Simple vs Complex Fibroadenomas - Are there any clear cut
distinguishing imaging features?
Poster No.:
C-1163
Congress:
ECR 2011
Type:
Scientific Exhibit
Authors:
J. Pinto , A. T. Aguiar , A. Vilaça , H. Duarte , A. Rodrigues , A.
1
1
2
1
1
1 1
2
2
2
Reis , J. L. Krug , R. Cardoso ; Santa Maria da Feira/PT, Porto/
PT
Keywords:
Ultrasound, Mammography, Breast
DOI:
10.1594/ecr2011/C-1163
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Purpose
Complex fibroadenomas (CF) are fibroadenomas harboring one or more of complex
features - epithelial calcifications, apocrine metaplasia, sclerosing adenosis and cysts
>3mm.
No imaging features have been clearly defined for the distinction of simple fibroadenomas
(SF) from complex ones which are associated with an increased risk of cancer. We
aimed to evaluate the accuracy of imaging features, individually and in association, for
the prediction of complexicity in fibroadenomas.
Methods and Materials
252 fibroadenomas were found at consecutive percutaneous needle or excisional
surgical biopsy performed between February 2009 and August 2010 in our Institution. Of
these, 63 (25%) were excluded because no images were available.
According to histologic diagnosis, each case was classified into SF or CF.
The presence of sonographic/mammographic features and their respective accuracy in
the prediction of complexicity were analysed.
In the case of CF, pathology result at core and excisional biopsy were compared.
Results
Of the 189 remaining, 159 (84%) were SF and 30 (16%) were CF. All patients were
women, and complex fibroadenomas were larger than SF (1,9cm vs 1,3cm; p=0.009;
Fig. 1). There was no significant difference in age between the two groups (median age,
FS=45 years; FS= 42years).
Image predictors of complexicity in fibroadenomas were: irregular shape (p<0.001),
suspect contours (ill defined, microlobulated or spiculated) (p<0.001), heterogeneous
echostructure (p<0.001), solid/cystic mixed content (p<0.001), presence of
microcalcifications (p=0.002) and posterior enhancement (p<0.001) (Fig. 2, 3, 4).
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The Receiver Operating Characteristic curve analysis demonstrated that the presence of
2 or more of the features mentioned earlier brought incremental accuracy to sonographic/
mammographic for the identification of CF (area under the ROC curve= 0.76) (Fig. 5).
We found a significant correlation with Atypical Lobular Hyperplasia (ALH) and
complexicity (p<0.001).
22 (73%) patients that had positive biopsy for the presence of CF underwent excisional
biopsy. After the later, it was found in one case (3%) foci of in situ ductal carcinoma (Fig.
6) and in other (3%) foci of in situ lobular carcinoma. The two had previously ALH on
percutaneous needle biopsy.
One case, in which the first biopsy result could not distinguish CF from Phyllodes Tumor,
also underwent excisional biopsy and turned out to be a CF.
Images for this section:
Fig. 1: Sample baseline characterisics.
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Fig. 2: Complex Fibroademoma presenting irregular contours, heterogeneous
echostructure with cystic areas and posterior acoustic enhancement.
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Fig. 3: Complex Fibroadenoma presenting spiculated contours and microcalcifications.
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Fig. 4: Imaging features of Simple Fibroadenomas (SF) and Complex Fibroadenomas
(CF). Imaging characteristics (*) witch have statistical association with diagnosis of CF (p
Page 6 of 11
Fig. 5: ROC curve analysis of imaging features accuracy in determination of Complex
Fibroadenomas. Note that the most accurate characteristic is the presence of two or more
imaging features (area under the curve=0,76).
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Fig. 6: Complex Fibroadenoma presenting irregular contours, heterogeneous
echostructure and microcalcifications. At core-needle biopsy it had Atypical Lobular
Hiperplasia and at excisional biopsy it had foci of in situ ductal carcinoma.
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Conclusion
CF were first described by Dupont et al, who reported that 22% of proven Fibroadenomas
were complex. In our study, we found that 16% of all biopsy-proven Fibroadenomas were
complex.
