Bilateral Diffuse Pseudoangiomatous Stromal Hyperplasia (PASH) Causing Gigantomastia in a 33-Year-Old Pregnant Woman: Case Report

A case report and a literature review of double mammary pseudoangiomatous stromal hyperplasia associated with galactoma during pregnancy

Pseudoangiomatous stromal hyperplasia (PASH) is a benign interstitial hyperplasia of the breast that usually occurs in premenopausal or perimenopausal women. It is usually characterized by localized lesions or clear boundary masses, and diffuse double breast enlargement is rare. PASH is considered a hormone-dependent disease that is commonly progesterone related. There are no imaging characteristics, and both benign and suspicious malignant signs can be seen. The definitive diagnosis of PASH depends on a pathological diagnosis, and it is necessary to be vigilant in distinguishing between benign and malignant tumors with similar breast histopathology. Here, we report the case of a 23-year-old multipara patient with bilateral diffuse pseudoangiomatous stromal hyperplasia of the breast during pregnancy who presented with macromastia and reviewed the literature to further understand the clinical features, pathological diagnosis, differential diagnosis, treatment and prognosis of pseudoangiomatous stromal hyperplasia of the breast.

Gestational Pseudoangiomatous Stromal Hyperplasia Presenting as Gigantomastia: A Case Report of a Rare Breast Entity with Clinical Recommendations by a Multidisciplinary Team

Introduction

Pseudoangiomatous stromal hyperplasia (PASH) presenting as gigantomastia is rare in pregnancy but can result in severe clinical consequences for both mother and fetus. Case Presentation. A 43-year-old female with a history of biopsy-proven bilateral PASH presented at 22 3/7 weeks gestation with massive bilateral breast enlargement that was symptomatic. After multidisciplinary care, she underwent bilateral mastectomies and delivered at term with no additional complications.

Conclusion

Pregnant women who undergo mastectomies for PASH-induced gigantomastia during their second trimesters will likely recover quickly, and fetal risks are low. Given the rarity of this breast entity, management guidelines are sparse. Our case report is an effort to comprehensively review this condition and share the clinical recommendations made by our institution's multidisciplinary team.

A rare case of gigantomastia caused by pseudoangiomatous stromal hyperplasia

Gigantomastia is a rare pathologic condition characterized by an excessive and abnormal breast hypertrophy. To date, there is no exact definition or classification of this disease. Pathogenesis still unclear. The purpose of this article is to present a case of extreme and disabling gigantomastia caused by pseudoangiomatous stromal hyperplasia, one of the rarest etiology of gigantomastia.

Repeated recurrence of bilateral gigantomastia after subcutaneous mastectomy caused by tumoral pseudoangiomatous stromal hyperplasia: a case report and review of literature

Pseudoangiomatous stromal hyperplasia (PASH) is an uncommon benign proliferative mesenchymal lesion of the breast with a hormonal-sensitive nature. Various manifestations of PASH, ranging from an incidental microscopic finding in a tissue biopsy to a large palpable mass or bilateral gigantomastia, have been described. For tumoral PASH, surgical excision is indicated for a growing and symptomatic mass with a small chance of recurrence. A recurrence of bilateral gigantomastia after surgical excision or reduction mammoplasty is not common but has been occasionally reported, leading to further mastectomy. Repeated recurrence of bilateral gigantomastia is extremely rare. Herein, we report a case of a 13-year-old girl who presented with the third recurrence of bilateral gigantomastia caused by tumoral PASH, after undergoing bilateral reduction mammoplasty, and later subcutaneous mastectomy. Precocious puberty occurred early in this child at the age of 9 years, which may have been a factor unmasking PASH at this young age. The incomplete removal of the PASH could also have been a recurrence risk in our case as extended masses underneath the pectoralis muscle were later identified on the MRI study. This highlights the advantage of preoperative imaging in cases with a very large tumoral PASH in order to maximize the chance of complete tumor removal.

