Vacuum-assisted excision followed by minimal access surgery for a large fibroadenoma: lessons from a hybrid approach – a case report

Abstract

Introduction:

Vacuum-assisted excision (VAE) and high-intensity focused ultrasound (HIFU) are minimally invasive alternatives to surgery for the treatment of breast fibroadenomas. While both methods are effective in selected cases, their utility in managing large fibroadenomas remains uncertain. This report highlights a case where both HIFU and VAE failed to achieve adequate treatment of a giant fibroadenoma, necessitating surgical excision.

Presentation of Case:

A 17-year-old girl patient presented with a large, palpable, mobile mass in the upper outer quadrant of the left breast, measuring approximately 9 × 8 cm on ultrasound. HIFU treatment performed several years prior failed to reduce the lesion’s volume or relieve symptoms. VAE using the Brevera system (9-G, 20-mm aperture needle) was attempted, with 10 aspiration cycles and 120 tissue cores obtained. Post-procedural imaging showed only 15–20% volume reduction. Due to insufficient shrinkage, complete excision was performed through a periareolar incision. The postoperative course was uneventful, with good cosmetic outcome.

Discussion:

This case demonstrates the limitations of HIFU and VAE in the treatment of large, fibrotic fibroadenomas. While VAE failed to achieve full excision, the partial debulking allowed for a smaller, more aesthetic surgical approach. The sequential use of VAE followed by limited open excision may be considered in select patients to optimize cosmetic outcomes.

Conclusion:

VAE is a well-established, minimally invasive option for the management of small to medium-sized fibroadenomas. However, its effectiveness in lesions exceeding 3–4 cm is limited. This case highlights the potential role of VAE as an adjunctive tool in selected cases of large fibroadenomas, where volume reduction can optimize less invasive surgical approaches. Careful patient selection remains critical to procedural success.

Introduction

Fibroadenomas are the most common benign breast tumors. While often asymptomatic, they may cause physical discomfort, anxiety, or cosmetic concerns, prompting intervention. Management options include observation, surgical excision, or minimally invasive techniques^[1–3^].

HIGHLIGHTS

• Vacuum-assisted excision was ineffective in achieving full removal of a 9 cm breast fibroadenoma.

• VAE enabled partial debulking (15–20% volume reduction), facilitating a smaller periareolar surgical excision.

• Hybrid minimally invasive approaches may offer cosmetic advantages in selected large benign breast tumors.

Indications for removal include size >2.5–3.0 cm, rapid growth, symptoms, recurrent inflammation, patient preference, or atypical imaging or histology^[1–7^].

Vacuum-assisted excision (VAE), which utilizes image-guided percutaneous biopsy systems, has emerged as an effective minimally invasive alternative to open surgery. This technique allows removal of fibroadenomas without general anesthesia or sutures, offering superior cosmetic results^[8–11^].

VAE is primarily indicated for patients with sonographically and clinically benign-appearing fibroadenomas, particularly when the lesion is symptomatic, growing, or when the patient prefers removal over observation. Complete excision rates are highest for lesions ≤1.5 cm in diameter^[12,13^].

Although increasingly adopted, data regarding the safety, oncological adequacy, and long-term outcomes of VAE remain under evaluation. Proper patient selection and pathological assessment of the excised specimen are essential to exclude lesions with malignant potential, such as phyllodes tumors.

This case report has been prepared in accordance with the SCARE 2020 guidelines[14].

Material and methods

A single case of a symptomatic breast fibroadenoma was treated with an attempted VAE under ultrasound guidance. The procedure was performed in a dedicated breast imaging unit using the Brevera Breast Biopsy System (Hologic Inc., Marlborough, MA, USA).

Pre-procedural ultrasound confirmed a well-defined, oval, hypoechoic lesion consistent with a fibroadenoma, measuring 9 cm and located in the inner lower quadrant of the right breast. The lesion was categorized as BI-RADS 2, and no previous biopsy had been performed.

Following informed consent, the procedure was conducted under sterile conditions and general anesthesia. A 9-G, 20-mm aperture needle was introduced through a small skin incision under continuous real-time ultrasound guidance. Multiple contiguous tissue cores were obtained using the Brevera system with integrated real-time imaging and tissue acquisition feedback. Excised tissue was sent for histopathological evaluation.

The work has been reported in line with the SCARE criteria[14].

Results

A 17-year-old girl presented with a large, palpable, mobile mass in the upper outer quadrant of the left breast, measuring approximately 9 × 8 cm on ultrasound. High-intensity focused ultrasound (HIFU) ablation had been performed 2 years earlier (Fig. 1), resulting in partial shrinkage during the first 9 months (Fig. 2). The patient was subsequently lost to follow-up and represented with recurrent enlargement.

