49
Breast Disease 35 (2015) 49–52 DOI 10.3233/BD-140380 IOS Press
Case report
Cystic fibroadenoma: Report of a rare case with review of literature Amoolya Bhata,∗, C. Vijayaa and V.S. Shankare Gowdab a
Department of Pathology, Sapthagiri Institute of Medical Sciences and Research Centre, Bangalore, Karnataka, India b Department of Surgery, Sapthagiri Institute of Medical Sciences and Research Centre, Bangalore, Karnataka, India
Abstract. Fibroadenomas with a predominant cystic change are called cystic fibroadenomas. These are extremely rare forms of fibroadenomas and only one case has been reported so far. They are classified under the category of complex fibroadenomas. Complex fibroadenomas are a rare variant of fibroadenomas occurring in elderly females. They are characterized by presence of one of the complex features along with the usual patterns of fibroadenoma such as cysts more than 3 mm, papillary apocrine metaplasia, or sclerosing adenosis. Patients with these lesions have higher chances of developing carcinoma of breast. We present a case of 35 years old lady with a freely mobile mass in the left breast diagnosed as cystic fibroadenoma after thorough histopathological examination of the lesion. Keywords: Complex fibroadenoma, cystic fibroadenoma, cystic breast mass
1. Introduction
2. Case report
Cystic fibroadenomas are fibroadenomas with extensive cystic change. They are extremely rare and are grouped under complex fibroadenomas. Complex fibroadenomas are variants of fibroadenomas with one or more of the complex features like apocrine papillary metaplasia, cysts more than 3 mm, epithelial calcifications or sclerosing adenosis [1,2]. They constitute about 16–22% of fibroadenomas, however complex fibroadenomas with predominant cystic change are rare [1,2]. Only one case has been reported in the literature. We present a unique case of complex fibroadenoma with multiple cysts comprising almost 75% of the tumor.
A 35-year old lady presented with the chief complaints of painless slowly enlarging lump in the left breast since 8 months. There was no history of cyclical mastalgia or nipple discharge. The patient was nulliparous and was non pregnant at the time of presentation. There was no significant family history. On examination the skin, nipple and areola were unremarkable. Palpation revealed a non-tender freely mobile firm mass in the upper outer quadrant measuring about 3 × 3 cm. Cytological examination of the lesion was not performed. Based on the clinical diagnosis of fibroadenoma, simple excision of the lesion was done. Gross examination revealed a well-defined nodule measuring 3 × 2.5 × 2 cm. The external surface was glistening and grey-white. Few cystic nodules were discernible. Cut section was grey white and showed multiple cystic spaces ranging in size from 0.5–1 cm in diameter containing thin serous fluid (Fig. 1).
∗ Corresponding author: Amoolya Bhat, Department of Pathology, Sapthagiri Institute of Medical Sciences and Research Centre, #15, Chikkasandra, Hesaraghatta Main road, Bangalore-90, Karnataka, India. Tel.: +91 9480315066; E-mail: [email protected].
c 2015 – IOS Press and the authors. All rights reserved 0888-6008/15/$27.50
50
A. Bhat et al. / Cystic fibroadenoma
Fig. 1. Gross examination showing dilated cystic spaces and well defined margins on cut section.
The histopathological examination showed a partially encapsulated lesion (Fig. 2a) showing multiple cysts lined by flattened to cuboidal cells with round to oval small nuclei and inconspicuous nucleoli. The lumen showed eosinophilic proteinaceous material (Fig. 2b). The adjacent areas showed nodules of benign apocrine cells bearing round to oval nuclei and abundant eosinophilic granular cytoplasm arranged in delicate papillary pattern (Fig. 2c). Also noted were areas of typical fibroadenoma with both intracanalicular and pericanalicular pattern of proliferation of ductal and stromal elements (Fig. 2d). Epithelial hyperplasia, sclerosis, calcifications and atypia were not seen in any of the sections studied. Thus a histopathological diagnosis of complex fibroadenoma with predominant cystic change was provided.
3. Discussion Fibroadenoma is the most common benign neoplasm of the breast seen in women of reproductive age group displaying proliferation of both ductal and stromal elements. Several variants of fibroadenomas have been enumerated one of which is complex fibroadenoma [1,2]. Complex fibro adenomas are defined as fibroadenomas showing one or more of the following features: cysts more than 3 mm, sclerosing adenosis, epithelial calcification and or papillary apocrine metaplasia [1– 3]. Their exact incidence is unknown; they comprised 16% of all the fibroadenomas in one study [2].
