Diagnostic difficulties in spontaneous infarction of a fibroadenoma in an adolescent: case report

Diagnosis of Infarcted Breast Lesions on FNAC, a Blustering Fool: Short Case Series

Introduction

Fine-needle aspiration cytology (FNAC) is often used as a screening tool. Cytopathologist should be aware of various mimickers of the malignancy. One of these is infarction of benign breast lesions. Careful examination of cytomorphological features will avoid the misdiagnosis of malignancy in such cases.

Material and Methods

Six cases were diagnosed as benign breast lesion for 4 years and 5 months in our newly established tertiary referral center. Histopathology follow-up was available in one case.

Results

Of six cases, three cases (50%) were reported as fibroadenoma with infarction, two cases (33%) as benign breast lesion with infarction favor fibroadenoma, and one as breast lesion with infarction favor phyllodes tumor in view of recurrence. Most were in the second or third decade of their life. All cases showed dyscohesive cells with pyknotic nuclei. Monolayered sheets of necrotic cells were seen in the four cases (66%). Viable cells were seen in four cases.

Conclusions

FNAC provides a rapid and accurate diagnosis of benign breast lesions with infarction in the hands of experienced pathologists who can help in better patient care. Small-sized uniform pyknotic nuclei of dyscohesive cells and regular nuclear membranes help to differentiate them from inflammatory and malignant lesions.

Giant fibroadenoma with massive infarction masquerading as malignancy: a case report

Fibroadenoma is a common benign breast lesion that usually affects women in their second and third decade of life and usually present as small mobile painless lump. However, it is important to recognize that a small percentage have been shown to progress to giant fibroadenomas. Giant fibroadenomas can undergo infarction leading to significant morbidity and difficulty to distinguish from the more aggressive phyllodes tumors or carcinoma. We report an interesting case of giant fibroadenoma (17 × 11 × 7 cm) with massive infarction during lactation, further complicated by lactational mastitis with close resemblance to cystosarcoma phyllodes. Detailed clinical evaluation and proper investigation in the form of USG breast and PET-CT scan helped us to delineate the nature of pathology. Simple excision of lesion with curvilinear incision was done with excellent cosmetic outcome. Histopathologic features were consistent with fibroadenoma (giant) with large areas of infarction. Fibroadenoma breast has varied clinical presentations. The course of disease may be complicated by pregnancy, lactation and inflammatory processes. Massive infarction may make the picture more dubious and masquerade with malignant transformation altering our treatment decision. The presence of necrosis on core biopsy or intra-operative finding should be cautiously interpreted and is not itself a sign of malignancy. Detailed clinical evaluation and comprehensive workup should be done before embarking on radical treatment.

Ultrasonographic features of spontaneous breast tumor infarction

BACKGROUND

The aim of this paper is to evaluate the ultrasonographic features of spontaneous breast tumor infarction.

METHODS

The pathologic information system database of the Department of Radiology was retrospectively searched. Between 2009 and 2011, nine cases in eight patients were pathologically confirmed as spontaneous breast tumor infarctions. Mammographic images and the ultrasonographic images were acquired. Two other radiologists analyzed the mammographic and ultrasonographic findings.

RESULTS

Most common features were oval, indistinct, heterogeneously hypoechoic mass with posterior enhancement. All lesions were classified as C4 (suspicious finding) except one case.

CONCLUSION

Spontaneous breast tumor infarction should be included in the differential diagnoses of hetereogeneously hypoechoic suspicious solid lesions mimicking malignancy.

Spontaneously infarcted fibroadenoma of the breast in an adolescent girl: sonographic findings

Spontaneous infarction in fibroadenoma unrelated to any known risk factors is extremely rare. Here, I present a case of a spontaneously infarcted fibroadenoma in an adolescent girl in whom no plausible predisposing factors were identified. High-resolution sonographic imaging showed a unique circumscribed, complex echoic mass containing a frondular solid portion.

Fine-needle aspiration cytology of breast lesions with spontaneous infarction: a five-year study

OBJECTIVE

To put forth the cytological features and diagnostic pitfalls of spontaneously infarcted breast lesions on fine-needle aspiration cytology (FNAC).

