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An Atypical Growth of a Giant Fibroadenoma after Trauma
Case Report An Atypical Growth of a Giant Fibroadenoma after Trauma Ali Izadpanah MD, CM, MSc 1,*, Mihiran Karunanayake BSc 2, Arash Izadpanah MD, CM 3, Hani Sinno MD, CM, MEng 1, Mirko Gilardino MD, CM, FRCSC, FACS 1 1
Division of Plastic and Reconstructive Surgery, McGill University, McGill University Health Centre, Montreal, Quebec, Canada Division of Plastic and Reconstructive Surgery, University of Manitoba, Winnipeg, Manitoba, Canada 3 Faculty of Medicine, McGill University, Montreal, Quebec, Canada 2
a b s t r a c t Background: Fibroadenomas are the most common benign breast lesion in female adolescents. However, it is important to recognize that a small percentage have been shown to progress to giant fibroadenomas. Giant fibroadenomas can spontaneously infarct leading to significant morbidity and are also difficult to distinguish from the more aggressive phyllodes tumors. Case: We describe the first case, to the best of our knowledge, of a 12-year-old girl who presented with a giant fibroadenoma complicated by a central infarct and an intra-lesional hemorrhage from a trauma to the breast. Summary and Conclusion: The complicated giant fibroadenoma with an intra-lesional hemorrhage has characteristics of both benign and malignant lesions, and is difficult to distinguish by history and physical alone. Ultrasonography is a valuable tool yet the core needle biopsy remains the gold standard to confirm the diagnosis. Key Words: Fibroadenoma, Giant, Trauma, Atypical, Hemorrhage, Adolescent
Introduction
Fibroadenomas are the most common benign breast lesion in female adolescents.1,2 They have a prevalence of 2.2% in women in their second and third decade of life; whereas in patients presenting to specialty clinics, the prevalence is between 7% and 13%.2 Other common breast lesions in the female adolescent breast include fibrocystic changes, inflammatory masses, mammary hamartoma, tubular adenoma, malignancies, and phyllodes tumor.1,2 Malignancies have been shown to occur in less than 1% of presenting breast lesions in adolescents.1 The history and physical examination can provide significant clues to the underlying etiology of the mass. The clinical history of a fibroadenoma is a mass that is normally asymptomatic, painless, presenting in late adolescence.3 They are firm, smooth, mobile, and non-tender masses without involvement of the nipple and overlying skin.3 Fibroadenomas can become complicated when they progress to giant fibroadenomas, occurring in 5%-10% of cases.3 They are characterized by a sudden and rapid growth. Giant fibroadenomas, defined as exceeding 500 g, greater than 5 cm in diameter or occupying more than four-fifths of the breast, can lead to skin stretching, enlargement of nippleareolar complex, distended veins, and skin ulceration secondary to pressure.4 Thus, at times it can be difficult to distinguish them from more aggressive types, such
The authors indicate no conflict of interest. Karunanayake, Izadpanah, and Sinno contributed to this work equally. * Address correspondence to: Ali Izadpanah, MD, McGill University Health Centre, 760 Upper Lansdowne Ave, Westmount, Quebec H3Y 1J8, Canada; Phone: (514) 965-3238 E-mail address: [email protected] (A. Izadpanah).
