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Endoscopic specimen pouch technique for removal of giant fibroadenomas of the breast
Journal of Pediatric Surgery (2012) 47, 803–807
www.elsevier.com/locate/jpedsurg
Endoscopic specimen pouch technique for removal of giant fibroadenomas of the breast Philip J. Cheng a , Lan T. Vu a , Darrell L. Cass a , M. John Hicks b , Mary L. Brandt a , Eugene S. Kim a,⁎ a
Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX 77030, USA Department of Pathology, Baylor College of Medicine, Houston, TX 77030, USA
b
Received 8 December 2011; revised 11 January 2012; accepted 25 January 2012
Key words: Giant fibroadenoma; Endoscopic pouch
Abstract Giant (juvenile or cellular) fibroadenoma of the breast is the most common tumor that present in adolescent girls. As benign tumors that can exceed 10 cm in diameter, giant fibroadenomas have historically necessitated large incisions to remove these masses, resulting in large unsightly scars. We describe the novel use of an endoscopic specimen pouch to facilitate the removal of these large tumors through minimal incisions in 3 patients. In follow-up, all 3 patients have had excellent cosmetic outcomes, no recurrences, and no postoperative complications. © 2012 Elsevier Inc. All rights reserved.
Fibroadenomas of the breast are common benign mesenchymal tumors that usually present in young women. Fibroadenomas are not considered true neoplasms; instead, they are aberrations of normal breast development or the result of hyperplastic processes [1,2]. Studies have shown that the prevalence of fibroadenomas in the female population range from 7% to 13% [1]. In the female pediatric and adolescent population, fibroadenomas are the most common breast tumors, accounting for 67% to 94% of adolescent breast pathology [3-6]. Any fibroadenoma that is larger than 5 cm in diameter or weighs more than 500 g can be classified as a giant fibroadenoma, also sometimes referred to as juvenile or cellular fibroadenoma [6,7]. Giant fibroadenomas typically present in adolescence [8], but they are much less common, making up less than 5% of
adolescent fibroadenomas [9]. Although these lesions are considered benign, they can cause distortion of the breast [6]. Accordingly, this condition can have profound psychologic effects on the patient, especially in developing adolescents. Because of the benign nature of these lesions, it is important to take into account cosmesis when considering the management options for the removal of fibroadenomas and to approach these masses with conservative surgical techniques. To this end, we report 3 cases in which a novel conservative surgical technique is used with giant fibroadenoma excision by placing the mobilized tumor into an endoscopic plastic bag in situ with removal through a small incision to provide optimal cosmesis.
1. Case 1 ⁎ Corresponding author. Texas Children's Hospital, Houston, TX 77030, USA. Tel.: +1 832 822 3135; fax: +1 832 825 3141. E-mail address: [email protected] (E.S. Kim). 0022-3468/$ – see front matter © 2012 Elsevier Inc. All rights reserved. doi:10.1016/j.jpedsurg.2012.01.064
A 17-year-old adolescent girl with a history of end-stage renal disease, status post kidney transplant 5 years
804 previously, presented with a left breast mass that she detected 1 month earlier on self-breast examination. She denied any pain, breast discharge, or systemic signs or symptoms. On physical examination, the breast mass was found to be 5 cm in diameter, mobile, and nontender. The mass was located in the medial upper quadrant of the left breast. With a preoperative diagnosis of fibroadenoma, no further workup or imaging was performed, and the patient was scheduled for an elective outpatient excision of the breast mass. In the operating room, a 1.5-cm periareolar incision was created along the inferior margin of the areola (Fig. 1A). Using a hemostat, blunt dissection, and limited cautery, the surface of the fibroadenoma was dissected free from the surrounding breast tissue. This was aided by the mobility of the mass and the mobility of the incision over the mass. To remove the mass, rather than enlarge the incision, a 10-mm endoscopic plastic bag (Autosuture Endo Catch Gold Specimen Pouch; Covidien, Mansfield, MA) was inserted into the surgical incision site (Fig. 1B). The pouch was deployed under the mass, and the mass was inserted into the bag. The opening of the bag was everted outwardly through the incision, and the mass was removed through the incision (Fig. 1C and D). Hemostasis was achieved, and the wound was closed in layers and dressed. The patient tolerated the procedure well and was taken to the recovery room in good condition.