STUDY DESIGN

We present 19 cases of spontaneously infarcted breast lesions encountered on FNAC over a 5-year period. Histological follow-up was correlated wherever available.

RESULTS

The majority of cases were seen in the second decade of life. The smears in all 19 cases were cellular. The cytomorphologic findings were scattered dyscohesive cells (n = 16), ghost cells (n = 11) and necrosis (n = 10). The dyscohesive cells were small and had a normal nuclear cytoplasmic ratio with pyknotic nuclei. The presence of viable epithelial cells or stromal fragments helped in the diagnosis of the primary breast lesion and was seen in all 19 cases. Cytology diagnoses were infarcted fibroadenoma (n = 11), infarcted breast lesion (n = 3), Phyllodes tumor (n = 2), papillary lesion (n = 2) and infarcted benign breast lesion (n = 1). Histopathology was available in 13 cases, 12 were concordant and 1 was inadequate for primary diagnosis.

CONCLUSION

An infarcted breast lesion poses diagnostic difficulties on cytology. It needs to be differentiated from inflammatory lesions and malignancy. A cytopathologist should be aware of the entity and recognize its cytomorphologic features.

Infarcted fibroadenoma of the breast: report of two new cases with review of the literature

INTRODUCTION

Fibroadenomas are the most common benign breast tumors in young women. Infarction is rarely observed in fibroadenomas and when present, it is usually associated with pregnancy or lactation. Infarction can exceptionally occur as a complication of previous fine-needle aspiration biopsy or during lactation and pregnancy.

MATERIALS AND METHODS

Retrospective review of 650 cases of fibroadenomas diagnosed at our institution during the 8-years period identified two cases of fibroadenomas with infarction (rate ~0.3%).

RESULTS

Two partially infarcted fibroadenomas were diagnosed on core biopsy and frozen section in an adolescent girl (13 years old) and in a young woman (25 years old), respectively. No preceding fine-needle aspiration biopsy was performed in these cases, nor were the patients pregnant or lactating at the time of the diagnosis.

CONCLUSION

Spontaneous infarction within fibroadenoma is a rare phenomenon in younger patients. The presence of necrosis on core biopsy or frozen section should be cautiously interpreted and is not a sign of malignancy.

VIRTUAL SLIDES

The virtual slide(s) for this article can be found here: http://www.diagnosticpathology.diagnomx.eu/vs/1556060549847356.

An atypical growth of a giant fibroadenoma after trauma

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.

Cytohistological correlation of early changes in spontaneously infarcted fibroadenoma-a rare case report

Fibroadenoma is the most commonly diagnosed benign tumour in adolescents and young women but spontaneous infarction in fibroadenoma is rarely seen. We report here a case of spontaneously infracted fibroadenoma in a 20 year old unmarried female without history of trauma or previous fine needle aspiration. It is important to recognize this entity because microscopic findings in an infarct are influenced by the duration of the infarct and on cytology it mimics mastitis, duct ectasia and even carcinoma.

Spontaneous Infarction in a Fibroadenoma of the Breast

SUMMARY: BACKGROUND: Fibroadenomas are common neoplasms in young women but occur in a wide age range from adolescent females to octogenians. CASE REPORT: A 21-year-old female patient presented with a 10-week history of a mass in her breast. Ultrasound examination demonstrated a 3.5 × 3 cm, well-circumscribed, semisolid mass. An excisional biopsy but no fine needle aspiration was performed. The patient had no history of pregnancy or lactation, or trauma or infection to the area of the lesion. The histopathological examination showed a spontaneously infarcted fibroadenoma. CONCLUSIONS: Spontaneous infarction is an uncommon complication in fibroadenoma of the breast, and there are very few reported cases in the literature.

