Novel Insights from Clinical Practice Gynecol Obstet Invest 2014;77:134–136 DOI: 10.1159/000357443
Received: August 26, 2013 Accepted after revision: November 20, 2013 Published online: February 5, 2014
Giant Fibroadenomatoid Hyperplasia of the Breast: A Case Report Hao Zhang Xin-Lu Wang Wei-Dong Ren Tie-Mei Shi Ultrasound Department, Shengjing Hospital, China Medical University, Shenyang, China
Established Facts • Already known fact 1: Fibroadenomatoid hyperplasia of the breast (FAHB) is a rare benign breast lesion and its clinical features are similar to fibroadenoma and fibrocystic changes. • Already known fact 2: FAHB could be present as a localized or diffused pattern in pathology. Most cases show no well-circumscribed mass lesions and no apparent capsules; it is usually identified as an incidental finding in other benign lesions or in random sampling in cancerous breast tissues.
Novel Insights • New information 1: The authors believe this study may be the first case with two giant masses reported. • New information 2: Comparative MRI ultrasound analysis will help make the differential diagnosis. • New information 3: FAHB should be differentiated from fibroadenoma and malignant lesions.
Key Words Fibroadenomatoid hyperplasia · Proliferative breast disease · Fibroadenomatoid change · Intraductal hyperplasia · Breast pathology
Abstract Fibroadenomatoid hyperplasia of the breast (FAHB) is a rare benign breast lesion and its clinical features are similar to fibroadenoma and fibrocystic changes. FAHB has been previously termed sclerosing lobular hyperplasia, fibroadenomatosis, fibroadenomatoid change, or fibroadenomatoid mastopathy. Typically, FAHB is derived from stroma and epithelia. The pathologic characteristics of FAHB are microfocal lobulocentric proliferation of stroma accompanied by epi-
thelial and myoepithelial components resembling similar histological changes, as found in fibroadenoma, apocrine hyperplasia, intraductal hyperplasia, and lobular hyperplasia. FAHB could be present as a localized or diffused pattern in pathology. Most cases show no well-circumscribed mass lesions and no apparent capsules; it is usually identified as an incidental finding in other benign lesions or in random sampling in cancerous breast tissues. FAHB is categorized as a benign proliferative breast disease and it has previously been reported; however, the authors believe this study may be the first case with two giant masses reported. Fiber adenoma hyperplasia is a rare cystic hyperplasia of breast pathology and its ultrasonographic manifestations are easily confused with breast cancer. Comparative MRI ultrasound analysis will help make the differential diagnosis. © 2014 S. Karger AG, Basel
© 2014 S. Karger AG, Basel 0378–7346/14/0772–0134$39.50/0 E-Mail [email protected] www.karger.com/goi
Dr. Tie-Mei Shi Ultrasound Department, 4F, Building No. 1B Shengjing Hospital, China Medical University 36 Sanhao Street, Shenyang 110004 (China) E-Mail shitm @ sj-hospital.org
Introduction
Fibroadenomatoid hyperplasia of the breast (FAHB) is a rare benign breast lesion and its clinical features are similar to fibroadenoma and fibrocystic changes. In the early 1930s, Cheatle and Cutler [1] first introduced the term ‘mazoplasia’ to describe bilateral painful nodular breasts and suggested that it is present to a certain degree in almost all women’s breasts. FAHB has been previously termed sclerosing lobular hyperplasia, fibroadenomatosis, fibroadenomatoid change, or fibroadenomatoid mastopathy [2]. Typically, FAHB is derived from stroma and epithelia. The pathologic characteristics of FAHB are microfocal lobulocentric proliferation of stroma accompanied by epithelial, and myoepithelial components resembling similar histological changes, as found in fibroadenoma, apocrine hyperplasia, intraductal hyperplasia, and lobular hyperplasia. FAHB could be present as a localized or diffused pattern in pathology. Most cases show no well-circumscribed mass lesions and no apparent capsules; it is usually identified as an incidental finding in other benign lesions or in random sampling in cancerous breast tissues. FAHB is categorized as a benign proliferative breast disease. FAHB has been reported previously [3], however, the authors believe this study may be the first case with two giant masses reported.
