One of the biggest and heaviest juvenile bilateral breast fibroadenoma: A case report

Abstract

Introduction

Giant juvenile fibroadenomas occurring at a mean age of 13 may be multiple and bilateral, accounting for approximately 0.5 % of all fibroadenomas. The pathogenesis of these tumors is closely linked to hormonal changes during puberty, characterized by increased estrogen stimulation, heightened estrogen receptor sensitivity, and reduced estrogen antagonists. These hormonal factors are pivotal in the rapid growth and substantial size observed in giant juvenile fibroadenomas.

Case presentation

An adolescent girl presented at the outpatient clinic with significant bilateral breast enlargement, causing redness and discomfort when sitting, leading to difficulty wearing age-appropriate clothing and chest wall pressure. Despite previous consultations attributing the condition to genetic causes, further investigation via radiological ultrasound indicated a probable diagnosis of bilateral breast mass fibroadenoma, occupying a substantial portion of the breast tissue. Consequently, the decision was made to perform bilateral breast surgery to remove the giant masses for histopathological analysis.

Discussion

The delayed diagnosis accentuated the case's complexity, highlighting the challenges in effectively identifying and managing giant fibroadenomas in adolescents. Despite the initial absence of alarming symptoms, these fibroadenomas' sheer size and impact underscored the importance of early detection and comprehensive evaluation in similar clinical presentations.

Conclusion

The surgeon must emphasize meticulous planning when deciding on the surgical approach for removing a giant juvenile fibroadenoma. This planning is crucial for preserving breast functionality, achieving a satisfactory cosmetic outcome, and addressing the psychological distress of young patients. Early detection and excision are imperative to safeguard breast tissue.

Highlights

• •Giant fibroadenoma breast is a challenging surgery to preserve breast tissue.
• •Bilateral giant fibroadenoma is rare, unusual.
• •Giant Juvenile breast fibroadenomas mean more than 10 cm in diameter.
• •Giant Juvenile breast fibroadenomas mean more than 500 g weight.

1. Introduction

Giant fibroadenomas in adolescents represent a unique clinical challenge. They are characterized by rapid growth and substantial size, often exceeding 10 cm in diameter or 500 g in weight, and replacing a significant portion of breast tissue, sometimes up to 90 %. When occurring in individuals aged 10–18, these tumors are termed giant juvenile fibroadenomas. The sheer magnitude of these lesions presents a formidable task for surgeons, as preserving breast tissue and ensuring acceptable cosmetic outcomes are paramount for the physiological and psychological well-being of the child, and the work has been reported in line with the SCARE criteria [1].

2. Case presentation

This case study is centred around a 13-year-old girl who presented at the outpatient clinic with massive bilateral fibroadenomas. Her complaint initially included a rapidly growing, painless lump in her right breast over nine months, associated with discomfort as shown in Fig. 1, Fig. 2, Fig. 3, Fig. 4a. Despite having regular menstrual cycles since attaining menarche two years prior, her medical history did not reveal any significant factors such as trauma, respiratory symptoms, weight loss, familial history of cancer, or exposure to chest irradiation or oral contraceptives. On examination, a single non-tender lump, approximately 25 cm × 25 cm, was palpable in the left breast. In contrast, the right breast exhibited a much larger lump measuring approximately 30 cm × 25 cm, occupying the entire breast and leading to asymmetrical enlargement with an enlarged nipple-areola complex. The overlying skin was dark and excoriated, and the dermatitis had superficial venous prominence and no nipple discharge. Both lumps had smooth surfaces, well-defined margins on palpation, and were firm in consistency. Importantly, they were not fixed to the skin or underlying structures, and there was no evidence of axillary lymphadenopathy, suggestive of fibroadenomas. Further diagnostic evaluation through fine-needle aspiration cytology (FNAC) from both lumps corroborated with the ultrasound findings. FNAC revealed tightly cohesive clusters of benign ductal epithelial cells in a branching pattern against fibro myxoid stroma in the background without any evidence of malignancy, confirming the diagnosis of fibroadenoma. Laboratory and biochemical parameters were normal. Lump excision through a sub-mammary incision was planned for the adolescence, and after proper informed consent and discussion with her parents, she was posted for lumpectomy under general anaesthesia. Both lumps were enucleated easily through an 8–10 cm sub-mammary incision, the surgery like we do subcutaneous mastectomy haemostasis was secured, we try to preserve nipple-areola complex, excessive redundant skin excised and reconstructive and the skin was approximated with subcuticular sutures after placing a redivac drain, are which was removed 72 h later (Fig. 4b). Gross examination revealed lumps with a smooth lobulated surface and firm consistency measuring approximately 25 cm × 25 cm and 30 cm × 25 cm, as shown in Fig. 5, and bilateral excised tissue weighted 3.6 kg, as shown in Fig. 6. Histopathological examination showed partially encapsulated glandular acini of the breast having a cleft-like lumen, increased fibro collagenous cell elements, and stromal oedema with no evidence of atypical cells, confirming the diagnosis of juvenile fibroadenoma. The post-operative recovery was uneventful. At the 7-day follow-up, the wound had healed satisfactorily, and breast symmetry was restored greatly. There were no complications at the 2-month follow-up, and breast development was normal.

