Scientific Letter
Giant breast fibroadenomas in adolescents: Diagnostic and therapeutic procedures
Fibroadenoma gigante de mama en adolescentes: procedimientos diagnóstico-terapéuticos
Beatriz Corredor Andrésa,b, María Márquez Riveraa,b, Fernando Lobo Bailónc, Beatriz González Melic, Daniel Azorín Cuadrillerod, María Teresa Muñoz Calvoa,b,e,f,
, Jesús Argentea,b,e,f,g
Corresponding author
a Servicio de Pediatría, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
b Servicio de Endocrinología, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
c Sección de Cirugía Plástica, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
d Servicio de Anatomía Patológica, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
e Departamento de Pediatría, Universidad Autónoma de Madrid, Madrid, Spain
f CIBER Fisiopatología de la Obesidad y Nutrición, Instituto de Salud Carlos III, Madrid, Spain
g IMDEA Instituto de Alimentación, CEI UAM+CSIC, Madrid, Spain
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=> "Dear Editor:" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "383" "paginaFinal" => "385" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Beatriz Corredor Andrés, María Márquez Rivera, Fernando Lobo Bailón, Beatriz González Meli, Daniel Azorín Cuadrillero, María Teresa Muñoz Calvo, Jesús Argente" "autores" => array:7 [ 0 => array:3 [ "nombre" => "Beatriz" "apellidos" => "Corredor Andrés" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 1 => array:3 [ "nombre" => "María" "apellidos" => "Márquez Rivera" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Fernando" 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"identificador" => "aff0025" ] 3 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">f</span>" "identificador" => "aff0030" ] 4 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 6 => array:3 [ "nombre" => "Jesús" "apellidos" => "Argente" "referencia" => array:5 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">e</span>" "identificador" => "aff0025" ] 3 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">f</span>" "identificador" => "aff0030" ] 4 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">g</span>" "identificador" => "aff0035" ] ] ] ] "afiliaciones" => array:7 [ 0 => array:3 [ "entidad" => "Servicio de Pediatría, Hospital Infantil Universitario Niño Jesús, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Endocrinología, Hospital Infantil Universitario Niño Jesús, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Sección de Cirugía Plástica, Hospital Infantil Universitario Niño Jesús, Madrid, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Servicio de Anatomía Patológica, Hospital Infantil Universitario Niño Jesús, Madrid, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Departamento de Pediatría, Universidad Autónoma de Madrid, Madrid, Spain" "etiqueta" => "e" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "CIBER Fisiopatología de la Obesidad y Nutrición, Instituto de Salud Carlos III, Madrid, Spain" "etiqueta" => "f" "identificador" => "aff0030" ] 6 => array:3 [ "entidad" => "IMDEA Instituto de Alimentación, CEI UAM<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>CSIC, Madrid, Spain" "etiqueta" => "g" "identificador" => "aff0035" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Fibroadenoma gigante de mama en adolescentes: procedimientos diagnóstico-terapéuticos" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1349 "Ancho" => 1000 "Tamanyo" => 527173 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">(A) Histological examination in case 3. Fibroepithelial proliferation with areas of pericanalicular and intracanalicular growth. No evidence of marked stromal growth, fat infiltration or cleft-like spaces. (B) Detail of <a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>A (H&E stain, 4×), showing a mildly hyperplastic epithelium and a stroma without cytological atypia or mitotic activity.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Breast masses are rare in girls and female adolescents, and they exceptionally have a malignant aetiology. The most frequent diagnosis in these masses is juvenile fibroadenoma. When its size exceeds 5<span class="elsevierStyleHsp" style=""></span>cm, it is called giant fibroadenoma (GFA), a large-sized benign tumour with rapid growth. The differential diagnosis of GFA includes inflammatory processes, benign proliferative lesions and phyllodes tumour.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,2</span></a> Due to the lack of specific clinical guidelines for its correct diagnosis and treatment, the management of breast masses may pose difficulties.</p><p id="par0010" class="elsevierStylePara elsevierViewall">We conducted a retrospective study of the breast masses larger than 5<span class="elsevierStyleHsp" style=""></span>cm managed between 2000 and 2017 in a paediatric hospital. We collected data on the clinical characteristics and the diagnostic tests and treatment used in each case. The data was retrieved from the health records adhering to the protocols established by the hospital.</p><p id="par0015" class="elsevierStylePara elsevierViewall">We present 4 cases of macromastia in patients with a median age of 15.3 years (range, 11.9–16.2), at Tanner stage 5 of pubertal development that sought care after developing a unilateral breast mass that was painless and growing quickly. On physical examination, the masses were painless, mobile, unattached to deeper tissues and with hypervascularization at the skin level (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A). None of the patients had nipple discharge or local lymphadenopathy.