Fig. 1. Two-dimensional ultrasound. A large mass with a relatively clear boundary; hypoechoic internal echoes with strong signals in the diameter of 0.07 cm.
Case Report A 24-year-old female came to our clinic with the chief complaint of a mass (fingernail size) identified in her left breast 3 days earlier. There was no obvious pain, redness, swollen skin, or discomfort reported. Only mild swelling and pain occurred before her menstrual cycle. Physical Examination Findings. Both breasts were symmetric; a tender mass of approximately 8 × 7 cm was identified in the right upper quadrant from the root of the right-side nipple. There was no clear boarder line and no pain with pressure. A relatively solid mass of about 7 × 7 cm was identified on the root of the left-side nipple with a flat, irregular shape and an unclear boarder line. There was no redness on the skin’s surface of both breasts. Color Doppler ultrasound scan revealed that both sides of the mammary glands were coarse heterogeneous. The mass of 5.5 × 5.3 × 1.8 cm was detected in the root area of the left nipple, and a mass of 7.3 × 5.1 × 1.6 cm was identified in the root area of the right nipple. The border line of the mass was clear, with no obvious fibrous capsule. The hypoechoic pattern was detected in the inner area of the mass, with scattered dots of a hyperechoic pattern. The biggest size was about 0.1 cm in diameter (fig. 1). Color Doppler Flow Imaging (CDFI) Findings. CDFI showed abundant blood flow signals in the mass, and the resistance index (RI) value was 0.73. A hypoechoic pattern was found in the mass, with a clear border line. Both sides of the axillary lymph nodes were
examined by CDFI, which showed a mass of 0.8 × 0.6 cm on the left side and a mass of 1.7 × 0.7 cm on the right side. The masses were well defined with a hyperechoic hilum and hypoechoic cortex. MRI Findings. MRI showed no evidence of obvious space-occupying lesions (fig. 2). Histopathology Findings. Hyperplasia was found in the ductal region, with stromal fibrous tissues forming dilated ducts, suggesting that it was fibroadenomatoid hyperplasia (fig. 3).
Fibroadenomatoid Hyperplasia of the Breast
Gynecol Obstet Invest 2014;77:134–136 DOI: 10.1159/000357443
Fig. 2. MRI shows no evidence of obvious space-occupying lesions.
135
Color version available online
Fig. 3. Frozen section: in the ductal area, stromal fibrous tissues with dilated ducts.
Discussion
FAHB is a well-described but rare benign breast lesion, usually accompanied with similar features of fibroadenoma and fibrocystic changes [4]. The mean age of patients diagnosed with FAHB is 36.6 years, based on several reports [5]. Our patient was much younger (24 years) than this average age, and the mass sizes were much larger than most reported cases that were usually identified with scattered masses. FAHB should be differentially diagnosed from fibroadenoma. The latter is the most common benign breast tumor in women under the age of 30 years and usually exhibits as a single lump. About 10–15% of women have several lumps that may affect both breasts. The lumps may be easily moveable under the skin, firm, painless, rubbery, and smooth, with or without well-defined borders. The classical presentation of a fibroadenoma on sonography is an elliptical or gently lobulated mass with aspect ratio 1 and has spiculated margins with posterior echo attenuation and microcalcifications. Breast malignancies have higher RIs than those of benign lesions (RI >0.7 was considered as high resistance). Although the RI of our patient was 0.73, the well-defined masses with scattered dots of hyperechoic pattern and the lack of microcalcifications helped us to make a diagnosis of a non-malignant lesion. Mammography is the established gold standard for breast cancer screening and diagnosis. It is relatively easier to evaluate the results in older women than that in younger women. This is because the older women’s breasts tend to be fattier, while the younger women’s breasts tend to be dense and full of mammary glands. MRI may have a higher diagnostic value in the diagnosis of mammary gland malignant diseases, compared with benign diseases [7, 8]. An ultrasound offers a diagnostic advantage to mammography or clinical examination in detecting benign cases of breast diseases. An ultrasound is particularly useful in differentiating between cysts and solid masses in palpable breast masses [9]. Our case also supports the notion that, before a final histopathologic confirmation from a biopsy is performed, using an ultrasound as a differential and diagnostic tool for the detection of fibroadenomatoid hyperplasia is valuable and recommended in clinical practice.
