In this episode of PodMD, specialist breast, endocrine and general surgeon Dr George Liang will be discussing the topic of fibroadenoma and phyllodes tumour, including what type of tumours they are, how a patient would typically present, the treatment options, when to refer and more.
Please note this is a machine generated transcription and may contain some errors.
*As always, all in this PODMD podcast is intended for health professionals and the comments are of a general nature. Information given is not intended as specific medical advice pertaining to any given patient. If you have a clinical issue with one of your patients please seek appropriate advice from a colleague with expertise in the area.
Today I’d like to welcome to the PodMD studio Dr George Liang.
Dr George Liang is a Specialist Breast, Endocrine and General Surgeon practicing at Cutting Edge Surgical Associates (CESA) in Castle Hill. CESA is a multidisciplinary clinic with other specialists in General, Colorectal, Head & Neck, Pancreatic & Hepatobiliary Surgery. He operates out of Norwest Private, Westmead Private and Strathfield Private Hospitals.
Dr Liang began his training at the University of Tasmania before undertaking specialty training in General, Breast and Endocrine Surgery through the Royal Australasian College of Surgeons, Breast Surgeons of Australia & New Zealand and Australia & New Zealand Endocrine Surgeons. George has over 12 years’ experience in his field having trained in Westmead, St George, Concord Hospitals in Sydney and Flinders Medical Centre in Adelaide.
Today, we’ll be discussing the topic of Fibroadenoma and Phyllodes Tumour.
*We do hope you enjoy this podcast but please remember that the advice here is of a general nature and is not intended as specific advice about a given patient. The views and opinions expressed in this podcast are those of the doctor, not PodMD.
If you do have a patient on whom you require specific advice, then please seek advice from a colleague with appropriate expertise in that area.
George, thanks for talking with us on PodMD today.
George: Thank you for having me.
The topic of today’s discussion is Fibroadenoma and Phyllodes Tumour. George, Can you describe for our listeners what Fibroadenoma and Phyllodes Tumours are?
George: Well, that’s a great question. Fibroadenoma and phylldoes are Quite similar, yet quite different biologically in in terms of their behaviour, however histopathologically they’re so similar, and hence why I’ve put these two pathologies together as a topic. They both belong to a group of breast disease and we call them ANDIs or A-N-D-I, and it stands for aberrations of normal breast development and involution.
Let’s start with fibroadenoma. It’s a solid, benign tumour. It’s very rarely associated with any malignancy at all. It has epithelial and stromal components and it usually affects women in their reproductive ages. So younger women and unfortunately some of these fibroadenomas can get larger during pregnancy. It can also get larger during their menstrual cycles. Or when they’re having issues and treatments, for example, IVF treatment for fertility, and it doesn’t regress somewhat during menopause.
There are a few different subtypes of fibroadenomas. The first one is just the usual subtypes, which is what we’ve spoken about. There is another type what we call a giant fibroadenoma. These are fibroadenomas that are over 5 centimetres in size, so they’re very very large. Very easy to find, and it really bothers women and they do grow quite rapidly. And then there is the juvenile fibroadenoma. Unfortunately, these are afflicts younger girls between the ages of 10 and 18. They tend to be very cellular and they tend to grow very quickly. They tend to bother a lot of younger girls because they tend to be not just solitary, but they tend to be bilateral, and they use usually a few on each breast.
Phyllodes itself is again, it is a fibroepithelial tumour. It’s called phyllodes is because it comes from a Greek word being leaf like architecture. So histopathologically it looks like a leaf and hence the name unlike fibroadenoma, it has a wide range of biological behaviour. It constitutes less than 1% of all breast tumours and usually afflicts our women in the older ages, between 40 and 50 rather than the younger age of fibroadenoma.
How would a patient with Fibroadenoma or Phyllodes Tumour typically present?
George: Well, there’s a few ways that women usually presents with fibroadenoma or phyllodes tumour itself. Usually the first one would be our women whom have palpated a new lump whilst they’re changing or while they’re having a shower or doing self breast examination, which they can’t perform, especially with a family history of breast cancers. It is usually a very well circumscribed tumour and it is described as a lump that moves very easily and it can disappear depending on their position. The term that was used generally are ‘breast mice’ because a mice can disappear very quickly and moves around. So Fibroadenoma itself is what we call a breast mice.