as phyllodes tumor, on initial presentation. Additionally, multiple studies have reported a spontaneous infarction, an uncommon complication that can occur in young women who are pregnant or are lactating.5,6 A giant fibroadenoma complicated by an intra-lesional hemorrhage and sudden enlargement secondary to trauma, to the best of our knowledge, has not been previously reported in the literature. In the present report, we describe a 12-year-old female presenting with a giant fibroadenoma complicated by a central infarct and intra-lesional hemorrhage from a trauma to the breast. Case
A 12-year-old girl presented to the emergency department in July of 2009 with a 4-month history of a progressively slowly enlarging, painless left breast mass. The day prior to her presenting to the ER, she described being kicked in the left breast by her brother, which lead to a rapid enlargement of the lump accompanied by new onset of pain and redness. She had no contralateral breast complaints or gynecologic complaints. Her contralateral breast was found to be Tanner stage III. She had reached menarche but she was not menstruating at the time of the incident. She also did not report having a fever or discharge. On physical examination, the left breast mass was located in the lower quadrants with approximate size of 8 9 cm, tender, firm, smooth and swollen. The nipple-areolar complex was distorted. The skin overlying the mass was erythematous and warm. The pain was managed with acetaminophen and codeine, and started on cephalexin for suspicion of a breast abscess. Ultrasonography confirmed a 7.3 9.3 8.9 cm oval shaped mass with mild echo-texture (Fig. 1). There was no color
1083-3188/$ - see front matter Ó 2012 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc. http://dx.doi.org/10.1016/j.jpag.2012.06.004
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A. Izadpanah et al. / J Pediatr Adolesc Gynecol 25 (2012) e115ee117
Fig. 1. (A) Ultrasound confirming a 7.3 9.3 8.9-cm oval shaped mass with mild echotexture. (B) Flow density showing lack of color Doppler flow signal.Ă
Doppler flow signal. One week later, a repeat ultrasonography demonstrated a well-delineated and circumscribed breast mass with patchy foci of hyper-echogenicity, which were described to be present in the initial ultrasonography but had gone unreported (Fig. 2). Additionally, there was a hypo/ anechoic focus in the center of the mass. Patient underwent a core needle biopsy revealing a benign spindle cell proliferation with intra-lesional hemorrhage and occasional possible degenerative ductular structures, which was consistent with a fibroadenoma. It was concluded that the trauma led to rapid enlargement and infarction of a newly developed giant fibroadenoma. After discussion of the risks and benefits, informed consent was obtained for an elective excision. A “grapefruit-sized” hard firm mass with an intact capsule was excised. Pressure dressings were applied to minimize the risk of a hematoma. There were no peri-operative complications and the breast healed well. Post-operatively, a 9.5 9.0 8.0 cm fibroadenoma with infarction of most of the central portion was confirmed by pathology. The child protection services were involved during the investigation. Ultimately, the trauma was deemed incidental. Summary and Conclusion
Fibroadenomas are the most common breast lesion in adolescent girls. It has previously been shown that there is regression in 10%-40% of cases.7 However, a small percentage of these lesions can progress to a giant fibroadenoma.4 Additionally, infarction has been reported in multiple studies.5,6,8,9 Trauma leading to a giant fibroadenoma has not been previously reported, yet we present a case of newly developed giant fibroadenoma with an intra-lesional hemorrhage due to direct injury to the breast. These complications can alter the typical presentation of a fibroadenoma
and lead to unusual radiologic and histologic findings. It is still imperative that the lesion is accurately diagnosed and treated accordingly to reduce the risk of permanent damage to the growing breast and cosmetic deformity. In the present case, the patient initially described a slowly enlarging, painless mass, which is typical of a fibroadenoma, the most common lesion in this age group. The rapid period of growth with pain following a direct trauma to the breast led to further investigation to rule out any malignant features of the lesion. Physical findings of the mass had a wide differential including a giant fibroadenoma, an inflammatory mass, a malignant mass, a mammary hamartoma, tubular adenoma and phyllodes tumor. Additionally, an infarcted giant fibroadenoma has characteristics of both an inflammatory and a malignant mass. There are minor differences between these masses that have been elucidated by different authors. Fibroadenomas were found to be on average less than 2 cm in diameter at presentation while phyllodes tumors were generally greater than 2 cm.4 Malignant masses are hard and fixed with axillary lymphadenopathy while inflammatory masses are characterized by sudden enlargement with pain and tenderness.1,3,8 However, the standard for diagnosis of a breast lesion in an adolescent female is ultrasonography followed by a core needle biopsy.10 Ultrasonography scan using a color Doppler and grey scale can be useful in confirming the presence of a mass and characterizing the mass as cystic or solid. The characteristic finding of a fibroadenoma is a well-circumscribed iso/ hypoechoic homogeneous mass, with posterior acoustic transmission that may be oval, round or macrolobulated.10 Giant fibroadenomas are well-circumscribed, avascular masses and lack peripheral cystic changes, which helps distinguish them from a phyllodes tumor.3
Fig. 2. (A) Ultrasound taken 1 week later, showing a well-delineated and circumscribed breast mass with patchy foci of hyperechogenicity. Additionally, there was a hypo/anechoic focus in the center of the mass. (B) Flow density showing lack of color Doppler flow signal.