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Sonographic examination of the breast revealed hypoechoic, lobulated masses with well-defined margins, in cases 1 and 3 with superficial hypervascularization. The findings in all patients were compatible with GFA or phyllodes tumour. The assessment of cases 1 and 4 included an MRI examination that revealed heterogeneous lesions that appeared isointense and hypointense on T1-weighted images and hyperintense on T2-weighted images, with no signs of infiltration. The radiological findings were not conclusive.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The diagnosis of GFA was confirmed after excision of the masses (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>); the maximum tumour diameter ranged between 5 and 14.5<span class="elsevierStyleHsp" style=""></span>cm and the mean weight was 1500<span class="elsevierStyleHsp" style=""></span>g. The surgical technique used in cases 1, 2, and 3 was simple excision (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B). In case 4, excision was followed by placement of a filled tissue expander that was emptied gradually with the purpose of helping the skin recover its elasticity progressively. We ought to mention that none of the patient experienced postoperative complications and all had good outcomes.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> presents the clinical characteristics, radiological and pathological findings and final diagnosis for each case.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Giant fibroadenomas are masses characterised by a diameter of more than 5<span class="elsevierStyleHsp" style=""></span>cm and rapid growth, and they are an infrequent type of fibroadenoma that accounts for 0.5–2% of the total cases.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1–3</span></a> Their aetiology is unknown, although it has been hypothesised that they may be caused by increased sensitivity to oestrogen.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> In most cases, the mass develops during pubertal development around the time of menarche. This could be explained by the high cellular activity of the lobules from the onset of puberty to approximately age 25 years.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4,5</span></a> The patients in our study were aged less than 17 years, which was consistent with the description of Sosin et al.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The differential diagnosis of GFA includes inflammatory processes, benign proliferative lesions (hamartoma, lipoma, virginal or juvenile hypertrophy of the breast and pseudoangiomatous stromal hyperplasia [PASH]) and phyllodes tumour.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2,3</span></a> The main diagnosis that needs to be excluded is phyllodes tumour, which corresponds to fewer than 1% of all breast tumours. Its clinical and sonographic features may be indistinguishable from those of GFA and even virginal hypertrophy or PASH. Virginal hypertrophy is characterised by a rapid growth of breast tissue due to hypersensitivity to estrogens.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> In very rare cases, breast masses correspond to lipoma, hamartoma or PASH.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4–6</span></a> The histological differential diagnosis includes virginal hypertrophy of the breast, breast hamartoma and, most importantly, phyllodes tumour. Fine-needle puncture aspiration biopsy is not useful to discriminate between these diseases. It is extremely difficult to distinguish GFA and phyllodes tumour in a core needle biopsy (CNB), and one study found that up to 25% of phyllodes tumours had initially been classified as fibroadenomas based on the CNB histology.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> Some authors have proposed histological features that would indicate surgical excision: increased stromal cellularity compared to a conventional fibroadenoma in more than 50% of the submitted tissue sample, stromal overgrowth viewed in a 10× microscopic field, stromal fragmentation and entrapment of fat in the lesion.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Ultrasound is the first-line imaging test for assessment of a breast mass during adolescence. Fibroadenomas appear as a round or oval mass, isoechoic or hypoechoic and with well-defined borders. Doppler ultrasound reveals hypervascularization in up to 80% of cases, and was found in 50% of our patients. The sonographic appearance may be the same in cases of virginal hypertrophy, PASH or phyllodes tumour, which calls for histological examination in masses larger than 5<span class="elsevierStyleHsp" style=""></span>cm or exhibiting rapid growth.<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">7–9</span></a> Magnetic resonance imaging of the breast is not used routinely. However, it may be useful to define the lesion better before surgery.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">The treatment of fibroadenomas depends mainly on their size. For those with a diameter of less than 5<span class="elsevierStyleHsp" style=""></span>cm in adolescents, treatment is conservative, as the risk of malignancy is nearly non-existent in the group aged less than 20 years. In cases of suspected GFA, complete excision of the mass is indicated for gross and histological examination, as GFA cannot be differentiated from some other masses, mainly phyllodes tumour, based on the clinical presentation and radiological features.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">If possible, surgery must spare healthy breast tissue and the nipple-areolar complex. Based on our results and the evidence published in the literature, simple excision, where the case allows it, is the treatment of choice on account of the low rate of postsurgical complications and the excellent cosmetic outcomes.