In another study involving 396 cases of fibroadenoma, 28.0% cases showed complex features characterized by apocrine metaplasia [4]. They occur in slightly elderly age group when compared to simple fibroadenomas [1–5]. The relative risk of development of breast cancer is 1.89 times in females with noncomplex fibroadenomas, but with complex fibroadenoma the risk was 3.1 times that of women in general population [1–3]. Histopathologically complex fibroadenomas are well defined lesions showing areas of simple fibroadenoma characterized by proliferation of epithelial and stromal elements in either intra canalicular or pericanalicular pattern, myxoid change in the stroma along with one or more of the following features like sclerosing adenosis, papillary apocrine metaplasia, epithelial calcifications or cysts greater than 3 mm in diameter [1–4]. In our case the nodule was well defined and showed multiple cysts greater than 3 mm in diameter occupying 75% of the mass along with papillary apocrine metaplasia. The surrounding breast tissue showed areas of classical fibroadenoma. There was no proliferation of ductal elements, necrosis or atypia in the epithelial cells. The differential diagnoses of cystic lesions of breast include various benign, and malignant lesions. Benign lesions include fibrocystic disease of the breast, cystic fibroadenoma, cystic papilloma, post-operative cysts, hematoma, abscess, lactating adenoma, galactocoele, parasitic cysts and fat necrosis, atypical lesions include atypical papilloma, atypical ductal hyperplasia, atypical lobular hyperplasia, ductal carcinoma in situ, malignant conditions include cystic papillary carcinomas, infiltrating ductal carcinoma, and infiltrating lobular carcinoma [6]. Fibrocystic disease of the breast shows dilated duct lobular units lined by cuboidal to columnar cells or apocrine cells and myoepithelial cells having bland round to oval nuclei and eosinophilic secretary material in lumen. The adjacent breast shows fibrosis, sclerosing adenosis, duct ectasia and lymphoplasmacytic infiltrations. However the dimensions of the cysts are not more than 3 mm and the lesions are poorly circumscribed. In our case the nodule was well circumscribed and the cysts measured more than 3 mm in diameter [4]. Haematoma represents localized collection of blood in the parenchyma of breast commonly seen after trauma or surgery of breast [7].
A. Bhat et al. / Cystic fibroadenoma
51
Fig. 2. Histopathological sections showing. a) well defined margins of the tumor and large cystic spaces within the tumor(H&E;x40), b) dilated cystic spaces lined by apocrine cells containing proteinaceous fluid(H&E; x 100), c) foci of papillary apocrine metaplasia(H&Ex100), d) adjacent areas showing features of typical fibroadenoma (H&E;x400).
Abscess results from mastitis and shows central neutrophilic exudates and necrotic material surrounded by breast tissue with features of acute inflammation [7]. Fat necrosis develops after trauma to the breast or surgery and shows granulomas consisting of foamy histiocytes and foreign body giant cells [7]. Galactocoeles develop during lactation. They represent collections of milk resulting from obliteration of terminal ducts. The microscopic examination shows dilated ducts lined by dual layered epithelium bearing secretary changes. The lumen shows amorphous acellular material. Ruptured cysts may show foamy macrophages and foreign body giant cells in the adjacent breast tissue [7]. The various malignant and premalignant conditions show varying degrees of atypia, pleomorphism, increased mitosis in the ductal epithelial cells, necrosis and infiltrations into adjacent stroma along with cystic change, which was lacking in our case. Cytological features, mainly apocrine metaplastic cells, cyst macrophages, bare nuclei and antler horn patterns of ductal epithelial cells overlap with those of fibrocystic disease of breast and other benign proliferative lesions [8]. Mammography cannot detect cystic change in the lesions of breast [2]. Ultrasonography can identify cystic nature of nodules, however differentiating benign lesions from atypical lesions warrants
histopathological examination [9]. Thus histopathological examination is gold standard in diagnosing the complex fibroadenomas. Complex fibroadenoma may be associated carcinoma in situ and frank carcinomas. 50% of these tend to be lobular carcinoma in situ (LCIS), 20% infiltrating lobular carcinoma, 20% ductal carcinoma in situ (DCIS), and the remaining 10% are infiltrating ductal carcinoma [1]. Complex fibroadenomas can be managed conservatively in the absence of high risk lesions, but it should be monitored on mammography biannually for 2 years, and annually thereafter [1]. Simultaneous presence of atypical lesion mandates excisional biopsy, to exclude malignancy. Such patients require follow up [1]. The post-operative period of our patient was uneventful. There was no recurrence at the end of two months follow up.
