views four years later of each patient.
Footnotes
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↵* Presented at the 8th International Conference of Anticancer Research, 17-22 October 2008, Kos, Greece.
- Received January 8, 2009.
- Revision received March 13, 2009.
- Accepted May 4, 2009.
- Copyright© 2009 International Institute of Anticancer Research (Dr. John G. Delinassios), All rights reserved
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