A Rare Case of Juvenil Giant Fibroadenoma

The most common cause of breast masses seen in young women is fibroadenomas. It is characterized as benign. Etiologically, increased estrogen and receptor susceptibility have been accused [1]. Mass growth usually stops when it reaches 2 cm in size. Those with a size greater than 5 cm are called giant fibroadenomes [2]. Juvenile giant fibroadenomas are very rare cases and constitute 0.5% of all fibroadenomas. In this study, we present a 12-year-old female patient of giant juvenile fibroadenoma.


Introduction
The most common cause of breast masses seen in young women is fibroadenomas. It is characterized as benign. Etiologically, increased estrogen and receptor susceptibility have been accused [1]. Mass growth usually stops when it reaches 2 cm in size. Those with a size greater than 5 cm are called giant fibroadenomes [2]. Juvenile giant fibroadenomas are very rare cases and constitute 0.5% of all fibroadenomas. In this study, we present a 12-year-old female patient of giant juvenile fibroadenoma.
Case Report 12 years old female patient was admitted to our clinic with complaints of rapid and excessive growth in her right breast. This complaints had existed for 2-3 months and there was not any systemic disease in the history of the patient A painless, circumferentially aligned, mobile mass covering the entire of both lower quadrants and upper inner quadrant was detected on the breast examination ( Figure 1). Her armpit examination was normal. Other physical examination findings were normal. Biochemical tests and hormone levels were normal. Ultrasonographic imaging of the patient revealed a solid mass, that has well defined border, with a heterogeneous structure of vascular blood vessels at the 100 × 65 × 45 mm retroareolar placement. Magnetic Resonance İmagination (MRI) revealed mass lesions covering both the lower and upper inner quadrants of the breast which was hyperintense and well defined border in the fat-suppressed T2-weighted series.
A true cut biopsy was performed for preliminary diagnosis and diagnosed as juvenil fibroadenoma. The mass was removed totally by periareolar incision. We did not made any attempt to provide nipple-areola complex symmetry since the patient's physical development continued. There were no complications in postoperative period. Histopathologic diagnosis was revealed as pericanalicular type Juvenil giant fibroadenoma (Figures 2 and 3). Postoperatively, cosmetic appearance was satisfactory (Figure 4).

Discussion and Conclusion
Giant juvenile fibroadenomas, composed of epithelium and/or stroma of the terminal lobule of the breast, represent only 0.5% of all fibroadenomas [1]. Fibroadenomas, which are well defined border and encapsulated, grow rapidly as they reach large sizes [3]. However, breast asymmetry, nipple irregularities, and congestion may occur with mass effect [4]. In our case, there was serious asymmetry reagrding the breast and nipple size.
Juvenile fibroadenomas usually present during puberty in the age range of 11-18 years and are usually painless lesions [5]. The youngest known case in the literature is a 13-month-old girl [6]. To date, there is a lack of specific guidelines regarding the optimal management of giant juvenile fibroadenomas likely due to conflicting diagnostic and treatment strategies. Breast surgeons, gynecologists, pediatricians, pediatric surgeons and plastic surgeons may encounter giant juvenile fibroadenoma. These patients should be referred to an experienced specialist and a more specific assessment and treatment strategy should be established on this issue. Imaging methods should be performed after breast and axillary examination in every patient who comes with the mass complaint in breast. Mammography is not preferred due to increased densities in women under 40 years of age [7]. For this reason, the most common method is USG in young women. Smith and Burrows. found that patients aged 25 and younger suspected to have a fibroadenoma on ultrasound had 78.8% accuracy in diagnosis based on histology [8]. Obtaining tissue is also required to differentiate between juvenile giant fibroadenomas and philloides tumors, malignant tumors. Care must be taken in terms of malignancy in the differential diagnosis and especially   phylloides tumors should be considered. Philloides tumor is a rare fibroepithelial breast tumor that accounts for less than 1% of all primary breast neoplasms, 2-3% of all fibroepithelial tumors [9,10]. They are similar benign fibroadenoma but distinguished from benign fibroadenomas, histologically increased cellularity and clinically local recurrence and metastatic spread. Therefore, the patient who is diagnosed with breast mass should be evaluated in terms of physical examination, imaging and biopsy. There are studies in the literature that suggest that Fine Needle Aspiration (FNA) biopsies are not reliable. one of the largest series of over 1,400 FNAs of adolescent breast masses, Kapina et al. concluded FNA is not required [11]. However, sensitivity of the true-cut biopsy in the literature is reported to be 88-98%, specificity 94-100%, and accuracy 93-99% [12,13]. Thus, in our case, true-cut biopsy was performed instead of fine needle biopsy for tissue obtaining after imaging and histopathological preliminary diagnosis came as juvenile fibroadenoma.
The treatment of juvenile fibroadenoma is excision or observation.
In cases of simple fibroadenoma, conservative treatment may be preferred as 10% of the lesions spontaneously resolve. However, in cases of giant fibroadenomas, surgical treatment should be performed and additional reconstructive procedures might be necessary. In the age of puberty, tumor excision and simultaneous breast reconstruction principles can be performed to protect the breast parenchyma, provide symmetry of the nipple-areola complex and avoid iatrogenic amastia [11,14]. Revision surgeries may be needed in order to provide a cosmetic appearance after the excision of the mass. In our case, we removed the mass by periareolar incision and the remaining breast tissue in the upper quadrant was sufficient to provide the symmetry when compared to the counter-breast. However, since the patient was in the age of growth, the possible revision operations for nipple-areolar complex symmetry were postponed after puberty.