P.J. Cheng et al. The gross examination and histopathologic features were consistent with a giant fibroadenoma with no atypical features and no evidence of phyllodes tumor. With 31 months of follow-up, the patient has had no evidence of recurrence with an excellent cosmetic outcome.
2. Case 2 A 13-year-old adolescent girl presented to the clinic with a 7-month history of a large left breast mass. She denied any pain, breast discharge, or systemic signs or symptoms. On physical examination, the breast mass was found to be approximately 8 cm in diameter, mobile, nontender, and located in the lateral upper quadrant of the left breast. No axillary lymphadenopathy was palpated. A diagnostic ultrasound was performed, which was consistent with a fibroadenoma. In the operating room, a 2-cm periareolar incision was created from the 11 o'clock to the 2 o'clock position. Similar to the first case, we used a hemostat, blunt dissection, and limited cautery to circumferentially dissect free the mass from the surrounding breast tissue. We inserted a 10-mm endoscopic specimen pouch into the surgical incision site, and the pouch was deployed under the mass, which was then
Fig. 1 Endoscopic specimen pouch use in the removal of a giant fibroadenoma of the breast. A, Image of a closed, small, cosmetic periareolar incision of the breast. B, Insertion of the endoscopic specimen pouch into the wound before deployment. C, Fibroadenoma removed intact within the endoscopic bag. D, Giant fibroadenoma of 5 cm in diameter removed through a 1.5-cm surgical incision site.
Endoscopic specimen pouch technique maneuvered into the bag. The opening of the bag was everted outwardly through the incision, and the mass was morcellated with an empty sponge stick clamp and removed piecemeal, similar to the technique of a laparoscopic splenectomy. After removal of the mass, hemostasis was achieved, and the wound was closed in layers and dressed. The patient tolerated the procedure well and was taken to the recovery room in good condition. The gross examination and histopathologic features were consistent with a giant fibroadenoma with no atypical features and no evidence of phyllodes tumor. The patient was seen in the office 1 month after excision of the breast mass. Cosmesis and symmetry were both excellent with no postoperative complications. She is scheduled for routine follow-up in 6 months.
3. Case 3 A 15-year-old adolescent girl presented to the clinic with a left breast mass that was self-detected several months earlier. She denied pain, breast discharge, or systemic signs or symptoms. On physical examination, the left breast mass was found to be 10 cm in diameter, mobile, and nontender and located in the center of the breast. No axillary lymphadenopathy was detected. The patient arrived with an ultrasound from an outside institution, which described the mass as 9.7 cm in diameter with no aggressive features. Because of the large size of the mass in comparison with the size of the breast, a magnetic resonance imaging was performed to help plan the resection approach and for possible reconstruction if necessary. The magnetic resonance imaging revealed a 10.5-cm mass superficial to the pectoralis muscle, with features of a giant fibroadenoma or phyllodes tumor. In the operating room, a 4-cm periareolar incision was created along the superior aspect of the areolar margin. Using a hemostat, blunt dissection, and limited cautery, the wellencapsulated surface of the fibroadenoma was entirely dissected free from the surrounding breast tissue. At this point, multiple unsuccessful attempts were made to deliver the mobilized mass through of the surgical incision site. A 10-mm Endo Catch pouch was then inserted into the wound, and the mass was manipulated intact into the bag. In this particular case, because of the large size, the mass was more easily maneuvered into the bag after detachment from the supporting metal ring of the Endo Catch device. With the traction of the plastic bag, the mass was removed intact without the need for morcellation. Hemostasis was achieved, and the wound was closed in layers and dressed. The patient tolerated the procedure well and was taken to the recovery room in good condition. The gross examination and histopathologic features were consistent with a giant fibroadenoma with no atypical features and no evidence of phyllodes tumor.
805 The patient was seen in follow-up 1 month later with an excellent cosmetic outcome and symmetry between both breasts. She is scheduled for routine reexamination in 6 months.