4. Conclusions We have presented a rare case of cystic fibroadenoma. Fibroadenoma showing extensive cystic change is extremely rare. Only one case has been reported so far. These tumors fall under the category of complex
52
A. Bhat et al. / Cystic fibroadenoma
fibroadenoma. Women with this diagnosis have higher relative risk of developing carcinoma of breast than those with non-complex fibroadenoma. They require follow up.
References [1]
[2]
[3]
A.K. Kaler, A.N. Roopa, H. Subramanyam, S. Shariff, Kusuma, Evaluation complex fibroadenoma: A most neglected variant of Fibroadenoma, J Pharm Biomed Sci 30 (2013), S3639. M. Guray Durak, I. Karaman, T. Canda, P. Balci, O. Harmancıo˘glu, Cystic Fibroadenoma of the Breast: A Case Report, Turkish Journal of Pathology 27 (2011), 254-256. M. Sklair-Levy, T. Sella, T. Alweiss, I. Craciun, E. Libson, B. Mally, Incidence and management of complex fibroadenomas,
AJR 190 (2008), 214-218. [4] R. Jaiswal, U. Dwivedi, S. Ghaoghave, Unusual variants of fibroadenoma breast, Journal of Evolution of Medical and Dental Sciences 2 (2013), 3687-3691. [5] P.H. Tan, G. Tse, A. Lee, Fibroepithelial tumors, in: WHO classification of tumors of breast, S.R. Lakhani, I.O. Ellis, S.J. Schnitt, P.H. Tan, M.J. van de Vijver, eds, IARC, Lyon, 2012, pp. 142-143. [6] N. Hines, P.J . Slanetz, R.L. Eisenberg, Cystic masses of the breast, AJR 194 (2010), W122-133. [7] P.P. Rosen, Rosen’s Breast Pathology, (3rd ed), Philadelphia, Pa: Lippincott Williams & Wilkins,2009. [8] L.G. Koss, M.R. Melamed, eds, Koss’ Diagnostic Cytology and Its Histopathologic Bases, (5th ed), Philadephia, Pa: Lippincott Williams and Wilkins, 2005. [9] S. Pongrattanaman, J. Prueksadee, Sonographic-pathologic correlation of complex cystic breast lesions, Asian Pac J Trop Dis 3 (2013), 51-55.
Copyright of Breast Disease is the property of IOS Press and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Breast Disease 35 (2015) 49–52 DOI 10.3233/BD-140380 IOS Press
Case report
Cystic fibroadenoma: Report of a rare case with review of literature Amoolya Bhata,∗, C. Vijayaa and V.S. Shankare Gowdab a
Department of Pathology, Sapthagiri Institute of Medical Sciences and Research Centre, Bangalore, Karnataka, India b Department of Surgery, Sapthagiri Institute of Medical Sciences and Research Centre, Bangalore, Karnataka, India
Abstract. Fibroadenomas with a predominant cystic change are called cystic fibroadenomas. These are extremely rare forms of fibroadenomas and only one case has been reported so far. They are classified under the category of complex fibroadenomas. Complex fibroadenomas are a rare variant of fibroadenomas occurring in elderly females. They are characterized by presence of one of the complex features along with the usual patterns of fibroadenoma such as cysts more than 3 mm, papillary apocrine metaplasia, or sclerosing adenosis. Patients with these lesions have higher chances of developing carcinoma of breast. We present a case of 35 years old lady with a freely mobile mass in the left breast diagnosed as cystic fibroadenoma after thorough histopathological examination of the lesion. Keywords: Complex fibroadenoma, cystic fibroadenoma, cystic breast mass
1. Introduction
2. Case report
Cystic fibroadenomas are fibroadenomas with extensive cystic change. They are extremely rare and are grouped under complex fibroadenomas. Complex fibroadenomas are variants of fibroadenomas with one or more of the complex features like apocrine papillary metaplasia, cysts more than 3 mm, epithelial calcifications or sclerosing adenosis [1,2]. They constitute about 16–22% of fibroadenomas, however complex fibroadenomas with predominant cystic change are rare [1,2]. Only one case has been reported in the literature. We present a unique case of complex fibroadenoma with multiple cysts comprising almost 75% of the tumor.
A 35-year old lady presented with the chief complaints of painless slowly enlarging lump in the left breast since 8 months. There was no history of cyclical mastalgia or nipple discharge. The patient was nulliparous and was non pregnant at the time of presentation. There was no significant family history. On examination the skin, nipple and areola were unremarkable. Palpation revealed a non-tender freely mobile firm mass in the upper outer quadrant measuring about 3 × 3 cm. Cytological examination of the lesion was not performed. Based on the clinical diagnosis of fibroadenoma, simple excision of the lesion was done. Gross examination revealed a well-defined nodule measuring 3 × 2.5 × 2 cm. The external surface was glistening and grey-white. Few cystic nodules were discernible. Cut section was grey white and showed multiple cystic spaces ranging in size from 0.5–1 cm in diameter containing thin serous fluid (Fig. 1).