A. Izadpanah et al. / J Pediatr Adolesc Gynecol 25 (2012) e115ee117
In the present case, the progressive loss of echotexture was 1 of the indications that guided the ultrasonographers in confirming the presence of hematoma. Initially, there were no focal areas to suggest fluid collection or abscess. Seven days post-trauma, follow-up ultrasonography demonstrated conspicuous different patchy foci of hyperechogenicity throughout the lesion without any posterior shadowing. There was a hypo-anechoic focus within the center of the mass with an irregular appearance, which was later discovered to be a central infarction. This was not in keeping with the report by Fowler et al, where they described ultrasonographic findings of an infarcted fibroadenoma as a central homogeneous fondular mass within an enveloping cyst.9 Color Doppler showed no significant asymmetric or obvious blood flow, a finding which could be consistent with previous reports of giant fibroadenomas.3 However, given the size and the history of current presentation, due to concerns regarding malignant phyllodes tumor, the patient underwent core needle biopsy of the lesion. On histopathologic examination, there was benign spindle cell proliferation, which was suggestive of a fibroadenoma. Gross examination of the resected mass revealed a central necrotic tissue with beige to brown discoloration. Fibroadenomas contain both connective tissue and epithelial proliferation.3 The infarcted fibroadenoma has a similar appearance to a necrotic carcinoma. However, a preserved reticulin network and viable fibroadenomatous tissue in the
e117
periphery help distinguish a necrotic carcinoma from an infarcted fibroadenoma.8 The complicated giant fibroadenoma with an intralesional hemorrhage had characteristics of both benign and malignant lesions. The history and physical offer valuable clues to the etiology of the lesion. Direct traumatic injury to the breast could suggest an intra-lesional hemorrhage, however a prompt work-up is indicated to rule out other possible malignant diagnoses. Ultrasonography is a valuable tool to assess breast lesions yet core needle biopsy remains the gold standard to confirm the diagnosis.
References 1. Neinstein LS: Breast disease in adolescents and young women. Pediatr Clin North Am 1999; 46:607 2. Santen RJ, Mansel R: Benign breast disorders. N Engl J Med 2005; 353:275 3. Chang DS, McGrath MH: Management of benign tumors of the adolescent breast. Plast Reconstr Surg 2007; 120:13e 4. Gatta G, Iaselli F, Parlato V, et al: Differential diagnosis between fibroadenoma, giant fibroadenoma and phyllodes tumour: sonographic features and core needle biopsy. Radiol Med 2011; 116:905 5. Lucey JJ: Spontaneous infarction of the breast. J Clin Pathol 1975; 28:937 6. Pambakian H, Tighe JR: Mammary Infarction. Br J Surg 1971; 58:601 7. Neinstein LS, Atkinson J, Diament M: Prevalence and longitudinal study of breast masses in adolescents. J Adolesc Health 1993; 14:277 8. Deshpande KM, Deshpande AH, Raut WK, et al: Diagnostic difficulties in spontaneous infarction of a fibroadenoma in an adolescent: case report. Diagn Cytopathol 2002; 26:26 9. Fowler CL: Spontaneous infarction of fibroadenoma in an adolescent girl. Pediatr Radiol 2004; 34:988 10. Weinstein SP, Conant EF, Orel SG, et al: Spectrum of US findings in pediatric and adolescent patients with palpable breast masses. Radiographics 2000; 20:1613