However, some women do come in complaining of pain, especially during their menstrual cycles, as these lesions usually grow in size. And sometimes that’s how a lesion is first detected because of pain. It can also be because young women comes in complaining of a lump there that is, I guess not nice to look at or they could see they could feel it and they really want it removed, even knowing that it is most likely a fibroadenoma.
So sometimes women do present because it is aesthetically not nice and it bothers them. In the advent of breast screen we do get a lot more now, coming in with findings of a lesion in their breast, especially after having a mammogram or ultrasound, a lot of these fibroadenomas do show up as a big calcifications and these are benign, but a lot of them do find it coming to see us because they do want it further investigation as a solid lump in the breast generally worries women.
What are the risks of the condition?
George: Well, fortunately our fibroadenoma has a very benign course generally, however, fibroadenoma as we mentioned earlier can cause pain, causes a lot of anxiety to women, and also can cause poor cosmesis or aesthetics to the breast itself and at times phyllodes can be mistaken for a fibroadenoma, especially when it’s larger in size where it’s larger than three to four centimetres in size. For these tumours I mentioned earlier has a wide range of biological behaviour and they do carry a risk of malignancy.
Histologically, they are categorised as benign, borderline and malignant, this is based on the histological findings, so there’s stromal cell [inaduibel], then mitotic activity, stromal overgrowth and tumours margins, so you’re looking if it’s infiltrative or not. Fortunately, still 70% of phyllodes tumour are benign and are very similar to fibroadenomas. Only 20% are borderline. However, 10% are malignant in nature and they behave differently to breast cancer and more like a sarcoma where they like where they’re more likely to spread through the blood or hematogenously, rather than through the lymph nodes, only less than 5% of malignant Floyd is really spread through the lymph nodes. Lung metastasis are the most common form of dissent metastases in phyllodes malignancy but even then this is quite rare.
What are the treatment options?
George: Well, let’s start with, there are obviously operative and nonoperative management for all these pathologies. Small fibroadenomas can be left alone and monitored via ultrasound and the first follow up after the first discovery is usually six months to measure the changes in their size, so we’re usually concerned if it has grown over 50% in size within the six months itself. However, if there are concerning features that are reported by the radiologist on the imaging core biopsy can be performed to rule out phyllodes tumour or breast cancer. Now some young women actually have a lot of fibroadenomas, so it is not actually practical, nor is it wise to remove all of them as it can cause a lot of scarring to the breast itself, so hence we generally leave the smaller fibroadenoma or the more indolent ones alone
Fibroadenomas over 3 to 4 centimetres or as I mentioned earlier, the ones that growing in size where it grows over 50% in size over the six months, ones that are painful or ones that have suspicious features on imaging, should be surgically excised, or should have an exceptional biopsy. These are usually day procedures and it can be done with a small incision. Phyllodes is a different animal altogether, should always be excised, especially when you know that it is phyllodes. It is faster growing than far greater numbers and usually it is larger than three to four centimetres in size.
The core biopsy should always be performed on these lesions if it is suspicious so that you can confirm the diagnosis of Floyd is prior and the reason that is because the reason that we approach the surgery is slightly different in the sense that we will need to get ideally a 1 centimetre margins of our breast tissue around the lesion itself, rather than just removing the lesion around its capsule, and the reason we do that is to reduce the risk of recurrence.
Have there been any developments in treatment in the last years or are there any in trials or development now?
George: Well, Fibroadenoma itself is benign in nature and current surgical excision produces group results and outcome. And as I mentioned, most of the time, as women progresses in age they do tend to shrink in size, and some of them do disappear overtime. These don’t tend to bother women, only the larger ones do. Unfortunately, phyllodes itself is still quite a rare tumour. As I mentioned less than 1% of all breast malignancy. There hasn’t been much development, but fortunately with the current appropriate treatment, our patients with phyllodes have very good prognosis still.
Are there any warning signs a GP or their patient can look out for?