WCAFTI: worrisome cytologic alterations following tissue infarction; a mimicker of malignancy in breast cytology

The acronym WCAFTI (cafti)-(Worrisome cytologic alterations following tissue infarction) is introduced here for the first time for the entity which describes the spectrum of cytologic changes seen in spontaneous infarction of an epithelial lesion. The pathology may be responsible for abnormal cytologic findings such as cellular dyshesiveness, nuclear enlargement with cytoplasmic blurring and irregular nuclei. Although, it is a rare event, it is essential for a cytologist to be aware of this new acronym WCAFTI to avoid misinterpretation of atypical cells and necrosis as indicators of malignancy. It is typically described here in a fibroadenoma from a 49-year-old female who sought medical help for pain in left breast mass.

Two cases of ductal adenoma of the Breast

We encountered two cases of ductal adenoma of the breast. In the first case, a 32-year-old woman presented with a two-year history of a left breast lump. Previous ultrasonography had demonstrated three tumors which were thought to be most likely fibroadenoma. On excisional biopsy of the largest , intraoperative pathological examination of frozen sections was suspicious for ductal carcinoma with a differential diagnosis of intraductal papilloma or intraductal papillary carcinoma. Ductal adenoma was diagnosed after pathological examination of the permanent sections. The second case was a 64-year-old woman who presented with a hard lump in her left breast. Mammography and ultrasonography demonstrated images typical of carcinoma. Aspiration biopsy cytology (ABC) repeated twice was reported as " indeterminate". Excisional biopsy was later done. Ductal adenoma (sclerosing papilloma) with hemorrhagic infarction was diagnosed. It is noteworthy that ductal adenoma have clinical and histopathological features that should be differentiated from carcinoma, especially when the tumor is accompanied by secondary changes such as hemorrhage or infarction.

Infarcted intraductal papilloma of the breast: Cytologic features with stage of infarction

Fine-needle aspiration cytology (FNAC) is being employed with increasing frequency for the pre-operative diagnostic workup of breast lesions. Although most cases show morphologic features very characteristic of specific entities, rare lesions with infarcted breast can cause problems in interpretation. We present cytologic findings in seven cases of an infarcted intraductal papilloma of the breast (IDPB) that was diagnosed by FNAC, and we also report the correlation of cytological features and stages of infarcted IDPB. In the early stage of infarction, numerous degenerative cells and necrotic debris were demonstrated. Isolated degenerative cells showed columnar, spindle, polygonal and fiber-like cells, with coagulated and smudged nuclei. Ghost cells were also seen. Extensive necrosis was demonstrated with a few sheets of ductal cells in the mid-stage of infarction. In the late stage of infarction, clusters of fibroblasts, ductal cells and necrotic debris were found. Knowledge of the characteristic cytologic pattern in different stages of infarcted IDPB may be helpful to suggest the probable pre-operative diagnosis of those lesions. Familiarity with this entity is important in preventing misdiagnosis of malignancy.

Spontaneous infarction of a pleomorphic adenoma in parotid gland: Diagnostic problems and review

Although infarction of parotid gland pleomorphic adenoma (PA) following fine-needle aspiration (FNA) has been well-documented, spontaneous infarction of PA has remained as an uncommon entity in the literature. To our knowledge, we report the second case of spontaneous infarction occurring in a parotid gland PA. A 44-yr-old man presented with a 2-yr history of slowly enlarging right parotid mass, which had become painful 1 mo before performing FNA biopsy. Smears revealed abundant necrotic debris, atypical squamous cells, and small cells with dark nuclei suggestive of a carcinoma. Histologic examination of the tissue fragments demonstrated degenerated clusters of cells and chondromyxoid matrix. The parotidectomy specimen had features consistent with those of an infarcted PA. Although appears to be rare, spontaneous infarction of PA should be considered in the differential diagnosis, since necrosis may mimic carcinoma and cause misinterpretation of necrosis as an indication of malignancy, in an otherwise benign salivary gland neoplasm.

Spontaneous infarction of fibroadenoma in an adolescent girl

A 12-year-old pre-menarcheal girl presented with a solitary breast mass and bloody nipple discharge. Ultrasonography showed an unusual mass with complex characteristics, composed of a frondular structure within a 2.3 x 1.5-cm cyst. Histologic diagnosis of the excised structure was an infarcted fibroadenoma. This case describes the clinical presentation and unique sonographic appearance of a rare, spontaneous infarction of a fibroadenoma in an adolescent girl.