Viewpoints Pseudoangiomatous Stromal Hyperplasia: A Rare Cause of Idiopathic Gigantomastia Adam J. Oppenheimer, MD Fiala Aesthetics Orlando, Fla. Daniel C. Oppenheimer, MD Department of Imaging Sciences, University of Rochester Rochester, N.Y. Thomas G. S. Fiala, MD Fiala Aesthetics, Altamonte Springs, Fla. Sharon Noori, MD Health First, Department of General Surgery, Holmes Regional Medical Center Melbourne, Fla.
Sir:
W
e read with interest Roy et al’s1 case report of a patient with pseudoangiomatous stromal hyperplasia (PASH) causing gigantomastia. We report a similar case in a 29-year-old woman with rapidly progressing macromastia (Fig. 1), who also complained of cyclical breast swelling and multiple palpable breast masses, with biopsy proven PASH. Although we commend the aesthetic result achieved by Roy et al1, we differ in our algorithm. Because of the propensity for PASH to recur and owing to its inherently diffuse involvement within the breast tissues, we opted for a more aggressive approach: bilateral Wise-pattern mastectomy with immediate tissue expander reconstruction. At the time of the mastectomy, several large (5–7 cm) discrete breast masses were identified, one of which was histopathologically consistent with a benign phyllodes tumor (a fibroepithelial stromal tumor with malignant potential). 2 Reconstruction proceeded using the Wise pattern: the lower pole of the breast was deepithelialized and used as soft-tissue reinforcement, reapproximating the dermal edge against the cut edge of the pectoralis major muscle, in place of an alloplastic dermal tissue matrix.3 Copyright © 2016 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons. All rights reserved. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially. Plast Reconstr Surg Glob Open 2016;4:e593; doi:10.1097/ GOX.0000000000000572; Published online 6 January 2016.
Fig. 1. Preoperative appearance of bilateral macromastia caused by PASH and phyllodes tumor of the right breast.
The patient’s expansion proceeded uneventfully, and no chemoradiation was recommended by the institutional tumor board. She underwent expander–implant exchange using 425-cc Sientra (Santa Barbara, Calif.) textured round base anatomic devices bilaterally and is without complications now 3 months postoperatively (Fig. 2). Although PASH is rare, and most commonly a benign clinical entity, there have been reports of malignancy arising within PASH.4 Indeed, in our patient, a phyllodes tumor was found as a synchronous mass. Although benign, this lesion does harbor malignant potential. Furthermore, recurrence rates up to 22% have been reported in the literature for PASH.5 Therefore, we feel that a more aggressive treatment plan is indicated when PASH is identified. Given the abundance of breast skin in these patients, a Wisepattern mastectomy with expander–implant based reconstruction is a viable and aesthetically pleasing option, which also obviates the burdensome need for ongoing oncological surveillance in these patients. Correspondence to Adam J. Oppenheimer, MD Fiala Aesthetics Orlando, FL [email protected]
DISCLOSURE The authors have no financial interest to declare in relation to the content of this article. The Article Processing Charge was paid for by the authors.
www.PRSGlobalOpen.com
1
PRS Global Open • 2016
Fig. 2. Postoperative appearance 3 months after second-stage reconstruction using Sientra round base 425-cc anatomic cohesive silicone gel breast implants. Wise-pattern mastectomy scar patterns can be visualized.
REFERENCES
1. Roy M, Lee J, Aldekhayel S, Dionisopoulos T. Pseudoangiomatous stromal hyperplasia: a rare cause of idiopathic gigantomastia. Plast Reconstr Surg Glob Open 2015;3:e501; DOI: 10.1097/GOX.0000000000000468. 2. Tan PH, Thike AA, Tan WJ, et al; Phyllodes Tumour Network Singapore. Predicting clinical behaviour of breast phyllodes tumours: a nomogram based on histological criteria and surgical margins. J Clin Pathol. 2012;65:69–76.
2
3. Prathap P, Harland RN. Wise pattern mastectomy with immediate breast reconstruction. Breast. 2004;13: 502–505. 4. Nassar H, Elieff MP, Kronz JD, et al. Pseudoangiomatous stromal hyperplasia (PASH) of the breast with foci of morphologic malignancy: a case of PASH with malignant transformation? Int J Surg Pathol. 2010;18:564–569. 5. Ryu EM, Whang IY, Chang ED. Rapidly growing bilateral pseudoangiomatous stromal hyperplasia of the breast. Korean J Radiol. 2010;11:355–358.