Division of Plastic and Reconstructive Surgery, McGill University, McGill University Health Centre, Montreal, Quebec, Canada Division of Plastic and Reconstructive Surgery, University of Manitoba, Winnipeg, Manitoba, Canada 3 Faculty of Medicine, McGill University, Montreal, Quebec, Canada 2
a b s t r a c t Background: Fibroadenomas are the most common benign breast lesion in female adolescents. However, it is important to recognize that a small percentage have been shown to progress to giant fibroadenomas. Giant fibroadenomas can spontaneously infarct leading to significant morbidity and are also difficult to distinguish from the more aggressive phyllodes tumors. Case: We describe the first case, to the best of our knowledge, of a 12-year-old girl who presented with a giant fibroadenoma complicated by a central infarct and an intra-lesional hemorrhage from a trauma to the breast. Summary and Conclusion: The complicated giant fibroadenoma with an intra-lesional hemorrhage has characteristics of both benign and malignant lesions, and is difficult to distinguish by history and physical alone. Ultrasonography is a valuable tool yet the core needle biopsy remains the gold standard to confirm the diagnosis. Key Words: Fibroadenoma, Giant, Trauma, Atypical, Hemorrhage, Adolescent
Introduction
Fibroadenomas are the most common benign breast lesion in female adolescents.1,2 They have a prevalence of 2.2% in women in their second and third decade of life; whereas in patients presenting to specialty clinics, the prevalence is between 7% and 13%.2 Other common breast lesions in the female adolescent breast include fibrocystic changes, inflammatory masses, mammary hamartoma, tubular adenoma, malignancies, and phyllodes tumor.1,2 Malignancies have been shown to occur in less than 1% of presenting breast lesions in adolescents.1 The history and physical examination can provide significant clues to the underlying etiology of the mass. The clinical history of a fibroadenoma is a mass that is normally asymptomatic, painless, presenting in late adolescence.3 They are firm, smooth, mobile, and non-tender masses without involvement of the nipple and overlying skin.3 Fibroadenomas can become complicated when they progress to giant fibroadenomas, occurring in 5%-10% of cases.3 They are characterized by a sudden and rapid growth. Giant fibroadenomas, defined as exceeding 500 g, greater than 5 cm in diameter or occupying more than four-fifths of the breast, can lead to skin stretching, enlargement of nippleareolar complex, distended veins, and skin ulceration secondary to pressure.4 Thus, at times it can be difficult to distinguish them from more aggressive types, such
The authors indicate no conflict of interest. Karunanayake, Izadpanah, and Sinno contributed to this work equally. * Address correspondence to: Ali Izadpanah, MD, McGill University Health Centre, 760 Upper Lansdowne Ave, Westmount, Quebec H3Y 1J8, Canada; Phone: (514) 965-3238 E-mail address: [email protected] (A. Izadpanah).