4. Discussion Giant (juvenile or cellular) fibroadenomas usually present during puberty as an encapsulated, rapidly growing breast masses [10]. Giant fibroadenomas are usually unilateral, but in isolated cases, patients with bilateral giant fibroadenomas have been reported [11]. Breast enlargement can occur in as little as a few weeks [9], and the mass can double in size within 3 to 6 months [10,12], growing larger than the existing normal breast tissue [13]. Local recurrence is not common but can occur [9]. In general, surgical excision is recommended if the breast mass continues to grow or causes cosmetic concerns [14,15]. It is ideal to excise a giant fibroadenoma before the tumor mass expands to the point of causing venous congestion, glandular distortion, pressure necrosis, or ulceration [16]. Because these patients tend to be young and have not yet completed full breast development, cosmesis becomes an important consideration when choosing a method for resection. Aggressive biopsy, resection, or dissection in the developing breast bud may cause subsequent cosmetic deformity [17]. Furthermore, traditional breast surgical techniques may not only scar breast tissue and skin but also have the potential to cause long-lasting psychologic harm [14]. More aggressive procedures, such as mastectomy or wide local excision, are usually reserved for the management of previously confirmed breast carcinoma or phyllodes tumor. After excision of giant fibroadenomas, the normal breast tissue will typically re-expand and remodel to some degree [17]. Current minimally invasive techniques, such as ultrasound-guided, vacuum-assisted excision; radiofrequency ablation; and cryotherapy, are not able to effectively remove a mass as large as a giant fibroadenoma. Complete local excision with sparing of breast tissue is often the treatment modality of choice [1,2,18]. There are numerous surgical techniques that have been reported to excise a giant fibroadenoma. The conventional approach is to make an incision directly over the tumor [19,20]; however, this can leave a visible scar, which may cause pain during lactation and widen or become hypertrophic. Accordingly, recent techniques have focused on optimizing cosmesis. These surgical procedures include reduction mammoplasty; inframammary excision; Swiss roll technique using a circumareolar incision with progressive rolling and dissecting of the mass outwardly and through the surgical incision site; extramammary endoscopic excision; and the use of an endoscopic plastic bag [21], which is the technique used in the current report.
806 We find that this technique has advantages over other reported techniques. First, simply by having the tumor in the plastic Endocatch bag and with upward traction on the bag, we have found that the tumor can often be delivered from the surgical incision site without the need to extend the incision or for morcellation. The malleable and pliable nature of these tumors in combination with the “slippery” interface between the plastic bag and the surrounding fatty breast tissue makes this possible. Second, although we have used the Endocatch bag to deliver large (N10 cm) tumors through small surgical incision sites in this report (1.5-4 cm), our surgical goal is to use a minimal size incision (approximately 1 cm) that will accommodate just the size of the Endocatch bag. Because cosmesis is an important factor when removing a benign lesion, the smaller surgical incision used in this technique will enhance cosmetic outcome with this operation. Removal of a giant fibroadenoma mass through such a minimal incision would be very difficult, if at all possible, using any of the other reported techniques without an Endocatch bag. Third, this technique is superior to other techniques, which use a bag, because it does not require purchase of a non–Food and Drug Administration–approved “over the counter” bag, which requires sterilization before use in the surgical theater. In addition to being presterilized and already in use clinically, the Endocatch bag comes preloaded in a lowprofile (1 cm) deployment device. One potential concern of this technique is morcellating a tumor in the setting of the possibility of a very rare malignancy, such as a malignant phyllodes tumor. As a group, phyllodes tumors are rare, representing 1% of all breast tumors and 8% in patients younger than 20 years [22]. Malignant phyllodes tumors are even more rare occurrences, seen in a very small subset of patients with phyllodes tumors. Although phyllodes tumor is a rare diagnosis in the pediatric population, removal of this particular tumor via an Endocatch bag, with or without morcellation, would not necessarily alter the use of the bag. Postoperative histopathologic diagnosis of a phyllodes tumor would either prompt close observation for recurrence or, in the very rare case of a malignant phyllodes tumor, require a wide excision of the previous resection site with at least 2-cm margins—which most likely would mean a mastectomy in the pediatric patient. In addition, the presence of the tumor captured in the Endocatch bag would minimize spillage and contamination of the original resection site. Another operative option would be to perform an incisional or core biopsy of the specimen while isolated within the Endocatch bag. Subsequent frozen section should be able to readily differentiate a fibroadenoma from a phyllodes tumor. However, we would be unlikely to proceed with a more aggressive resection or mastectomy until final histopathologic analysis has been completed with confirmation of the preliminary frozen section diagnosis on examination of additional routinely processed tissue.