A Systematic Literature Review of the Clinical Presentation, Management, and Outcome of Gestational Gigantomastia in the 21st Century

BACKGROUND

Gestational gigantomastia (GG) is an uncommon pregnancy condition, and the underlying cause of GG has yet to be determined. Medical management and surgery are two treatment options for GG, and breast reduction or mastectomy with delayed reconstruction is the only available surgical option. We have conducted this systematic review to summarize and critically analyze all the GG data in the literature.

METHODS

The preferred reporting items for systematic reviews and meta-analysis (PRISMA) guidelines were adhered to in reporting this article. A systematic search was conducted in February 2022 for published case reports and case series on GG using the PubMed, MEDLINE, and Cochrane databases. The following keywords were used: macromastia, gestational gigantomastia, and gestational.

RESULTS

A total of 639 articles were searched, and only 66 case reports published between 1962 and 2022 were included. The mean patient's age at presentation was 28.79 years old. The majority of the patients were in their first trimester (n = 23, 47%). The main complaint was rapid bilateral breast enlargement (n = 54, 80.59%). Bromocriptine was the most common medical management used (n = 19/35, 54.28%). Bilateral breast reduction was the most common surgery (n = 24/48, 50%). Most patients had uneventful recovery (n = 40/54, 74.07%).

CONCLUSION

Gigantomastia is a difficult condition, in terms of its management. We have found that surgery is the gold-standard among all the cases reported; while Bromocriptine was the most commonly administered medical therapy. This systematic review provides a guideline for plastic surgeons to better facilitate their care of these patients.

LEVEL OF EVIDENCE III

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Pseudoangiomatous stromal hyperplasia of the breast, imaging and clinical perspective: A review

Pseudoangiomatous stromal hyperplasia (PASH) is a benign breast pathology, which most commonly presents incidentally along with other breast pathologies. The etiology and pathogenesis of PASH are still unknown; however, there is some evidence suggesting PASH is hormone dependent. The clinical history, presentation, and imaging appearance of PASH are variable. Clinically, PASH has a wide spectrum of presentations, from being silent to gigantomastia. On imaging, PASH demonstrates various benign to suspicious features. Here we summarize PASH's clinical presentation, histopathology, imaging features, and management.

Bilateral multicenter pseudohemangiomatous interstitial hyperplasia of the breast: a case report

Bilateral multicenter breast pseudohemangiomatous stromal hyperplasia (PASH) is a rare, benign breast disease. Here, we report on a female patient with bilateral multicenter PASH who underwent a mastectomy and prosthetic reconstruction. The surgery was successful, and no recurrence was observed during the 18 months of follow up.

Radiological Spectrum of Pseudoangiomatous Stromal Hyperplasia of Breast—A Case Series

Pseudoangiomatous stromal hyperplasia (PASH) is a benign mesenchymal tumor-like lesion of the breast. It is commonly seen as incidental background changes of the intralobular stroma in biopsy specimens performed for other breast lesions. Less frequently, it presents as a nodular form that has a benign morphology on imaging, mimicking fibroadenoma or as a diffuse form causing progressive massive gigantomastia. Diagnosis is established by biopsy. Knowledge of the imaging appearance of PASH not only facilitates proper assessment of radiopathological correlation but also helps in deciding further management of these lesions. Occasionally, nodular PASH may have a suspicious appearance on imaging wherein excision biopsy is indicated to exclude a coexisting carcinoma.

Idiopathic gigantomastia in a patient on polypharmacy

Gigantomastia is an uncommon benign condition characterized by massive breast enlargement. It is most often due to hormonal imbalance secondary to puberty or pregnancy, or induced by a pharmacological agent but can also be idiopathic. Herein, we report a rare case of idiopathic gigantomastia in a 46-year-old female on antiepileptic multiple-drug therapy who underwent total bilateral mastectomy to relieve associated pain.