George: Well, I guess when seeing a new patient it’s always important to take a thorough history and patients should always have breast imaging. Including mammograms or Tomo synthesis as well as ultrasound of the breast and if necessary are core biopsy or fine needle aspirations as per recommended by the breast radiologist. In terms of features to look out for, I guess as mentioned earlier, features Lookout for including in history, or rapidly enlarging lesions. So, if the patient complaints of a lesion that has grown very quickly over the course of weeks or months, these should be taken seriously and these should be biopsy and followed by referral to a breast surgeon, so we’re talking about lesions that are over three to four centimetres size, especially.
In terms of the smaller fibrate, enormous, they should be follow up again in six months with another ultrasound, and if they do grow more than 50% in size then they should be referred as well to a breast surgeon as well as to have a core biopsy to determine their histopathology. Tender fibroadenomas or lesions that are painful should also be referred as these can reduce the quality of life for women and they should be removed as this would, I guess, treat the pain itself.
What is the likelihood of recurrence of the condition?
George: Once excised fibroadenoma is very unlikely to recur, especially when it’s completely excised. The reason that it does recur is most likely because it has not been completely excised. However, women are always at more risk of developing more fibroadenomas elsewhere in the breast or on the contralateral side. Now, as we mentioned earlier in the talk itself, phyllodes itself is a completely different animal. It has a high risk of recurrence, especially if a good margin has not been taken with the tumour itself. Now risk of recurrence for facilities or for all facilities is about 13% over the five years. Malignant phyllodes itself has three times higher risk of recurrence compared to a benign phyllodes and the borderline ones are sitting somewhere in between. The prognosis itself for a benign phyllodes is excellent, it’s close to 100% over the next five years, and for borderline it is 98% even for malignant phyllodes itself, the prognosis is good, it sits at 88% / 5 years.
When should a GP refer?
George: The GP should start referring someone fibroadenoma, especially when it’s large in size 3 to 4 centimetre in size, fibroadenoma that’s enlarging by over 50% in size over six months, or with a history of acute progression in size. Tender, so tender fibroadenoma, a fibroadenoma that’s affecting a patient’s cosmesis and their confidence. So these should be removed. Juvenile fibroadenoma sore patients, younger patients with fibroadenomas should be taken seriously and they should be referred early so that they can be monitored over time as the larger thyroid members should be removed as they tend to be more cellular and they’re more likely to get larger over time. The last ones are patients with suspicious imaging for phyllodes or has a positive core biopsy with floaties or that are atypical. They should be referred as soon as possible so they can be treated.
What role does the GP play in the treatment of the condition?
George: Our GPS play a very big role. GPs are the first doctors that the patients usually see and there’s so many women out there with fibroadenoma. And of course, not all fibroadenoma needs to be treated. The most important thing is to be able to determine the red flags and to know when to refer appropriately. So many women have multiple fibromas as I mentioned. So a lot of GPs do tend to fall with their patients long term with ultrasounds to monitor these fibroadenomas and one of the roles of our GPS as well is to reassure patients.
As we mentioned earlier, Fibroadenoma are mostly benign and in the event it is phyllodes the prognosis is good and patients should be reassured are one of the. Other roles that I always say it’s important for GPs is to encourage women to front up to breast screen. It is available in every state in Australia, especially for women after the age of 45 or someone with a family history of breast cancer, and these are especially important because these women should perhaps start having breast examinations and breast imaging earlier than the general population.
Thank you for your time here today in the PodMD studio. To sum up for us, could you please identify the three key take home messages from today’s podcast on Fibroadenoma and phyllodes tumour
George: Well, I guess to sum up large fibroadenomas over size of three to four centimetres, or rapidly enlarging fibroadenoma’s should be considered high risk of being phyllodes tumour and hence it should be biopsy and referred immediately for an excisional biopsy or excision. Juvenile fibroadenoma that afflicts women between the age of 10 and 18 should be referred early for close monitoring, as the larger fibroadenomas should be removed earlier as they tend to grow in size and #3 is that fellow human itself is categorised into 3 categories, benign, borderline and malignant. Risk of recurrence and distant metastasis is increased with malignant phyllodes.
Thanks for your time and the insights you’ve provided.
George: Thank you.