P.J. Cheng et al. Herein, we describe an endoscopic specimen pouch technique to assist delivery of fibroadenomas from their in situ locations. Through a cosmetic periareolar surgical incision, giant fibroadenomas that are several times the size of the incision can be safely extracted with the aid of a 10-mm endoscopic specimen pouch. In our experience, this technique is effective and easily performed and provides excellent cosmetic results in the pediatric population. In addition, the use of the bag could potentially protect against tumor and contamination of the resection site if morcellation is necessary. As such, we recommend this technique in the operative management of giant fibroadenomas.
References [1] Greenberg R, Skornick Y, Kaplan O. Management of breast fibroadenomas. J Gen Intern Med 1998;13:640-5. [2] Neinstein LS. Breast disease in adolescents and young women. Pediatr Clin North Am 1999;46:607-29. [3] De Silva NK, Brandt ML. Disorders of the breast in children and adolescents, part 2: breast masses. J Pediatr Adolesc Gynecol 2006;19: 415-8. [4] Gobbi D, Dall'Igna P, Alaggio R, et al. Giant fibroadenoma of the breast in adolescents: report of 2 cases. J Pediatr Surg 2009;44: e39-41. [5] Tea MK, Asseryanis E, Kroiss R, et al. Surgical breast lesions in adolescent females. Pediatr Surg Int 2009;25:73-5. [6] Templeman C, Hertweck SP. Breast disorders in the pediatric and adolescent patient. Obstet Gynecol Clin North Am 2000;27:19-34. [7] Musio F, Mozingo D, Otchy DP. Multiple, giant fibroadenoma. Am Surg 1991;57:438-41. [8] Jayasinghe Y, Simmons PS. Fibroadenomas in adolescence. Curr Opin Obstet Gynecol 2009;21:402-6. [9] Simmons RM, Cance WG, Iacicca MV. A giant juvenile fibroadenoma in a 12-year-old girl: a case for breast conservation. Breast J 2000;6: 418-20. [10] Dolmans GH, Hoogbergen MM, van Rappard JH. Giant fibroadenoma of one breast: immediate bilateral reconstruction. J Plast Reconstr Aesthet Surg 2007;60:1156-7. [11] Mukhopadhyay M, Patra R, Mondal S, et al. Bilateral giant juvenile fibroadenoma of breasts. J Indian Assoc Pediatr Surg 2009; 14:68-9. [12] Greydanus DE, Matytsina L, Gains M. Breast disorders in children and adolescents. Prim Care 2006;33:455-502. [13] Nambiar R, Kutty MK. Giant fibro-adenoma (cystosarcoma phyllodes) in adolescent females—a clinicopathological study. Br J Surg 1974;61:113-7. [14] Liu H, Huang CK, Yu PC, et al. Retromammary approach for endoscopic resection of benign breast lesions. World J Surg 2009;33: 2572-8. [15] Osanai T, Nihei Z, Ichikawa W, et al. Endoscopic resection of benign breast tumors: retromammary space approach. Surg Laparosc Endosc Percutan Tech 2002;12:100-3. [16] Park CA, David LR, Argenta LC. Breast asymmetry: presentation of a giant fibroadenoma. Breast J 2006;12:451-61. [17] Biggers BD, Lamont JP, Etufugh CN, et al. Inframammary approach for removal of giant juvenile fibroadenomas. J Am Coll Surg 2009;208:e1-4. [18] Maharaj D, Naraynsingh V, Ramdass M. Management of giant fibroadenomas: a case for small incisions for large tumors. Breast J 2003;9:141.
Endoscopic specimen pouch technique [19] Kitamura K, Hashizume M, Sugimachi K, et al. Early experience of endoscopic extirpation of benign breast tumors via an extramammary incision. Am J Surg 1998;176:235-8. [20] Kitamura K, Inoue H, Ishida M, et al. Endoscopic extirpation of benign breast tumors using an extramammary approach. Am J Surg 2001;181:211-4.