References 1 Cheatle GL, Cutler M: Desquamative epithelial hyperplasia: mazoplasia; in Tumors of the Breast. London, Arnold, 1931, pp 77–91. 2 Liu TH: Diagnostic Pathology. Beijing, People’s Medical Publishing House, 1994, pp 566–572. 3 Wu LS, Chen AY: Ultrasound analysis of fibroadenomatoid hyperplasia of the breast (in Chinese). Chin J Ultrasound Diagn 2001; 2: 71–73. 4 Kamal M, Evans AJ, Denley H, Pinder SE, Ellis IO: Fibroadenomatoid hyperplasia: a cause
136
of suspicious microcalcification on mammographic screening. AJR Am J Roentgenol 1998;171:1331–1334. 5 Yi MG, Hwang MS, Lee JK, Park BH: US findings of fibroadenomatoid hyperplasia of the breast. J Korean Soc Med Ultrasound 2000;19: 197–201. 6 Scholl C: Sonographic features of benign breast masses: a case review. eRADIMAGING 2009;19. 7 Occhionero M, Restaino G, Ciuffreda M, Carbone A, Sallustio G, Ferrandina G: Uterine inver-
Gynecol Obstet Invest 2014;77:134–136 DOI: 10.1159/000357443
sion in association with uterine sarcoma: a case report with MRI findings and review of the literature. Gynecol Obstet Invest 2012;73:260–264. 8 Perez-Medina T, Orensanz I, Pereira A, Valero de Bernabé J, Engels V, Troyano J, SanFrutos L, Iglesias E: Three-dimensional angioultrasonography for the prediction of malignancy in ovarian masses. Gynecol Obstet Invest 2013;75:120–125. 9 Sickles EA, Filly RA, Callen PW: Benign breast lesions: ultrasound detection and diagnosis. Radiology 1984;151:467–470.
Zhang/Wang/Ren/Shi
Copyright: S. Karger AG, Basel 2014. Reproduced with the permission of S. Karger AG, Basel. Further reproduction or distribution (electronic or otherwise) is prohibited without permission from the copyright holder.
Received: August 26, 2013 Accepted after revision: November 20, 2013 Published online: February 5, 2014
Giant Fibroadenomatoid Hyperplasia of the Breast: A Case Report Hao Zhang Xin-Lu Wang Wei-Dong Ren Tie-Mei Shi Ultrasound Department, Shengjing Hospital, China Medical University, Shenyang, China
Established Facts • Already known fact 1: Fibroadenomatoid hyperplasia of the breast (FAHB) is a rare benign breast lesion and its clinical features are similar to fibroadenoma and fibrocystic changes. • Already known fact 2: FAHB could be present as a localized or diffused pattern in pathology. Most cases show no well-circumscribed mass lesions and no apparent capsules; it is usually identified as an incidental finding in other benign lesions or in random sampling in cancerous breast tissues.
Novel Insights • New information 1: The authors believe this study may be the first case with two giant masses reported. • New information 2: Comparative MRI ultrasound analysis will help make the differential diagnosis. • New information 3: FAHB should be differentiated from fibroadenoma and malignant lesions.