∗ Corresponding author: Amoolya Bhat, Department of Pathology, Sapthagiri Institute of Medical Sciences and Research Centre, #15, Chikkasandra, Hesaraghatta Main road, Bangalore-90, Karnataka, India. Tel.: +91 9480315066; E-mail: [email protected].
c 2015 – IOS Press and the authors. All rights reserved 0888-6008/15/$27.50
50
A. Bhat et al. / Cystic fibroadenoma
Fig. 1. Gross examination showing dilated cystic spaces and well defined margins on cut section.
The histopathological examination showed a partially encapsulated lesion (Fig. 2a) showing multiple cysts lined by flattened to cuboidal cells with round to oval small nuclei and inconspicuous nucleoli. The lumen showed eosinophilic proteinaceous material (Fig. 2b). The adjacent areas showed nodules of benign apocrine cells bearing round to oval nuclei and abundant eosinophilic granular cytoplasm arranged in delicate papillary pattern (Fig. 2c). Also noted were areas of typical fibroadenoma with both intracanalicular and pericanalicular pattern of proliferation of ductal and stromal elements (Fig. 2d). Epithelial hyperplasia, sclerosis, calcifications and atypia were not seen in any of the sections studied. Thus a histopathological diagnosis of complex fibroadenoma with predominant cystic change was provided.
3. Discussion Fibroadenoma is the most common benign neoplasm of the breast seen in women of reproductive age group displaying proliferation of both ductal and stromal elements. Several variants of fibroadenomas have been enumerated one of which is complex fibroadenoma [1,2]. Complex fibro adenomas are defined as fibroadenomas showing one or more of the following features: cysts more than 3 mm, sclerosing adenosis, epithelial calcification and or papillary apocrine metaplasia [1– 3]. Their exact incidence is unknown; they comprised 16% of all the fibroadenomas in one study [2].
In another study involving 396 cases of fibroadenoma, 28.0% cases showed complex features characterized by apocrine metaplasia [4]. They occur in slightly elderly age group when compared to simple fibroadenomas [1–5]. The relative risk of development of breast cancer is 1.89 times in females with noncomplex fibroadenomas, but with complex fibroadenoma the risk was 3.1 times that of women in general population [1–3]. Histopathologically complex fibroadenomas are well defined lesions showing areas of simple fibroadenoma characterized by proliferation of epithelial and stromal elements in either intra canalicular or pericanalicular pattern, myxoid change in the stroma along with one or more of the following features like sclerosing adenosis, papillary apocrine metaplasia, epithelial calcifications or cysts greater than 3 mm in diameter [1–4]. In our case the nodule was well defined and showed multiple cysts greater than 3 mm in diameter occupying 75% of the mass along with papillary apocrine metaplasia. The surrounding breast tissue showed areas of classical fibroadenoma. There was no proliferation of ductal elements, necrosis or atypia in the epithelial cells. The differential diagnoses of cystic lesions of breast include various benign, and malignant lesions. Benign lesions include fibrocystic disease of the breast, cystic fibroadenoma, cystic papilloma, post-operative cysts, hematoma, abscess, lactating adenoma, galactocoele, parasitic cysts and fat necrosis, atypical lesions include atypical papilloma, atypical ductal hyperplasia, atypical lobular hyperplasia, ductal carcinoma in situ, malignant conditions include cystic papillary carcinomas, infiltrating ductal carcinoma, and infiltrating lobular carcinoma [6]. Fibrocystic disease of the breast shows dilated duct lobular units lined by cuboidal to columnar cells or apocrine cells and myoepithelial cells having bland round to oval nuclei and eosinophilic secretary material in lumen. The adjacent breast shows fibrosis, sclerosing adenosis, duct ectasia and lymphoplasmacytic infiltrations. However the dimensions of the cysts are not more than 3 mm and the lesions are poorly circumscribed. In our case the nodule was well circumscribed and the cysts measured more than 3 mm in diameter [4]. Haematoma represents localized collection of blood in the parenchyma of breast commonly seen after trauma or surgery of breast [7].
