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

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.

Invasive breast cancer with complete infarct necrosis: Presentation of case

INTRODUCTION AND IMPORTANCE

Infarction occurs occasionally in benign mammary tumors but is extremely rare in breast cancer, with few cases having been reported.

PRESENTATION OF CASE

A 53-year-old woman presented to our hospital with a mass and pain in the upper lateral region of the right breast. She underwent a needle biopsy and was histologically diagnosed as having invasive carcinoma. A ring-enhancing spherical mass was seen on contrast-enhanced computed tomography and magnetic resonance images. She underwent a right partial mastectomy with sentinel lymph node biopsy for T2N0M0 breast cancer. Macroscopically, the tumor was a yellow mass. Histopathologically, the site contained extensively necrotic tissue with foam cell aggregation, lymphocytic infiltration, and fibrosis in the periphery. No viable tumor cells were observed. The patient was followed up without postoperative chemotherapy or radiotherapy.

CLINICAL DISCUSSION

Ultrasound examination performed before the biopsy showed blood flow inside the tumor, but a review of the histopathological tissue after surgery revealed generally low viability of the tumor cells in the biopsy specimen, and the possibility that the tumor had a strong tendency to be necrotic from the beginning was considered. It is presumed that some immunological mechanism was working.

CONCLUSION

We have encountered a case of breast cancer with complete infarct necrosis. Infarct necrosis may be present if a contrast-enhanced image shows ring-like contrast.

Breast MRI during pregnancy and lactation: clinical challenges and technical advances

The breast experiences substantial changes in morphology and function during pregnancy and lactation which affects its imaging properties and may reduce the visibility of a concurrent pathological process. The high incidence of benign gestational-related entities may further add complexity to the clinical and radiological evaluation of the breast during the period. Consequently, pregnancy-associated breast cancer (PABC) is often a delayed diagnosis and carries a poor prognosis. This state-of-the-art pictorial review illustrates how despite currently being underutilized, technical advances and new clinical evidence support the use of unenhanced breast MRI during pregnancy and both unenhanced and dynamic-contrast enhanced (DCE) during lactation, to serve as effective supplementary modalities in the diagnostic work-up of PABC.

Breast Cytology and Pathology in Pregnancy and Lactation

Breast tissue reveals some physiologic changes during pregnancy and lactation due to hormonal alterations. Whole range of breast diseases including inflammatory, benign and malignant neoplasms can be seen in pregnancy but due to concurrent physiologic changes, may lead to diagnostic challenges. This chapter reviews sampling methods and histologic features of common benign breast lesions in pregnancy and lactation periods.

Use of ultrasound combined with magnetic resonance imaging for diagnosis of breast masses and fibroids

Objective

To investigate the clinical value of ultrasound plus magnetic resonance imaging (MRI) for the diagnosis of breast masses and fibroids.

Methods

Clinical data for 357 patients with breast masses diagnosed at our hospital were analyzed retrospectively. The diagnostic performances were compared between 243 patients who underwent routine ultrasound examinations (control group) and 114 patients who underwent routine ultrasound plus MRI (test group).

Results

The overall accordance rates of routine ultrasound and routine ultrasound plus MRI for the diagnosis of breast masses, based on postoperative pathological diagnoses, were 70.78% (172/243) and 90.35% (103/114). The addition of MRI significantly improved the overall diagnostic performance of routine ultrasound for breast masses. The diagnostic accordance rate of routine ultrasound for the diagnosis of breast fibroids (fibroadenomas) was 74.12% (63/85 cases) compared with 93.94% (31/33 cases) for routine ultrasound plus MRI. The diagnostic performance of routine ultrasound plus MRI was therefore also significantly higher than routine ultrasound alone for diagnosing breast fibroids.

Conclusions

Routine ultrasound plus MRI can greatly improve the diagnostic accordance rates for breast masses and fibroadenomas.

Fibroepithelial lesions; The WHO spectrum

Fibroepithelial lesions of the breast comprise a morphologically and biologically heterogeneous group of biphasic tumors with epithelial and stromal components that demonstrate widely variable clinical behavior. Fibroadenomas are common benign tumors with a number of histologic variants, most of which pose no diagnostic challenge. Cellular and juvenile fibroadenomas can have overlapping features with phyllodes tumors and should be recognized. Phyllodes tumors constitute a spectrum of lesions with varying clinical behavior and are graded as benign, borderline or malignant based on a set of histologic features according to recommendations by the World Health Organization (WHO). Recent developments have significantly expanded our understanding of the pathogenesis of fibroepithelial lesions, highlighting fibroadenomas as true neoplasms and underscoring a commonality with phyllodes tumors in the form of recurrent MED12 exon 2 mutations. In addition, sequencing studies have elucidated pathways associated with phyllodes tumor progression. Accurate diagnosis and grading of phyllodes tumors are important for patient management and prognosis, as grade broadly correlates with increasing local recurrence risk, and essentially only malignant tumors metastasize. However, classification of fibroepithelial lesions in many cases remains challenging on both core biopsy and excision specimens. A commonly encountered problem at the benign end of the spectrum is the distinction of benign phyllodes tumor from cellular fibroadenoma, which is largely due to the subjective nature of histologic features used in diagnosis and histologic overlap between lesions. Grading is further complicated by the requirement to integrate multiple subjective and ill-defined parameters. On the opposite end of the histologic spectrum, malignant phyllodes tumors must be distinguished from more common metaplastic carcinomas and from primary or metastatic sarcomas, which can be especially difficult in core biopsies. Immunohistochemistry can be useful in the differential diagnosis but should be interpreted with attention to caveats. This review provides an overview and update on the spectrum of fibroepithelial lesions, with special emphasis on common problems and practical issues in diagnosis.