Key Words Fibroadenomatoid hyperplasia · Proliferative breast disease · Fibroadenomatoid change · Intraductal hyperplasia · Breast pathology
Abstract Fibroadenomatoid hyperplasia of the breast (FAHB) is a rare benign breast lesion and its clinical features are similar to fibroadenoma and fibrocystic changes. FAHB has been previously termed sclerosing lobular hyperplasia, fibroadenomatosis, fibroadenomatoid change, or fibroadenomatoid mastopathy. Typically, FAHB is derived from stroma and epithelia. The pathologic characteristics of FAHB are microfocal lobulocentric proliferation of stroma accompanied by epi-
thelial and myoepithelial components resembling similar histological changes, as found in fibroadenoma, apocrine hyperplasia, intraductal hyperplasia, and lobular hyperplasia. FAHB could be present as a localized or diffused pattern in pathology. Most cases show no well-circumscribed mass lesions and no apparent capsules; it is usually identified as an incidental finding in other benign lesions or in random sampling in cancerous breast tissues. FAHB is categorized as a benign proliferative breast disease and it has previously been reported; however, the authors believe this study may be the first case with two giant masses reported. Fiber adenoma hyperplasia is a rare cystic hyperplasia of breast pathology and its ultrasonographic manifestations are easily confused with breast cancer. Comparative MRI ultrasound analysis will help make the differential diagnosis. © 2014 S. Karger AG, Basel
© 2014 S. Karger AG, Basel 0378–7346/14/0772–0134$39.50/0 E-Mail [email protected] www.karger.com/goi
Dr. Tie-Mei Shi Ultrasound Department, 4F, Building No. 1B Shengjing Hospital, China Medical University 36 Sanhao Street, Shenyang 110004 (China) E-Mail shitm @ sj-hospital.org
Introduction
Fibroadenomatoid hyperplasia of the breast (FAHB) is a rare benign breast lesion and its clinical features are similar to fibroadenoma and fibrocystic changes. In the early 1930s, Cheatle and Cutler [1] first introduced the term ‘mazoplasia’ to describe bilateral painful nodular breasts and suggested that it is present to a certain degree in almost all women’s breasts. FAHB has been previously termed sclerosing lobular hyperplasia, fibroadenomatosis, fibroadenomatoid change, or fibroadenomatoid mastopathy [2]. Typically, FAHB is derived from stroma and epithelia. The pathologic characteristics of FAHB are microfocal lobulocentric proliferation of stroma accompanied by epithelial, and myoepithelial components resembling similar histological changes, as found in fibroadenoma, apocrine hyperplasia, intraductal hyperplasia, and lobular hyperplasia. FAHB could be present as a localized or diffused pattern in pathology. Most cases show no well-circumscribed mass lesions and no apparent capsules; it is usually identified as an incidental finding in other benign lesions or in random sampling in cancerous breast tissues. FAHB is categorized as a benign proliferative breast disease. FAHB has been reported previously [3], however, the authors believe this study may be the first case with two giant masses reported.
Fig. 1. Two-dimensional ultrasound. A large mass with a relatively clear boundary; hypoechoic internal echoes with strong signals in the diameter of 0.07 cm.
Case Report A 24-year-old female came to our clinic with the chief complaint of a mass (fingernail size) identified in her left breast 3 days earlier. There was no obvious pain, redness, swollen skin, or discomfort reported. Only mild swelling and pain occurred before her menstrual cycle. Physical Examination Findings. Both breasts were symmetric; a tender mass of approximately 8 × 7 cm was identified in the right upper quadrant from the root of the right-side nipple. There was no clear boarder line and no pain with pressure. A relatively solid mass of about 7 × 7 cm was identified on the root of the left-side nipple with a flat, irregular shape and an unclear boarder line. There was no redness on the skin’s surface of both breasts. Color Doppler ultrasound scan revealed that both sides of the mammary glands were coarse heterogeneous. The mass of 5.5 × 5.3 × 1.8 cm was detected in the root area of the left nipple, and a mass of 7.3 × 5.1 × 1.6 cm was identified in the root area of the right nipple. The border line of the mass was clear, with no obvious fibrous capsule. The hypoechoic pattern was detected in the inner area of the mass, with scattered dots of a hyperechoic pattern. The biggest size was about 0.1 cm in diameter (fig. 1). Color Doppler Flow Imaging (CDFI) Findings. CDFI showed abundant blood flow signals in the mass, and the resistance index (RI) value was 0.73. A hypoechoic pattern was found in the mass, with a clear border line. Both sides of the axillary lymph nodes were
examined by CDFI, which showed a mass of 0.8 × 0.6 cm on the left side and a mass of 1.7 × 0.7 cm on the right side. The masses were well defined with a hyperechoic hilum and hypoechoic cortex. MRI Findings. MRI showed no evidence of obvious space-occupying lesions (fig. 2). Histopathology Findings. Hyperplasia was found in the ductal region, with stromal fibrous tissues forming dilated ducts, suggesting that it was fibroadenomatoid hyperplasia (fig. 3).
Fibroadenomatoid Hyperplasia of the Breast
Gynecol Obstet Invest 2014;77:134–136 DOI: 10.1159/000357443
Fig. 2. MRI shows no evidence of obvious space-occupying lesions.