A. Bhat et al. / Cystic fibroadenoma
51
Fig. 2. Histopathological sections showing. a) well defined margins of the tumor and large cystic spaces within the tumor(H&E;x40), b) dilated cystic spaces lined by apocrine cells containing proteinaceous fluid(H&E; x 100), c) foci of papillary apocrine metaplasia(H&Ex100), d) adjacent areas showing features of typical fibroadenoma (H&E;x400).
Abscess results from mastitis and shows central neutrophilic exudates and necrotic material surrounded by breast tissue with features of acute inflammation [7]. Fat necrosis develops after trauma to the breast or surgery and shows granulomas consisting of foamy histiocytes and foreign body giant cells [7]. Galactocoeles develop during lactation. They represent collections of milk resulting from obliteration of terminal ducts. The microscopic examination shows dilated ducts lined by dual layered epithelium bearing secretary changes. The lumen shows amorphous acellular material. Ruptured cysts may show foamy macrophages and foreign body giant cells in the adjacent breast tissue [7]. The various malignant and premalignant conditions show varying degrees of atypia, pleomorphism, increased mitosis in the ductal epithelial cells, necrosis and infiltrations into adjacent stroma along with cystic change, which was lacking in our case. Cytological features, mainly apocrine metaplastic cells, cyst macrophages, bare nuclei and antler horn patterns of ductal epithelial cells overlap with those of fibrocystic disease of breast and other benign proliferative lesions [8]. Mammography cannot detect cystic change in the lesions of breast [2]. Ultrasonography can identify cystic nature of nodules, however differentiating benign lesions from atypical lesions warrants
histopathological examination [9]. Thus histopathological examination is gold standard in diagnosing the complex fibroadenomas. Complex fibroadenoma may be associated carcinoma in situ and frank carcinomas. 50% of these tend to be lobular carcinoma in situ (LCIS), 20% infiltrating lobular carcinoma, 20% ductal carcinoma in situ (DCIS), and the remaining 10% are infiltrating ductal carcinoma [1]. Complex fibroadenomas can be managed conservatively in the absence of high risk lesions, but it should be monitored on mammography biannually for 2 years, and annually thereafter [1]. Simultaneous presence of atypical lesion mandates excisional biopsy, to exclude malignancy. Such patients require follow up [1]. The post-operative period of our patient was uneventful. There was no recurrence at the end of two months follow up.
4. Conclusions We have presented a rare case of cystic fibroadenoma. Fibroadenoma showing extensive cystic change is extremely rare. Only one case has been reported so far. These tumors fall under the category of complex
52
A. Bhat et al. / Cystic fibroadenoma
fibroadenoma. Women with this diagnosis have higher relative risk of developing carcinoma of breast than those with non-complex fibroadenoma. They require follow up.
References [1]
[2]
[3]
A.K. Kaler, A.N. Roopa, H. Subramanyam, S. Shariff, Kusuma, Evaluation complex fibroadenoma: A most neglected variant of Fibroadenoma, J Pharm Biomed Sci 30 (2013), S3639. M. Guray Durak, I. Karaman, T. Canda, P. Balci, O. Harmancıo˘glu, Cystic Fibroadenoma of the Breast: A Case Report, Turkish Journal of Pathology 27 (2011), 254-256. M. Sklair-Levy, T. Sella, T. Alweiss, I. Craciun, E. Libson, B. Mally, Incidence and management of complex fibroadenomas,
AJR 190 (2008), 214-218. [4] R. Jaiswal, U. Dwivedi, S. Ghaoghave, Unusual variants of fibroadenoma breast, Journal of Evolution of Medical and Dental Sciences 2 (2013), 3687-3691. [5] P.H. Tan, G. Tse, A. Lee, Fibroepithelial tumors, in: WHO classification of tumors of breast, S.R. Lakhani, I.O. Ellis, S.J. Schnitt, P.H. Tan, M.J. van de Vijver, eds, IARC, Lyon, 2012, pp. 142-143. [6] N. Hines, P.J . Slanetz, R.L. Eisenberg, Cystic masses of the breast, AJR 194 (2010), W122-133. [7] P.P. Rosen, Rosen’s Breast Pathology, (3rd ed), Philadelphia, Pa: Lippincott Williams & Wilkins,2009. [8] L.G. Koss, M.R. Melamed, eds, Koss’ Diagnostic Cytology and Its Histopathologic Bases, (5th ed), Philadephia, Pa: Lippincott Williams and Wilkins, 2005. [9] S. Pongrattanaman, J. Prueksadee, Sonographic-pathologic correlation of complex cystic breast lesions, Asian Pac J Trop Dis 3 (2013), 51-55.
Copyright of Breast Disease is the property of IOS Press and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