807 [21] Rojananin S, Ratanawichitrasin A. Limited incision with plastic bag removal for a large fibroadenoma. Br J Surg 2002;89: 787-8. [22] Rodriguez Ogando A, Fernandez Lopez T, Rodriguez Castano MJ, et al. Cystosarcoma phyllodes of the breast: a case report in a 12-year-old girl. Clin Transl Oncol 2010;12:704-6.
www.elsevier.com/locate/jpedsurg
Endoscopic specimen pouch technique for removal of giant fibroadenomas of the breast Philip J. Cheng a , Lan T. Vu a , Darrell L. Cass a , M. John Hicks b , Mary L. Brandt a , Eugene S. Kim a,⁎ a
Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX 77030, USA Department of Pathology, Baylor College of Medicine, Houston, TX 77030, USA
b
Received 8 December 2011; revised 11 January 2012; accepted 25 January 2012
Key words: Giant fibroadenoma; Endoscopic pouch
Abstract Giant (juvenile or cellular) fibroadenoma of the breast is the most common tumor that present in adolescent girls. As benign tumors that can exceed 10 cm in diameter, giant fibroadenomas have historically necessitated large incisions to remove these masses, resulting in large unsightly scars. We describe the novel use of an endoscopic specimen pouch to facilitate the removal of these large tumors through minimal incisions in 3 patients. In follow-up, all 3 patients have had excellent cosmetic outcomes, no recurrences, and no postoperative complications. © 2012 Elsevier Inc. All rights reserved.
Fibroadenomas of the breast are common benign mesenchymal tumors that usually present in young women. Fibroadenomas are not considered true neoplasms; instead, they are aberrations of normal breast development or the result of hyperplastic processes [1,2]. Studies have shown that the prevalence of fibroadenomas in the female population range from 7% to 13% [1]. In the female pediatric and adolescent population, fibroadenomas are the most common breast tumors, accounting for 67% to 94% of adolescent breast pathology [3-6]. Any fibroadenoma that is larger than 5 cm in diameter or weighs more than 500 g can be classified as a giant fibroadenoma, also sometimes referred to as juvenile or cellular fibroadenoma [6,7]. Giant fibroadenomas typically present in adolescence [8], but they are much less common, making up less than 5% of
adolescent fibroadenomas [9]. Although these lesions are considered benign, they can cause distortion of the breast [6]. Accordingly, this condition can have profound psychologic effects on the patient, especially in developing adolescents. Because of the benign nature of these lesions, it is important to take into account cosmesis when considering the management options for the removal of fibroadenomas and to approach these masses with conservative surgical techniques. To this end, we report 3 cases in which a novel conservative surgical technique is used with giant fibroadenoma excision by placing the mobilized tumor into an endoscopic plastic bag in situ with removal through a small incision to provide optimal cosmesis.
1. Case 1 ⁎ Corresponding author. Texas Children's Hospital, Houston, TX 77030, USA. Tel.: +1 832 822 3135; fax: +1 832 825 3141. E-mail address: [email protected] (E.S. Kim). 0022-3468/$ – see front matter © 2012 Elsevier Inc. All rights reserved. doi:10.1016/j.jpedsurg.2012.01.064
A 17-year-old adolescent girl with a history of end-stage renal disease, status post kidney transplant 5 years
804 previously, presented with a left breast mass that she detected 1 month earlier on self-breast examination. She denied any pain, breast discharge, or systemic signs or symptoms. On physical examination, the breast mass was found to be 5 cm in diameter, mobile, and nontender. The mass was located in the medial upper quadrant of the left breast. With a preoperative diagnosis of fibroadenoma, no further workup or imaging was performed, and the patient was scheduled for an elective outpatient excision of the breast mass. In the operating room, a 1.5-cm periareolar incision was created along the inferior margin of the areola (Fig. 1A). Using a hemostat, blunt dissection, and limited cautery, the surface of the fibroadenoma was dissected free from the surrounding breast tissue. This was aided by the mobility of the mass and the mobility of the incision over the mass. To remove the mass, rather than enlarge the incision, a 10-mm endoscopic plastic bag (Autosuture Endo Catch Gold Specimen Pouch; Covidien, Mansfield, MA) was inserted into the surgical incision site (Fig. 1B). The pouch was deployed under the mass, and the mass was inserted into the bag. The opening of the bag was everted outwardly through the incision, and the mass was removed through the incision (Fig. 1C and D). Hemostasis was achieved, and the wound was closed in layers and dressed. The patient tolerated the procedure well and was taken to the recovery room in good condition.
P.J. Cheng et al. The gross examination and histopathologic features were consistent with a giant fibroadenoma with no atypical features and no evidence of phyllodes tumor. With 31 months of follow-up, the patient has had no evidence of recurrence with an excellent cosmetic outcome.