135
Color version available online
Fig. 3. Frozen section: in the ductal area, stromal fibrous tissues with dilated ducts.
Discussion
FAHB is a well-described but rare benign breast lesion, usually accompanied with similar features of fibroadenoma and fibrocystic changes [4]. The mean age of patients diagnosed with FAHB is 36.6 years, based on several reports [5]. Our patient was much younger (24 years) than this average age, and the mass sizes were much larger than most reported cases that were usually identified with scattered masses. FAHB should be differentially diagnosed from fibroadenoma. The latter is the most common benign breast tumor in women under the age of 30 years and usually exhibits as a single lump. About 10–15% of women have several lumps that may affect both breasts. The lumps may be easily moveable under the skin, firm, painless, rubbery, and smooth, with or without well-defined borders. The classical presentation of a fibroadenoma on sonography is an elliptical or gently lobulated mass with aspect ratio 1 and has spiculated margins with posterior echo attenuation and microcalcifications. Breast malignancies have higher RIs than those of benign lesions (RI >0.7 was considered as high resistance). Although the RI of our patient was 0.73, the well-defined masses with scattered dots of hyperechoic pattern and the lack of microcalcifications helped us to make a diagnosis of a non-malignant lesion. Mammography is the established gold standard for breast cancer screening and diagnosis. It is relatively easier to evaluate the results in older women than that in younger women. This is because the older women’s breasts tend to be fattier, while the younger women’s breasts tend to be dense and full of mammary glands. MRI may have a higher diagnostic value in the diagnosis of mammary gland malignant diseases, compared with benign diseases [7, 8]. An ultrasound offers a diagnostic advantage to mammography or clinical examination in detecting benign cases of breast diseases. An ultrasound is particularly useful in differentiating between cysts and solid masses in palpable breast masses [9]. Our case also supports the notion that, before a final histopathologic confirmation from a biopsy is performed, using an ultrasound as a differential and diagnostic tool for the detection of fibroadenomatoid hyperplasia is valuable and recommended in clinical practice.
References 1 Cheatle GL, Cutler M: Desquamative epithelial hyperplasia: mazoplasia; in Tumors of the Breast. London, Arnold, 1931, pp 77–91. 2 Liu TH: Diagnostic Pathology. Beijing, People’s Medical Publishing House, 1994, pp 566–572. 3 Wu LS, Chen AY: Ultrasound analysis of fibroadenomatoid hyperplasia of the breast (in Chinese). Chin J Ultrasound Diagn 2001; 2: 71–73. 4 Kamal M, Evans AJ, Denley H, Pinder SE, Ellis IO: Fibroadenomatoid hyperplasia: a cause
136
of suspicious microcalcification on mammographic screening. AJR Am J Roentgenol 1998;171:1331–1334. 5 Yi MG, Hwang MS, Lee JK, Park BH: US findings of fibroadenomatoid hyperplasia of the breast. J Korean Soc Med Ultrasound 2000;19: 197–201. 6 Scholl C: Sonographic features of benign breast masses: a case review. eRADIMAGING 2009;19. 7 Occhionero M, Restaino G, Ciuffreda M, Carbone A, Sallustio G, Ferrandina G: Uterine inver-
Gynecol Obstet Invest 2014;77:134–136 DOI: 10.1159/000357443
sion in association with uterine sarcoma: a case report with MRI findings and review of the literature. Gynecol Obstet Invest 2012;73:260–264. 8 Perez-Medina T, Orensanz I, Pereira A, Valero de Bernabé J, Engels V, Troyano J, SanFrutos L, Iglesias E: Three-dimensional angioultrasonography for the prediction of malignancy in ovarian masses. Gynecol Obstet Invest 2013;75:120–125. 9 Sickles EA, Filly RA, Callen PW: Benign breast lesions: ultrasound detection and diagnosis. Radiology 1984;151:467–470.
Zhang/Wang/Ren/Shi
Copyright: S. Karger AG, Basel 2014. Reproduced with the permission of S. Karger AG, Basel. Further reproduction or distribution (electronic or otherwise) is prohibited without permission from the copyright holder.
