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Featured Commentary

Our online subscription format, SRGS Connect, features 10 commentaries on recently published articles in top medical journals with each new edition. The commentaries are by practicing surgeons and focus on the strengths and weaknesses of the research and its contribution to advancing the field of surgery.

Below is a sample of one of the commentaries published in the current edition of SRGS Connect, What You Should Know.

Hubbard JL, Cagle K, Davis JW, et al. Criteria for excision of suspected fibroadenomas of the breast. Am J Surg. 2015; 209(2):297-301.

Commentary by: Mary A. Hooks, MD, MBA, FACS

The article by Hubbard et al addressed the issue of establishing criteria for decision making in the surgical treatment of fibroadenomas. It is a retrospective study spanning 9 years (2002–2011). Criteria they considered included: characteristics related to the patient's history (age, ethnicity, breast cancer risk factors and method of detection); physical exam findings, including whether the mass was palpable and characteristics of borders, mobility and texture; the size of the mass, which was recorded based on either ultrasound results or physical exam findings (when ultrasound was not performed or recorded); imaging results, including height/width ratio, BIRADS category, and echogenicity; results of pre-operative biopsy confirmed fibroadenoma in 87% of cases.

Of note is that ultrasound was performed in only 78% of cases and pre-operative needle biopsy was performed in only 25% of cases. Based on their statistical analysis, they determined the following criteria useful for deciding when to observe a mass: age less than 35 years; physical exam findings of a mobile and well-circumscribed mass; size less than 2.5 cm; and percutaneous biopsy confirming fibroadenoma.

This paper clearly confirms the need to establish criteria for when to excise masses suspected of being benign fibroadenomas. Ninety-four percent of the masses excised in this study were benign and only 5.8% were not fibroadenomas. Of those masses with non-fibroadenoma pathology, only two were malignant phyllodes tumors and none were invasive mammary carcinoma or DCIS. This paper very appropriately emphasizes the importance of clinical/radiologic/pathologic correlation and the need for additional work up if these components are not aligned.

There are also several criticisms of this paper. The authors did not describe how they identified the "preoperative diagnosis" of fibroadenoma; whether it was on pathology reports, operative reports or both. They do appropriately disclose their assumptions about history and physical exam findings. If data were missing, then they assumed that the history was negative or that the physical exam was normal, but they did not report the number of cases in which these assumptions were applied. This is particularly important since part of the study period (we do not know how much) was prior to electronic records and assumptions may have been made in cases of unclear handwriting. The authors state that the indications for excision were based on size (including change in size), characteristics of the mass, patient discomfort, and ultrasound characteristics; however, patient discomfort was not included in their statistical analysis, so we do not know how many of these patients contributed to decision making. In addition, the authors did not describe the experience of the clinicians performing the physical exams, imaging or pre-operative biopsies, OR changes in practice over the period of the study. I suspect there may have been a change in practice over time, but this is not addressed in the article.

Other criteria that merit consideration include: associated symptoms particularly pain and architectural distortion of the breast; change in size over time (as percentage of size); patient characteristics, including level of anxiety or preference otherwise; imaging characteristics including experience of radiologist(s); biopsy techniques including image guidance and needle size; histology results including stromal cellularity, nuclear atypia, mitotic count and immunohistochemistry for proliferation indices such as Ki-67 and Topo II . For adolescent girls with benign appearing solid breast masses, Jawahar et al concluded that needle biopsy may not even be required in the diagnostic work up if history, clinical findings, and imaging characteristics all favor fibroadenoma. This emphasizes the importance of age and different considerations for very young patients.

In conclusion, a large majority of solid masses with benign clinical and imaging features have benign pathology following surgical excision and therefore do not require surgical excision. This is particularly true for patients that have percutaneous biopsy confirming benign pathology. Anytime there is deviation from characteristics associated with benign pathology as described above, or there is not alignment of the clinical findings, imaging characteristics and pathology results surgical excision should be performed.

Suggested Reading

  1. Sala MA, et al. Indications for diagnostic open biopsy of mammographic screen-detected lesions preoperatively diagnosed as fibroadenomas by needle biopsy and their outcomes. Clin.Rad. 2015;1-8.
  2. Jacobs TW, et al. Fibroepithelial lesions with cellular stroma on breast core needle biopsy. Am J Clin Pathol. 2005;124:342-354.
  3. Jawahar A, et al. Biopsy versus conservative management of sonographically benign-appearing solid breast masses in adolescents. J Ultrasound Med. 2015;34:617-625.