2. Case 2 A 13-year-old adolescent girl presented to the clinic with a 7-month history of a large left breast mass. She denied any pain, breast discharge, or systemic signs or symptoms. On physical examination, the breast mass was found to be approximately 8 cm in diameter, mobile, nontender, and located in the lateral upper quadrant of the left breast. No axillary lymphadenopathy was palpated. A diagnostic ultrasound was performed, which was consistent with a fibroadenoma. In the operating room, a 2-cm periareolar incision was created from the 11 o'clock to the 2 o'clock position. Similar to the first case, we used a hemostat, blunt dissection, and limited cautery to circumferentially dissect free the mass from the surrounding breast tissue. We inserted a 10-mm endoscopic specimen pouch into the surgical incision site, and the pouch was deployed under the mass, which was then
Fig. 1 Endoscopic specimen pouch use in the removal of a giant fibroadenoma of the breast. A, Image of a closed, small, cosmetic periareolar incision of the breast. B, Insertion of the endoscopic specimen pouch into the wound before deployment. C, Fibroadenoma removed intact within the endoscopic bag. D, Giant fibroadenoma of 5 cm in diameter removed through a 1.5-cm surgical incision site.
Endoscopic specimen pouch technique maneuvered into the bag. The opening of the bag was everted outwardly through the incision, and the mass was morcellated with an empty sponge stick clamp and removed piecemeal, similar to the technique of a laparoscopic splenectomy. After removal of the mass, hemostasis was achieved, and the wound was closed in layers and dressed. The patient tolerated the procedure well and was taken to the recovery room in good condition. The gross examination and histopathologic features were consistent with a giant fibroadenoma with no atypical features and no evidence of phyllodes tumor. The patient was seen in the office 1 month after excision of the breast mass. Cosmesis and symmetry were both excellent with no postoperative complications. She is scheduled for routine follow-up in 6 months.
3. Case 3 A 15-year-old adolescent girl presented to the clinic with a left breast mass that was self-detected several months earlier. She denied pain, breast discharge, or systemic signs or symptoms. On physical examination, the left breast mass was found to be 10 cm in diameter, mobile, and nontender and located in the center of the breast. No axillary lymphadenopathy was detected. The patient arrived with an ultrasound from an outside institution, which described the mass as 9.7 cm in diameter with no aggressive features. Because of the large size of the mass in comparison with the size of the breast, a magnetic resonance imaging was performed to help plan the resection approach and for possible reconstruction if necessary. The magnetic resonance imaging revealed a 10.5-cm mass superficial to the pectoralis muscle, with features of a giant fibroadenoma or phyllodes tumor. In the operating room, a 4-cm periareolar incision was created along the superior aspect of the areolar margin. Using a hemostat, blunt dissection, and limited cautery, the wellencapsulated surface of the fibroadenoma was entirely dissected free from the surrounding breast tissue. At this point, multiple unsuccessful attempts were made to deliver the mobilized mass through of the surgical incision site. A 10-mm Endo Catch pouch was then inserted into the wound, and the mass was manipulated intact into the bag. In this particular case, because of the large size, the mass was more easily maneuvered into the bag after detachment from the supporting metal ring of the Endo Catch device. With the traction of the plastic bag, the mass was removed intact without the need for morcellation. Hemostasis was achieved, and the wound was closed in layers and dressed. The patient tolerated the procedure well and was taken to the recovery room in good condition. The gross examination and histopathologic features were consistent with a giant fibroadenoma with no atypical features and no evidence of phyllodes tumor.
805 The patient was seen in follow-up 1 month later with an excellent cosmetic outcome and symmetry between both breasts. She is scheduled for routine reexamination in 6 months.