Fig. 1.

Bilateral breast swelling in supine position.

Fig. 2.

Bilateral breast swelling in sitting position.

Fig. 3.

Huge giant breast swelling with excoriation of skin.

Fig. 4.

a Huge unpleasant both breast. b Surgical incision.

Fig. 5.

Bilateral specimen excised fibroadenoma.

Fig. 6.

Heaviest weight both 3.6 kg.

3. Discussion

Giant juvenile fibroadenomas occurring at a mean age of 13 may be multiple and bilateral, accounting for approximately 0.5 % of all fibroadenomas. The pathogenesis of these tumors is closely linked to hormonal changes during puberty, characterized by increased estrogen stimulation, heightened estrogen receptor sensitivity, and reduced estrogen antagonists. These hormonal factors are pivotal in the rapid growth and substantial size observed in giant juvenile fibroadenomas [2,3]. In clinical practice, distinguishing giant juvenile fibroadenomas from other breast conditions is crucial due to the varying treatment approaches and prognoses associated with different diagnoses. The differential diagnoses for giant juvenile fibroadenomas include phyllodes tumors [4], breast hypertrophy, breast abscess, breast cyst, lipoma, hamartoma, and adenocarcinoma. Each of these conditions necessitates specific management strategies:

A simple aspiration can be curative in cases of breast cysts, relieving symptoms and reducing the size of the cyst. Incision and drainage are required for breast abscesses to alleviate infection and promote healing. Juvenile breast hypertrophy may necessitate reduction mammoplasty to address esthetic concerns and functional discomfort. Phyllodes tumors, although rare, require wide excision or mastectomy due to their potential for aggressive behavior and recurrence. Therefore, when encountering a case of giant juvenile fibroadenoma, it is imperative for the surgeon to thoroughly evaluate and exclude these differential diagnoses. This process may involve clinical examination, imaging studies such as ultrasound and mammography, and histopathological evaluation through techniques like fine-needle aspiration cytology or core needle biopsy. Accurate diagnosis and appropriate treatment planning are essential for achieving optimal outcomes and preserving breast function and cosmesis in affected individuals [[5], [6], [7]].

Furthermore, the psychological impact of giant fibroadenomas in adolescents cannot be understated. These tumors can significantly affect body image, self-esteem, and quality of life, especially during a critical period of emotional development. Therefore, a multidisciplinary approach involving surgical, psychological, and supportive care is essential to address the holistic needs of patients with giant juvenile fibroadenomas.

In conclusion, giant juvenile fibroadenomas pose unique challenges in diagnosis and management due to their size, hormonal influences, and potential differentials. A thorough understanding of these aspects is crucial for providing personalised and effective care to affected individuals, emphasising the importance of early detection, accurate diagnosis, and comprehensive treatment strategies.