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">In conclusion, ultrasound is the first-line imaging test for assessment of a mass in the breast, and a full gross and histological examination is necessary in masses with diameters of more than 5<span class="elsevierStyleHsp" style=""></span>cm and/or exhibiting rapid growth, as fine needle aspiration and core needle biopsies are not useful in this type of lesion. The surgical treatment of choice is simple excision.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Corredor Andrés B, Márquez Rivera M, Lobo Bailón F, González Meli B, Azorín Cuadrillero D, Muñoz Calvo MT, et al. Fibroadenoma gigante de mama en adolescentes: procedimientos diagnóstico-terapéuticos. An Pediatr (Barc). 2018;89:381–383.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1077 "Ancho" => 1000 "Tamanyo" => 114859 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) Breast tumour in case 1 before surgery. (B) Outcome after simple excision of the tumour.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1349 "Ancho" => 1000 "Tamanyo" => 527173 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">(A) Histological examination in case 3. Fibroepithelial proliferation with areas of pericanalicular and intracanalicular growth. No evidence of marked stromal growth, fat infiltration or cleft-like spaces. (B) Detail of <a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>A (H&E stain, 4×), showing a mildly hyperplastic epithelium and a stroma without cytological atypia or mitotic activity.</p>" ] ] 2 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">CNB, core needle biopsy; FNAB, fine needle aspiration biopsy; GFA, giant fibroadenoma.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Case \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Race \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Age (years) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Time elapsed from onset (months) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Localisation \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Suspected diagnosis after ultrasound \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Diagnosis after FNAB<span class="elsevierStyleSup">a</span>/CNB<span class="elsevierStyleSup">b</span> Excisional biopsy<span class="elsevierStyleSup">c</span> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Type of surgery \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Gross tumour volume (cm) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Final diagnosis after analysis of specimen \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Caucasian \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Unilateral \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">GFA/phyllodes tumour \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Virginal breast hypertrophy<span class="elsevierStyleSup">c</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Simple excision \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">14.5<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>11.5<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">GFA \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Caucasian \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">16.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Not documented \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Unilateral \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">GFA/phyllodes tumour \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">GFA<span class="elsevierStyleSup">a</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Simple excision \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>4<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">GFA \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Caucasian \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Unilateral \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">GFA/phyllodes tumour \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">GFA<span class="elsevierStyleSup">b</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Simple excision \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>8<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>8.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">GFA \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Black \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">24 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Unilateral \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">GFA/phyllodes tumour \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">GFA<span class="elsevierStyleSup">a</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Simple excision + tissue expansion \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">GFA \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1912026.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Clinical, radiological and gross and histological characteristics of the cases.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" 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| Year/Month | Html | Total | |
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| 2020 September | 39 | 19 | 58 |
| 2020 August | 51 | 7 | 58 |
| 2020 July | 47 | 18 | 65 |
| 2020 June | 40 | 10 | 50 |
| 2020 May | 41 | 19 | 60 |
| 2020 April | 27 | 23 | 50 |
| 2020 March | 32 | 22 | 54 |
| 2020 February | 34 | 12 | 46 |
| 2020 January | 41 | 15 | 56 |
| 2019 December | 44 | 25 | 69 |
| 2019 November | 30 | 10 | 40 |
| 2019 October | 54 | 12 | 66 |
| 2019 September | 28 | 19 | 47 |
| 2019 August | 34 | 21 | 55 |
| 2019 July | 31 | 34 | 65 |
| 2019 June | 24 | 19 | 43 |
| 2019 May | 46 | 23 | 69 |
| 2019 April | 64 | 48 | 112 |
| 2019 March | 21 | 10 | 31 |
| 2019 February | 35 | 26 | 61 |
| 2019 January | 42 | 13 | 55 |
| 2018 December | 137 | 39 | 176 |
| 2018 November | 18 | 6 | 24 |
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