4. Discussion Giant (juvenile or cellular) fibroadenomas usually present during puberty as an encapsulated, rapidly growing breast masses [10]. Giant fibroadenomas are usually unilateral, but in isolated cases, patients with bilateral giant fibroadenomas have been reported [11]. Breast enlargement can occur in as little as a few weeks [9], and the mass can double in size within 3 to 6 months [10,12], growing larger than the existing normal breast tissue [13]. Local recurrence is not common but can occur [9]. In general, surgical excision is recommended if the breast mass continues to grow or causes cosmetic concerns [14,15]. It is ideal to excise a giant fibroadenoma before the tumor mass expands to the point of causing venous congestion, glandular distortion, pressure necrosis, or ulceration [16]. Because these patients tend to be young and have not yet completed full breast development, cosmesis becomes an important consideration when choosing a method for resection. Aggressive biopsy, resection, or dissection in the developing breast bud may cause subsequent cosmetic deformity [17]. Furthermore, traditional breast surgical techniques may not only scar breast tissue and skin but also have the potential to cause long-lasting psychologic harm [14]. More aggressive procedures, such as mastectomy or wide local excision, are usually reserved for the management of previously confirmed breast carcinoma or phyllodes tumor. After excision of giant fibroadenomas, the normal breast tissue will typically re-expand and remodel to some degree [17]. Current minimally invasive techniques, such as ultrasound-guided, vacuum-assisted excision; radiofrequency ablation; and cryotherapy, are not able to effectively remove a mass as large as a giant fibroadenoma. Complete local excision with sparing of breast tissue is often the treatment modality of choice [1,2,18]. There are numerous surgical techniques that have been reported to excise a giant fibroadenoma. The conventional approach is to make an incision directly over the tumor [19,20]; however, this can leave a visible scar, which may cause pain during lactation and widen or become hypertrophic. Accordingly, recent techniques have focused on optimizing cosmesis. These surgical procedures include reduction mammoplasty; inframammary excision; Swiss roll technique using a circumareolar incision with progressive rolling and dissecting of the mass outwardly and through the surgical incision site; extramammary endoscopic excision; and the use of an endoscopic plastic bag [21], which is the technique used in the current report.
806 We find that this technique has advantages over other reported techniques. First, simply by having the tumor in the plastic Endocatch bag and with upward traction on the bag, we have found that the tumor can often be delivered from the surgical incision site without the need to extend the incision or for morcellation. The malleable and pliable nature of these tumors in combination with the “slippery” interface between the plastic bag and the surrounding fatty breast tissue makes this possible. Second, although we have used the Endocatch bag to deliver large (N10 cm) tumors through small surgical incision sites in this report (1.5-4 cm), our surgical goal is to use a minimal size incision (approximately 1 cm) that will accommodate just the size of the Endocatch bag. Because cosmesis is an important factor when removing a benign lesion, the smaller surgical incision used in this technique will enhance cosmetic outcome with this operation. Removal of a giant fibroadenoma mass through such a minimal incision would be very difficult, if at all possible, using any of the other reported techniques without an Endocatch bag. Third, this technique is superior to other techniques, which use a bag, because it does not require purchase of a non–Food and Drug Administration–approved “over the counter” bag, which requires sterilization before use in the surgical theater. In addition to being presterilized and already in use clinically, the Endocatch bag comes preloaded in a lowprofile (1 cm) deployment device. One potential concern of this technique is morcellating a tumor in the setting of the possibility of a very rare malignancy, such as a malignant phyllodes tumor. As a group, phyllodes tumors are rare, representing 1% of all breast tumors and 8% in patients younger than 20 years [22]. Malignant phyllodes tumors are even more rare occurrences, seen in a very small subset of patients with phyllodes tumors. Although phyllodes tumor is a rare diagnosis in the pediatric population, removal of this particular tumor via an Endocatch bag, with or without morcellation, would not necessarily alter the use of the bag. Postoperative histopathologic diagnosis of a phyllodes tumor would either prompt close observation for recurrence or, in the very rare case of a malignant phyllodes tumor, require a wide excision of the previous resection site with at least 2-cm margins—which most likely would mean a mastectomy in the pediatric patient. In addition, the presence of the tumor captured in the Endocatch bag would minimize spillage and contamination of the original resection site. Another operative option would be to perform an incisional or core biopsy of the specimen while isolated within the Endocatch bag. Subsequent frozen section should be able to readily differentiate a fibroadenoma from a phyllodes tumor. However, we would be unlikely to proceed with a more aggressive resection or mastectomy until final histopathologic analysis has been completed with confirmation of the preliminary frozen section diagnosis on examination of additional routinely processed tissue.
P.J. Cheng et al. Herein, we describe an endoscopic specimen pouch technique to assist delivery of fibroadenomas from their in situ locations. Through a cosmetic periareolar surgical incision, giant fibroadenomas that are several times the size of the incision can be safely extracted with the aid of a 10-mm endoscopic specimen pouch. In our experience, this technique is effective and easily performed and provides excellent cosmetic results in the pediatric population. In addition, the use of the bag could potentially protect against tumor and contamination of the resection site if morcellation is necessary. As such, we recommend this technique in the operative management of giant fibroadenomas.
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