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.

Spontaneous infarcted adenoma of the mammary gland in a Wistar Hannover GALAS rat

Spontaneous massive infarction of mammary gland tumors has been reported to occur infrequently in humans. A subcutaneous mass (18 × 17 × 10 mm) was observed in the right axilla extending to the chest region of a 110-week-old female Wistar Hannover GALAS rat. Histopathologically, a well-circumscribed mass with lobular structures was present in the subcutis. Most of the mass was occupied by extensive coagulative necrosis of neoplastic cells with relatively uniform acinar and ductal structures. Although each necrotic acinar structure was separated by reticular fibers, periacinar stromal collagen fibers were not abundant. Considering the site of occurrence and histological features, the necrotic tissue was diagnosed as adenoma of the mammary gland. The necrotic region lacked hemorrhage and obvious inflammatory cell infiltration, indicating the necrosis was caused by infarction. Although multiple necrosis and focal infarction are occasionally observed in large-sized tumors in rodents, especially in adenocarcinomas, the present case was characteristic, with the massive infarction involving most parts of the tumor despite the relatively small size and low atypia of neoplastic cells. This is a rare case of spontaneous infarcted adenoma of the mammary gland in rats histologically resembling human cases.

Breast infarction during pregnancy and lactation: A case report

Spontaneous infarction is a rare condition associated with the physiological hyperplasia of breast tissue associated with pregnancy and lactation. The causes of and mechanism underlying the occurrence of this complication remain largely unknown. The present study describes a rare case of breast infarction occurring during pregnancy and lactation in a 20-year-old woman. At 2 months of gestation, the patient noticed a soft and painless lump (size, ~5×4 cm) in the right breast. The lump grew to eventually occupy the entire breast. The patient was hospitalized 1 month after delivery and underwent a mastectomy. Histopathological study of the resected breast tissue revealed that 90% of the breast tissue had undergone infarction, with the infarct located centrally, under the areola. Involution of the breast tissue and small focal hemorrhages were noted, along with acute or chronic inflammatory cell infiltration in the interstitial tissue. Some breast ducts showed cystic dilatation, while some small blood vessels showed dilatation and congestion. Postoperative recovery of the patient was uneventful. This was a case of breast infarction with irregular, high-grade fever. The findings of core-biopsy were inconclusive, which highlights the importance of Mammotome™ biopsy or surgical excision in the diagnosis in such cases.

Breast Necrosis after Chemotherapy for Recurrent Ovarian Cancer: Report of a Case and Review of the Literature

Breast necrosis is a rare event due to abundant blood supply of the breast. We present an unusual case of partial breast necrosis after chemotherapy for recurrent ovarian cancer. Necrotic tissue sloughed with conservative management and the wound was repaired surgically. We believe that this is the first case report of breast necrosis as a systemic complication of chemotherapy.

Intraductal fibroadenoma under the nipple in an 11-year-old female

Recently, Chung et al. have reported the detailed clinicopathological features of an extremely rare case sharing similar histopathological characteristics with fibroadenomas, phyllodes tumours, intraductal papillomas or ductal adenomas, given the name of intraductal fibroadenomatosis, as an unusual variant of intracanalicular fibroadenoma. Herein we demonstrated a very unusual case of intraductal fibroadenoma of the breast with admixture of components of intracanalicular type fibroadenoma or benign phyllodes tumour and a smaller amount of intraductal papilloma, occupying the one duct and some adjacent ductules, presenting as a well-demarcated nodule.

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.

Pleomorphic carcinoma of the breast associated with cyst formation: a unique surgical case focusing on cytological and immunohistochemical findings. Cystic breast PC

A mammary nodular lesion was recognized one month before the surgery in the right upper breast of a 55-year-old female. The fine needle aspiration cytology specimens contained many individual bizarre, multi-nucleated, and/or giant cells having hyperchromatic pleomorphic nuclei, prominent nucleoli, and relatively abundant cytoplasm, admixed with numerous mitotic figures in a hemorrhagic or inflammatory background. A small amount of sheet-like or three-dimensional clusters of malignant cells coexisted. We first interpreted it as high-grade malignancy, such as invasive carcinoma, not otherwise specified. A right breast-conserving surgery was performed, and gross examination revealed a cystic cavity-formed and solid tumor lesion, measuring 35 × 35 × 25 mm and looking gray-yellowish to -whitish. On microscopic examination, the tumor was composed of a diffuse proliferation of highly atypical cells devoid of adhesive characteristics, including many multi-nucleated giant bizarre cells, in a haphazard fashion with stromal invasion, alternating with sarcomatoid features of spindle tumor cells. The cystic cavity was surrounded by hemorrhagic and inflammatory granulation tissue and lined by mostly denuded but atypical tumor cells or bland-looking flattened epithelial cells. Immunohistochemically, these tumor cells are specifically positive for all epithelial markers. Therefore, we made a conclusive diagnosis of pleomorphic carcinoma of the breast with cyst formation. We should be aware that, owing to its characteristic findings, cytopathologists can diagnose correctly, based on careful cytological examination of adequate samplings.

Virtual slides

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