as phyllodes tumor, on initial presentation. Additionally, multiple studies have reported a spontaneous infarction, an uncommon complication that can occur in young women who are pregnant or are lactating.5,6 A giant fibroadenoma complicated by an intra-lesional hemorrhage and sudden enlargement secondary to trauma, to the best of our knowledge, has not been previously reported in the literature. In the present report, we describe a 12-year-old female presenting with a giant fibroadenoma complicated by a central infarct and intra-lesional hemorrhage from a trauma to the breast. Case
A 12-year-old girl presented to the emergency department in July of 2009 with a 4-month history of a progressively slowly enlarging, painless left breast mass. The day prior to her presenting to the ER, she described being kicked in the left breast by her brother, which lead to a rapid enlargement of the lump accompanied by new onset of pain and redness. She had no contralateral breast complaints or gynecologic complaints. Her contralateral breast was found to be Tanner stage III. She had reached menarche but she was not menstruating at the time of the incident. She also did not report having a fever or discharge. On physical examination, the left breast mass was located in the lower quadrants with approximate size of 8 9 cm, tender, firm, smooth and swollen. The nipple-areolar complex was distorted. The skin overlying the mass was erythematous and warm. The pain was managed with acetaminophen and codeine, and started on cephalexin for suspicion of a breast abscess. Ultrasonography confirmed a 7.3 9.3 8.9 cm oval shaped mass with mild echo-texture (Fig. 1). There was no color
1083-3188/$ - see front matter Ó 2012 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc. http://dx.doi.org/10.1016/j.jpag.2012.06.004
e116
A. Izadpanah et al. / J Pediatr Adolesc Gynecol 25 (2012) e115ee117
Fig. 1. (A) Ultrasound confirming a 7.3 9.3 8.9-cm oval shaped mass with mild echotexture. (B) Flow density showing lack of color Doppler flow signal.Ă
Doppler flow signal. One week later, a repeat ultrasonography demonstrated a well-delineated and circumscribed breast mass with patchy foci of hyper-echogenicity, which were described to be present in the initial ultrasonography but had gone unreported (Fig. 2). Additionally, there was a hypo/ anechoic focus in the center of the mass. Patient underwent a core needle biopsy revealing a benign spindle cell proliferation with intra-lesional hemorrhage and occasional possible degenerative ductular structures, which was consistent with a fibroadenoma. It was concluded that the trauma led to rapid enlargement and infarction of a newly developed giant fibroadenoma. After discussion of the risks and benefits, informed consent was obtained for an elective excision. A “grapefruit-sized” hard firm mass with an intact capsule was excised. Pressure dressings were applied to minimize the risk of a hematoma. There were no peri-operative complications and the breast healed well. Post-operatively, a 9.5 9.0 8.0 cm fibroadenoma with infarction of most of the central portion was confirmed by pathology. The child protection services were involved during the investigation. Ultimately, the trauma was deemed incidental. Summary and Conclusion
Fibroadenomas are the most common breast lesion in adolescent girls. It has previously been shown that there is regression in 10%-40% of cases.7 However, a small percentage of these lesions can progress to a giant fibroadenoma.4 Additionally, infarction has been reported in multiple studies.5,6,8,9 Trauma leading to a giant fibroadenoma has not been previously reported, yet we present a case of newly developed giant fibroadenoma with an intra-lesional hemorrhage due to direct injury to the breast. These complications can alter the typical presentation of a fibroadenoma
and lead to unusual radiologic and histologic findings. It is still imperative that the lesion is accurately diagnosed and treated accordingly to reduce the risk of permanent damage to the growing breast and cosmetic deformity. In the present case, the patient initially described a slowly enlarging, painless mass, which is typical of a fibroadenoma, the most common lesion in this age group. The rapid period of growth with pain following a direct trauma to the breast led to further investigation to rule out any malignant features of the lesion. Physical findings of the mass had a wide differential including a giant fibroadenoma, an inflammatory mass, a malignant mass, a mammary hamartoma, tubular adenoma and phyllodes tumor. Additionally, an infarcted giant fibroadenoma has characteristics of both an inflammatory and a malignant mass. There are minor differences between these masses that have been elucidated by different authors. Fibroadenomas were found to be on average less than 2 cm in diameter at presentation while phyllodes tumors were generally greater than 2 cm.4 Malignant masses are hard and fixed with axillary lymphadenopathy while inflammatory masses are characterized by sudden enlargement with pain and tenderness.1,3,8 However, the standard for diagnosis of a breast lesion in an adolescent female is ultrasonography followed by a core needle biopsy.10 Ultrasonography scan using a color Doppler and grey scale can be useful in confirming the presence of a mass and characterizing the mass as cystic or solid. The characteristic finding of a fibroadenoma is a well-circumscribed iso/ hypoechoic homogeneous mass, with posterior acoustic transmission that may be oval, round or macrolobulated.10 Giant fibroadenomas are well-circumscribed, avascular masses and lack peripheral cystic changes, which helps distinguish them from a phyllodes tumor.3
Fig. 2. (A) Ultrasound taken 1 week later, showing a well-delineated and circumscribed breast mass with patchy foci of hyperechogenicity. Additionally, there was a hypo/anechoic focus in the center of the mass. (B) Flow density showing lack of color Doppler flow signal.