Althoug the mean age obtained for CF was concordant with the literature (47 years
and 42 years, respectively), we did not found any difference between the two groups.
In fact, the mean age of SF was augmented when compared to the findings of most
authors (28.5years vs 45years). We believe that there was a selection bias in the sample
because the hospital is oncologic and follows essentially patients with a previous history
of malignancy.
We found a small mean size of the SF when compared to the one described in the
literature (1,3cm vs 2,5cm, respectively). The elevated mean age of the patients and
the oncologic character of the hospital may explain why few large Fibroadenomas were
biopsied. In spite of this, the mean size of the CF was in agreement with the literature
(1,9cm vs 1,3cm, respectively). Most recent studies reported that CF were smaller than
SF. In fact, according to pathology studies, the natural history of the fibroadenomas
is to regress with age becoming smaller over time and probably acquiring complex
characteristics during this period.
Until now there was no evidence of mammographic or sonographic features
that distinguished complex from simple Fibroadenomas. In our study we found
that CF had more frequently an irregular shape, suspect contours (ill defined,
microlobulated or spiculated), heterogeneous echostructure, mixed content, presence of
microcalcifications and posterior enhancement.
Owing to the fact that some of the diagnostic criteria of CF are the presence of cysts
>3mm and epithelial calcifications, is not surprising that we had found an association
with heterogeneous echostructure, mixed content, presence of microcalcifications and
posterior enhancement. The presence of cysts and increased stromal cellularity in coreneedle biopsy result makes its differentiation from Phyllodes Tumor sometimes difficult.
In these cases, excisional biopsy is imperative because of the tendency that Phyllodes
Tumors have to recur with a higher grade if they were only partially excised.
Literature on management of Complex Fibroadenomas is scarce and controversial.
The biggest prospective study made about long-term risk of breast cancer in women
with Fibroadenoma, conclude that in patients with a family history of breast cancer the
relative risk associated with CF was three times greater than associated with noncomplex
Page 9 of 11
fibroadenoma. A more recent study found an association between the presence of ALH
and fibroadenoma's complexity. In fact, all the cases of ALH (n=7; 3.7%) were CF. It is
well established that when core biopsy result reveals a high-risk lesion as ALH, excisional
biopsy is indicated to rule out malignancy. In our study, after the excisional biopsy 3%
of the CF changed of diagnosis for in situ ductal carcinoma and another 3% for in situ
lobular carcinoma, making worthwhile having a aggressive management for CF.
Our study is limited by a selection bias related to the fact that it was made in an oncologic
hospital, having essentially patients with personal history of cancer. Beyond that, the
small number of patients with diagnosis of CF who underwent core-needle biopsy or
excisional biopsy for comparison, and the incomplete follow-up of patients who were
submitted only at core-biopsy also constitute study´s limitations.
There are some imaging features that could be associated with CF helping the radiologist
to identify these lesions.
According to our results, we recommend excisional biopsy shortly after the diagnosis is
made. However, larger series are indicated to validate these findings.
References
Kuiper A; et al - Histopathology of Fibroadenoma of the Breast. Am J Clin Pathol, 2001;
115: 736-742.
Dupont WD, Page DL, Parl FF, et al. Long-term risk of breast cancer in women with
fibroadenoma. N Engl J Med, 1994; 331: 10-15.
Sklair-Levy M; et al - Incidence and Management of Complex Fibroadenomas. AJR,
2008; 190: 214-218.
Greenberg R, Skornick Y, Kaplan O. Management of Breast Fibroadenomas. J Gen
Intern Med, 1998; 13: 640-645.
Foster MC; et al - Lobular Carcinoma in Situ and Atypical Lobular Hyperplasia at CoreNeedle Biopsy: Is Excisional Biopsy Necessary? Radiology, 2004; 231: 813-819.
American College of Radiology: Illustrated Breast Imaging Reporting and Data System
th
(BI-RADS), 4 ed. Reston, VA, American College of Radiology.
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Personal Information
Joana Serra Pinto
Hospital Santa Maria da Feira, Centro Hospitalar de entre o Douro e Vouga, Portugal
[email protected]
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