Sir:
W
e read with interest Roy et al’s1 case report of a patient with pseudoangiomatous stromal hyperplasia (PASH) causing gigantomastia. We report a similar case in a 29-year-old woman with rapidly progressing macromastia (Fig. 1), who also complained of cyclical breast swelling and multiple palpable breast masses, with biopsy proven PASH. Although we commend the aesthetic result achieved by Roy et al1, we differ in our algorithm. Because of the propensity for PASH to recur and owing to its inherently diffuse involvement within the breast tissues, we opted for a more aggressive approach: bilateral Wise-pattern mastectomy with immediate tissue expander reconstruction. At the time of the mastectomy, several large (5–7 cm) discrete breast masses were identified, one of which was histopathologically consistent with a benign phyllodes tumor (a fibroepithelial stromal tumor with malignant potential). 2 Reconstruction proceeded using the Wise pattern: the lower pole of the breast was deepithelialized and used as soft-tissue reinforcement, reapproximating the dermal edge against the cut edge of the pectoralis major muscle, in place of an alloplastic dermal tissue matrix.3 Copyright © 2016 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons. All rights reserved. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially. Plast Reconstr Surg Glob Open 2016;4:e593; doi:10.1097/ GOX.0000000000000572; Published online 6 January 2016.
Fig. 1. Preoperative appearance of bilateral macromastia caused by PASH and phyllodes tumor of the right breast.
The patient’s expansion proceeded uneventfully, and no chemoradiation was recommended by the institutional tumor board. She underwent expander–implant exchange using 425-cc Sientra (Santa Barbara, Calif.) textured round base anatomic devices bilaterally and is without complications now 3 months postoperatively (Fig. 2). Although PASH is rare, and most commonly a benign clinical entity, there have been reports of malignancy arising within PASH.4 Indeed, in our patient, a phyllodes tumor was found as a synchronous mass. Although benign, this lesion does harbor malignant potential. Furthermore, recurrence rates up to 22% have been reported in the literature for PASH.5 Therefore, we feel that a more aggressive treatment plan is indicated when PASH is identified. Given the abundance of breast skin in these patients, a Wisepattern mastectomy with expander–implant based reconstruction is a viable and aesthetically pleasing option, which also obviates the burdensome need for ongoing oncological surveillance in these patients. Correspondence to Adam J. Oppenheimer, MD Fiala Aesthetics Orlando, FL [email protected]
DISCLOSURE The authors have no financial interest to declare in relation to the content of this article. The Article Processing Charge was paid for by the authors.
www.PRSGlobalOpen.com
1
PRS Global Open • 2016
Fig. 2. Postoperative appearance 3 months after second-stage reconstruction using Sientra round base 425-cc anatomic cohesive silicone gel breast implants. Wise-pattern mastectomy scar patterns can be visualized.
REFERENCES
1. Roy M, Lee J, Aldekhayel S, Dionisopoulos T. Pseudoangiomatous stromal hyperplasia: a rare cause of idiopathic gigantomastia. Plast Reconstr Surg Glob Open 2015;3:e501; DOI: 10.1097/GOX.0000000000000468. 2. Tan PH, Thike AA, Tan WJ, et al; Phyllodes Tumour Network Singapore. Predicting clinical behaviour of breast phyllodes tumours: a nomogram based on histological criteria and surgical margins. J Clin Pathol. 2012;65:69–76.
2
3. Prathap P, Harland RN. Wise pattern mastectomy with immediate breast reconstruction. Breast. 2004;13: 502–505. 4. Nassar H, Elieff MP, Kronz JD, et al. Pseudoangiomatous stromal hyperplasia (PASH) of the breast with foci of morphologic malignancy: a case of PASH with malignant transformation? Int J Surg Pathol. 2010;18:564–569. 5. Ryu EM, Whang IY, Chang ED. Rapidly growing bilateral pseudoangiomatous stromal hyperplasia of the breast. Korean J Radiol. 2010;11:355–358.
