Vacuum-assisted excision followed by minimal access surgery for a large fibroadenoma: lessons from a hybrid approach - a case report.

Introduction: Vacuum-assisted excision (VAE) and high-intensity focused ultrasound (HIFU) are minimally invasive alternatives to surgery for the treatment of breast fibroadenomas. While both methods are effective in selected cases, their utility in managing large fibroadenomas remains uncertain. This report highlights a case where both HIFU and VAE failed to achieve adequate treatment of a giant fibroadenoma, necessitating surgical excision. Presentation of Case: A 17-year-old girl patient presented with a large, palpable, mobile mass in the upper outer quadrant of the left breast, measuring approximately 9 × 8 cm on ultrasound. HIFU treatment performed several years prior failed to reduce the lesion's volume or relieve symptoms. VAE using the Brevera system (9-G, 20-mm aperture needle) was attempted, with 10 aspiration cycles and 120 tissue cores obtained. Post-procedural imaging showed only 15-20% volume reduction. Due to insufficient shrinkage, complete excision was performed through a periareolar incision. The postoperative course was uneventful, with good cosmetic outcome. Discussion: This case demonstrates the limitations of HIFU and VAE in the treatment of large, fibrotic fibroadenomas. While VAE failed to achieve full excision, the partial debulking allowed for a smaller, more aesthetic surgical approach. The sequential use of VAE followed by limited open excision may be considered in select patients to optimize cosmetic outcomes. Conclusion: VAE is a well-established, minimally invasive option for the management of small to medium-sized fibroadenomas. However, its effectiveness in lesions exceeding 3-4 cm is limited. This case highlights the potential role of VAE as an adjunctive tool in selected cases of large fibroadenomas, where volume reduction can optimize less invasive surgical approaches. Careful patient selection remains critical to procedural success.