A. Izadpanah et al. / J Pediatr Adolesc Gynecol 25 (2012) e115ee117
In the present case, the progressive loss of echotexture was 1 of the indications that guided the ultrasonographers in confirming the presence of hematoma. Initially, there were no focal areas to suggest fluid collection or abscess. Seven days post-trauma, follow-up ultrasonography demonstrated conspicuous different patchy foci of hyperechogenicity throughout the lesion without any posterior shadowing. There was a hypo-anechoic focus within the center of the mass with an irregular appearance, which was later discovered to be a central infarction. This was not in keeping with the report by Fowler et al, where they described ultrasonographic findings of an infarcted fibroadenoma as a central homogeneous fondular mass within an enveloping cyst.9 Color Doppler showed no significant asymmetric or obvious blood flow, a finding which could be consistent with previous reports of giant fibroadenomas.3 However, given the size and the history of current presentation, due to concerns regarding malignant phyllodes tumor, the patient underwent core needle biopsy of the lesion. On histopathologic examination, there was benign spindle cell proliferation, which was suggestive of a fibroadenoma. Gross examination of the resected mass revealed a central necrotic tissue with beige to brown discoloration. Fibroadenomas contain both connective tissue and epithelial proliferation.3 The infarcted fibroadenoma has a similar appearance to a necrotic carcinoma. However, a preserved reticulin network and viable fibroadenomatous tissue in the
e117
periphery help distinguish a necrotic carcinoma from an infarcted fibroadenoma.8 The complicated giant fibroadenoma with an intralesional hemorrhage had characteristics of both benign and malignant lesions. The history and physical offer valuable clues to the etiology of the lesion. Direct traumatic injury to the breast could suggest an intra-lesional hemorrhage, however a prompt work-up is indicated to rule out other possible malignant diagnoses. Ultrasonography is a valuable tool to assess breast lesions yet core needle biopsy remains the gold standard to confirm the diagnosis.
References 1. Neinstein LS: Breast disease in adolescents and young women. Pediatr Clin North Am 1999; 46:607 2. Santen RJ, Mansel R: Benign breast disorders. N Engl J Med 2005; 353:275 3. Chang DS, McGrath MH: Management of benign tumors of the adolescent breast. Plast Reconstr Surg 2007; 120:13e 4. Gatta G, Iaselli F, Parlato V, et al: Differential diagnosis between fibroadenoma, giant fibroadenoma and phyllodes tumour: sonographic features and core needle biopsy. Radiol Med 2011; 116:905 5. Lucey JJ: Spontaneous infarction of the breast. J Clin Pathol 1975; 28:937 6. Pambakian H, Tighe JR: Mammary Infarction. Br J Surg 1971; 58:601 7. Neinstein LS, Atkinson J, Diament M: Prevalence and longitudinal study of breast masses in adolescents. J Adolesc Health 1993; 14:277 8. Deshpande KM, Deshpande AH, Raut WK, et al: Diagnostic difficulties in spontaneous infarction of a fibroadenoma in an adolescent: case report. Diagn Cytopathol 2002; 26:26 9. Fowler CL: Spontaneous infarction of fibroadenoma in an adolescent girl. Pediatr Radiol 2004; 34:988 10. Weinstein SP, Conant EF, Orel SG, et al: Spectrum of US findings in pediatric and adolescent patients with palpable breast masses. Radiographics 2000; 20:1613