Successful management of diffuse bilateral pseudoangiomatous stromal hyperplasia of the mammary glands by reductive mammoplasty

Pseudoangiomatous stromal hyperplasia (PASH) is a benign breast condition commonly presented as an incidental microscopic finding. However, it can also manifest as a mass-forming lesion (tumorous PASH) or as gigantomastia (diffuse PASH). Most of the previously reported cases are unilateral tumorous PASH treated by mastectomy. In this article, we reported a rare case of diffuse bilateral PASH. A 21-year-old woman presented with a two-year history of bilateral breast enlargement and neck pain. Physical examination revealed asymmetrical bilateral macromastia with profound ptosis. Breast ultrasound demonstrated no cysts or masses in both breasts. The decision was made to perform an inverted T bilateral reductive mammoplasty which was performed successfully through a superior-central pedicle approach. Microscopic examination of the specimens confirmed the diagnosis of PASH without any evidence for malignancy. Nine months postoperatively, the size for both breasts was optimal the patient was satisfied. Recognition and reporting of this rare form of PASH is essential for proper investigation, pathology understanding, risk factors recognition, prognosis assessment and treatment methods selection.

The effect of hormones on an uncommon breast disorder pseudoangiomatous stromal hyperplasia: a case report and literature review

Pseudoangiomatous stromal hyperplasia (PASH) is a benign proliferation of the breast, with few cases reported to date. While the etiology of the disease is uncertain, a prevailing theory is that PASH is hormonally responsive, especially in the presence of progesterone. Literature review shows a correlation between PASH development and oral contraceptive pill (OCP) use. We report a case of a 28-year-old autistic female who underwent excision of palpable bilateral breast masses where the histology of the left breast mass identified as PASH. Our patient had a history of multiple medications including OCPs and cytochrome p450 inhibitors that could lead to an increase in progesterone levels. Thus, supporting a theory that medications, in addition to OCPs, may lead to an increased occurrence of PASH in pre-menopausal women.

Management of recurrent bilateral multifocal pseudoangiomatous stromal hyperplasia (PASH)

Pseudoangiomatous stromal hyperplasia (PASH) is a benign hyperplastic condition of the breast that can lead to macromastia. The standard treatment for PASH is focal excision or rarely reduction mammoplasty. We present a rare case of postpartum bilateral rapid breast enlargement and axillary growth that was refractory to reduction mammoplasty. Ultimately, the patient required bilateral mastectomy and two-stage implant-based breast reconstruction. This more extensive form along with its management represents one of the few reported cases in the literature. The decision to pursue bilateral mastectomy was undertaken after exhausting more conservative options. Excellent aesthetic outcome and pain relief was obtained following definitive extirpative and reconstructive surgery.

A case of acute onset gigantomastia in a 20-year-old woman

Gigantomastia is an abnormal and rare breast condition characterized by excessive breast tissue growth that can result in physical and psychosocial debilitation. While the etiology is not fully understood, it is postulated that abnormal endogenous hormone stimulation plays a contributory role and often requires mastectomy for definitive treatment. Proliferation of all elements is commonly observed, including glands, ducts, stroma, fat, vessels and skin. Pseudoangiomatous stromal hyperplasia (PASH) is an additional benign breast disease defined microscopically by proliferation of mammary stroma. PASH often clinically presents as an incidental finding while evaluating other benign or malignant lesions, or less commonly as a palpable, well-circumscribed breast mass. Uncommon cases have been reported in which PASH presents as a bilateral, diffuse process. In this case presentation, we report a rare case of a 20-year-old woman presenting with acute onset gigantomastia most likely due to diffuse PASH.