The delayed diagnosis accentuated the case's complexity, highlighting the challenges in effectively identifying and managing giant fibroadenomas in adolescents. Despite the initial absence of alarming symptoms, these fibroadenomas' sheer size and impact underscored the importance of early detection and comprehensive evaluation in similar clinical presentations [8]. The subsequent decision to perform reconstructive surgery underscores the critical role of surgical intervention in restoring both physical and emotional wellness in affected individuals. By sharing this case and its findings, we aim to contribute to the understanding and managing of giant fibroadenomas in the adolescent population, emphasising the importance of early detection and comprehensive treatment strategies. Additionally, the diagnostic journey for giant juvenile fibroadenomas relies significantly on imaging modalities such as ultrasound and fine-needle aspiration cytology (FNAC). These methods are safe, reliable, and cost-effective, with excellent patient compliance. Utilizing ultrasound imaging and FNAC allows for a thorough pre-operative assessment, aiding in formulating an optimal surgical plan tailored to the individual patient's needs. In the case of our 13-year-old post-pubertal patient with a giant juvenile fibroadenoma in her right breast, the pre-operative diagnosis was established through ultrasound imaging and FNAC. Ultrasound provided detailed visualisation of the mass, including its size, borders, and internal characteristics, while FNAC facilitated the identification of benign ductal epithelial cells characteristic of fibroadenomas. This combined approach ensured accurate pre-operative assessment, enabling us to make informed decisions regarding the most suitable surgical procedure for the patient's condition. By leveraging these diagnostic tools effectively, clinicians can enhance diagnostic accuracy, streamline treatment planning, and ultimately improve patient outcomes in cases of giant juvenile fibroadenomas and other breast lesions.

This rapidly growing lump was not only uncomfortable for the child but also psychologically and emotionally crippling her due to her external appearance. Such a large swelling compresses and distorts the normal architecture of the breast, leading to its impaired development. Thus, treating this entity should not only excise the lump completely but also preserve as much breast tissue as possible for future normal development, as well as make it cosmetically acceptable. Various techniques of excision of the lump have been described, which aim at cosmesis and minimising distortion. A simple inframammary or circumareolar approach with or without T-shaped lateral extension and without reconstructive procedures has shown good cosmetic and post-operative results. The ‘Swiss roll’ technique and ‘Saw tooth’ operation have been reported to have excellent outcomes in maintaining the shape and symmetry of the breast [6,7].

We present a case of a giant fibroadenoma in a 13-year-old female, notable for its exceptionally large size and weight of 3.6 kg. The patient presented with a markedly enlarged breast and discomfort. A precise balance between appropriate resection and the ideal esthetic result for a developing breast necessitates meticulous surgical planning. As in this instance, every attempt should be taken to maintain the growing breast regardless of the size of the tumor.

4. Conclusion

The important take-home message for the surgeon is careful planning regarding the surgical technique to be used for the excision of a giant juvenile fibroadenoma to preserve the functionality of the breast, ensuring an acceptable cosmetic result and alleviation of the psychological distress of the child or adolescent. Early detection and excision mandatory to preserve breast tissue.

Consent

Written informed consent was obtained from the patient's parents for publication and any accompanying images. The editor-in-chief of this journal can review a copy of the written consent upon request.

Ethical approval

Ethical approval by the University of Alkafeel approval committee.

Funding

Nil.

Author contribution

Samer Makki Mohamed Al Hakkak corresponding author. Study concept or design, data collection, data analysis or interpretation, writing the paper.

Firas Shaker Mahmoud writing the paper.

Ali Najeh Awwady design of manuscript and grammar checking.

Alaa Abood Najim Al Wadees data collection.

Maryam Samer Al Hakkak Plagrisium checker.

Guarantor

Samer Makki Mohamed Al Hakkak.

Research registration number

Not applicable.

Conflict of interest statement

All authors have no conflicts of interest.