Figure 1.

US image before HIFU.

Figure 2.

US image immediately after HIFU.

Given the patient’s and her parents’ preference for a minimally invasive approach, and prior benign histology, an attempted VAE was performed using the Brevera system (Hologic Inc.) with a 9-G, 20-mm aperture needle under real-time ultrasound guidance.

The procedure was carried out under general anesthesia and strict aseptic conditions. A total of 10 aspiration cycles were performed (Fig. 3), yielding approximately 120 tissue cores (Fig. 4). Despite this, the total lesion volume was reduced by only 15–20%, as confirmed by post-procedural ultrasound. The residual mass remained firm, well-defined, and only partially debulked.

Figure 3.

X-ray image of the specimen.

Figure 4.

Macroscopic view of the specimen.

Due to the unsatisfactory reduction and persistent cosmetic deformity, the procedure was converted to surgical excision. A 3.7 cm periareolar incision was used to achieve complete enucleation of the residual mass (Fig. 5). Histopathology confirmed a fibroadenoma without atypia or malignant transformation.

Figure 5.

Surgical excision of the fibroadenoma.

The postoperative course was uneventful. The patient reported high cosmetic satisfaction, and no hematoma, infection, or recurrence was observed at 3-month follow-up.

Discussion

VAE is increasingly recognized as a safe and effective alternative to open excision for small and medium-sized fibroadenomas, providing excellent cosmetic outcomes and low morbidity^[1,15^]. However, its efficacy decreases markedly with larger, fibrotic, or recurrent lesions^[16,17^].

In the present case, a giant recurrent fibroadenoma (>9 cm) was first managed with HIFU, which failed to achieve durable shrinkage. Nonsurgical ablation techniques, while appealing, remain unreliable for large or dense fibroadenomas.^[18–20^]

An attempt at percutaneous removal using VAE was made because of patient preference for a minimally invasive approach. Nevertheless, the limited tissue collapsibility and fibrous content restricted the achievable volume reduction to 15–20%, necessitating conversion to open excision.

From an oncologic perspective, this case also underscores the importance of adequate histopathological assessment in large or recurrent breast tumors. Lesions exceeding 5 cm, particularly in young patients, may represent phyllodes tumors rather than simple fibroadenomas. The malignant potential of such tumors cannot be reliably excluded by core or vacuum biopsies alone. Complete excision remains the gold standard for definitive diagnosis and treatment in these scenarios.

Therefore, while VAE represents a valuable tool for small, benign, and well-characterized fibroadenomas, its role in giant or recurrent lesions should be considered only within a carefully selected clinical context, with a readiness to proceed to surgical excision if oncological or technical limitations arise. In our case, VAE served as an adjunct, reducing tissue tension and facilitating a smaller incision for final surgical removal.

Conclusion

VAE is a well-established minimally invasive option for small to medium-sized fibroadenomas. However, its effectiveness and oncological safety in large, recurrent, or indeterminate lesions are limited. This case highlights both the technical boundaries and potential hybrid use of VAE in managing giant fibroadenomas.

Careful patient selection, multidisciplinary discussion, and readiness for surgical excision remain essential, especially when malignancy or phyllodes tumor cannot be confidently excluded.

Ethical approval

Local ethics committee at Medical University – Pleven, Bulgaria, has approved the study. Approval Number: 610/21.10.2020.

Consent

Written informed consent was obtained from the patient for publication and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Sources of funding

The support of the project BG16RFPR002-1.014-0002-С001 “CENTRE OF COMPETENCE IN PERSONALIZED MEDICINE, 3D AND TELEMEDICINE, ROBOTIC ASSISTED AND MINIMALLY INVASIVE SURGERY” funded by the PRIDST 2021-2027, co-funded by thе EU is greatly acknowledged.

Author contribution

D.D.: Study concept and design, data collection, data analysis and interpretation, writing the paper. M.S.: Data collection, writing the paper. S.P.: Data collection, writing the paper. M.K.: Study concept and design, data collection, data analysis and interpretation, writing the paper.

Conflicts of interest disclosure

No relevant conflict of interest.

Research registration unique identifying number (UIN)

Internet Archive link https://archive.org/details/osf-registrations-9y8jp-v1. Registration DOI: https://doi.org/10.17605/OSF.IO/9Y8JP.

Guarantor

Martin Karamanliev.

Provenance and peer review

Not commissioned; externally peer reviewed.

Data availability statement

Data sharing is not applicable to this article as no datasets were generated or analysed during the current study.