Pseudoangiomatous Stromal Hyperplasia (PASH) of the Breast: An Uncommon Finding in an Uncommon Patient

BACKGROUND Pseudoangiomatous stromal hyperplasia (PASH) is an uncommon benign breast lesion. CASE REPORT PASH is reported in a young female in treatment for neurological diseases with multi-drug therapy (clonazepam, valproate and risperidone). Her menstrual cycles are irregular, and she reached menarche very late. CONCLUSIONS The higher PASH prevalence in premenopausal woman (the majority of whom are actively taking oral contraceptive pills), in 24% to 47% of men with gynecomastia and during pregnancy supports a hormonal etiology; the interaction between clonazepam, valproate, risperidone and progesterone could increase the level of progesterone that could stimulate PASH growth.

Immunohistochemistry for diagnosis and prognosis of breast cancer: a review

Breast cancer is the most prevalent malignant tumor and main oncologic cause of mortality in women. Although most diagnosis of breast pathology is accomplished using hematoxylin and eosin stained sections, some cases require immunohistochemistry for proper evaluation. We investigated the latter cases including distinctions between ductal and lobular carcinoma, in situ and invasive carcinoma, typical ductal hyperplasia and atypical ductal hyperplasia/ductal carcinoma in situ, papillary and spindle cell lesion assessment, metastasis evaluation, and assessment of prognostic and therapy markers. E-cadherin is used to differentiate ductal and lobular carcinoma; 34βE12, CK8, p120 catenin and β-catenin also produce consistent results. Myoepithelial cell (MEC) stains are used to evaluate in situ and invasive carcinoma; calponin, smooth muscle myosin heavy chain and p63 are sensitive/specific markers. 34βE12 and CK5/6 are positive in ductal hyperplasia, which enables its differentiation from atypical ductal hyperplasia and ductal carcinoma in situ. CK 5/6, ER and MEC markers are consistent options for evaluating papillary lesions. Spindle cell lesions can be assessed using β-catenin, SMA, CD34, p63, CKs and hormone receptors. It is important to differentiate primary carcinomas from metastases; the most commonly used markers to identify breast origin include mammaglobin, GCDFP-15, GATA3 and ER, although none of these is completely sensitive or specific. Immunohistochemistry can be used to evaluate central prognostic and predictive factors including molecular subtypes, HER2, hormone receptors, proliferation markers (Ki-67) and lymph-vascular invasion markers including ERG, CD31, CD34, factor VIII and podoplanin. Owing to the complexity of mammary lesions, diagnosis also depends on each particular situation, evaluation of cytological characteristics revealed by immunochemistry and correlation with histological findings.

Developmental disorders and malformations of the breast

Developmental abnormalities and malformations of the breast are rare and encompass a variety of genetic, syndromic, acquired and sporadic conditions. Abnormalities in development may include irregularities in the nipple areolar complex and/or the underlying glandular tissue, resulting in under or overdevelopment of breasts. Age of presentation and clinical severity is dependent on the underlying biologic cause. Abnormalities may involve the entirety of unilateral or bilateral breasts, particularly in association with syndromic conditions or endocrine abnormalities. Disordered development may also be focal, resulting in tumor-like lesions such as hamartomas, pseudoangiomatous stromal hyperplasia and gynecomastia. In this review, we discuss the disorders of breast development including etiologies, clinical presentations and corresponding histopathologic features.

Differential Diagnosis of Benign Spindle Cell Lesions

Spindle cell lesions of the breast cover a wide spectrum of diseases ranging from reactive tumor-like lesions to high-grade malignant tumors. The recognition of the benign spindle cell tumor-like lesions (nodular fasciitis; reactive spindle cell nodule after biopsy, inflammatory pseudotumor/inflammatory myofibroblastic tumor; fascicular variant of pseudoangiomatous stromal hyperplasia) and tumors (myofibroblastoma, benign fibroblastic spindle cell tumor, leiomyoma, schwannoma, spindle cell lipoma, solitary fibrous tumor, myxoma) is crucial to avoid confusion with morphologically similar but more aggressive bland-appearing spindle cell tumors, such as desmoid-type fibromatosis, low-grade (fibromatosis-like) spindle cell carcinoma, low-grade fibrosarcoma/myofibroblastic sarcoma and dermatofibrosarcoma protuberans.