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doi: 10.5146/tjpath.2011.01084Olgu Suumu/Case Report

254 Cilt/Vol. 27, No. 3, 2011; Saa/Page 254-256

Received : 24.08.2010Acceped : 24.10.2010

Correspondence:Merih GRAy DURAK

Department o Pathology, Dokuz Eyll Unversty, Faculty o Medcne,

ZMR, URKEYE-mail: merih.guray@deu.edu.tr Phone: +90 232 412 34 01

Cstc fbroadeoma o the Breast: A Case Report

Memenin Kistik Fibroadenomu: Olgu Sunumu

Merh GRAy DURAK1, Ilg KARAMAn1, Tla CAnDA1, Par BALCI2, mer HARMAnCIOLU3

Departments of1Pathology, 2Radiology and3General Surgery, Dokuz Eyll University, Faculty of Medicine, ZMR, TURKEY

ABStRACt

Fibroadenoma is the most common breast tumor in adolescent andyoung women. Fibroadenomas that consist o sclerosing adenosis,papillary apocrine metaplasia, epithelial calciications, and/or cystsgreater than 3 mm are considered as complex ibroadenoma. Terelative risk o developing breast cancer in patients with complexibroadenoma is increased, compared to women with noncomplex

ibroadenoma. Extensive cystic degeneration in a ibroadenoma, socalled cystic ibroadenoma is very rare. Herein, we present a case osuch a lesion in a 43-year-old emale who has been on ollow-up oribrocystic changes o the breast, and discuss both radiological andhistopathologic dierential diagnosis o this lesion with other cysticlesions o the breast, including cystic papilloma. Te patient is ree odisease aer 17 months o clinical ollow-up.

Key Words: Cystic degeneration, Fibroadenoma, Breast

Z

Fibroadenom, adolesan dnem ve gen kadnlarda en sk grlenmeme tmrdr. Fibroadenoma skleroze adenozis, papiller apokrinmetaplazi, epitelyal kalsiikasyonlar ve/veya 3 mmden byk kistikyaplar elik ediyor ise kompleks ibroadenom olarak isimlendirilir.Kompleks ibroadenom olgularnda meme kanseri gelime riski,nonkompleks ibroadenomlara gre daha azladr. Yaygn kistik

dejenerasyon gsteren ibroadenomlar ise kistik ibroadenomolarak tanmlanmakta olup, olduka nadirdirler. Burada, memeninibrokistik deiiklikleri nedeni ile izlem altnda olan 43 yandakibir kadn hastada saptanan nadir bir kistik ibroadenom olgususunularak, bu lezyonun kistik papillom gibi memenin dier kistiklezyonlar ile radyolojik ve histopatolojik ayrc tans tartlmtr.Klinik olarak 17 aylk izlem sonucu, hastada herhangi bir rekrrensya da malignite geliimi saptanmamtr.

Anahtar Szckler: Kistik dejenerasyon, Fibroadenom, Meme

INtRODUCtION

Fibroadenoma is the most common breast tumor bothclinically and pathologically in adolescent and youngwomen. Cystic changes, usually measuring between 1 mmto 10 mm, may occur within these benign ibroepithelialtumors. Fibroadenomas that consist o cysts greater than3 mm, sclerosing adenosis, epithelial calciications, and/orpapillary apocrine metaplasia are considered as complexibroadenoma (1). It is well known that the relative risko developing breast carcinoma in patients with complexibroadenoma is increased, compared to women withnoncomplex ibroadenoma (2). Predominant cysticdegeneration o the tumor that grossly constitutes most

o the tumor, so called cystic ibroadenoma, is very rare.Herein, we present a rare case o cystic ibroadenoma o thebreast in a 43-year-old emale.

CASE REPORt

A 43-year-old emale with a history o ibrocystic changeso the breast, presented with a palpable lump in herright breast. She had no amily history o breast cancer.Clinical examination revealed a non-tender, mobile, well-circumscribed cystic lesion in the lower inner quadrant o theright breast. Mammography showed a well-circumscribedmass lesion with thickened wall (Figure 1). On sonography,the mass was hypoechoic and sharply deined, reminiscento a cystic lesion with thick and irregular wall. Te lesionwas excised. Gross examination o the specimen showeda sharply demarcated cystic lesion that was 3.3x1.7 cmin size, with a jelly-like dense homogeneous, dark yellow

material in its lumen, reminiscent o galactocele (Figure2). Te thickness o the cyst wall was approximately 3 mm,and the inner surace had papillary oldings reminiscent ocystic papilloma.

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Histologic examination o the lesion demonstrated a cystilled with dense secretory material that included coarsepapillary projections into the cystic cavity. Some areas othe cyst wall had classical ibroadenoma appearance withelongated compressed ducts and stromal prolieration,

and some areas showed ducts with apocrine epithelialmetaplasia (Figure 3). Surrounding breast parenchymaconsisted o ibroadenomatoid nodules. Te lesion wasdiagnosed as cystic ibroadenoma o the breast, and becausethe largest dimension o the cyst was greater than 3 mm, itwas considered as a complex ibroadenoma. Te patient iswell, and ree o disease or recurrences aer 17 months oollow-up.

DISCUSSION

Fibroadenoma is the most common cause o breast lumpsin young women. It is a benign ibroepithelial tumoro the breast, composed o both stromal and epithelialcomponents. In most cases, a painless, well-circumscribed,solitary breast lump is detected by sel examination othe patient. Over time, this tumor may undergo somedegenerative changes, such as myxoid degeneration,metaplastic changes including smooth muscle (myoid)metaplasia, adipose dierentiation, rarely osteochondroidmetaplasia, or inarction (1,3). In some ibroadenomas,discrete round cysts measuring between 1 mm to 10 mmare ound. I the tumor has cysts greater than 3 mm, orassociated sclerosing adenosis, epithelial calciications, or

papillary apocrine metaplasia, it is considered as complexibroadenoma. Predominant cystic degeneration o this

Figure 1: Mediolateral oblique mammogram reveals a solid, oval-shaped, well-circumscribed mass with no calciication.

Figure 2: Grossly, this well-circumscribed cystic lesion hasa ibrous capsule at the periphery, and a jelly-like, dense,homogeneous dark yellow material in its lumen.

Figure 3: Histologically, the lesion is predominantly cystic. Tecyst wall is composed o stromal prolieration and elongatedcompressed ducts, with some ducts showing apocrine epithelialmetaplasia (H&E; x20).

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tumor is very rare (1). Nevertheless, cystic ibroadenoma,that is thought to arise rom ectopic mammary glands havebeen reported in other organs as well, such as vulva (4) andprostate (5).

In most ibroadenoma cases, mammography revealsa homogeneous, round or oval, circumscribed mass.However, mammography cannot distinguish whether amass is solid or cystic. Ultrasound examination is usuallypreerred or characterizing o cystic breast masses.Radiologically, cystic lesions o the breast can simply becategorized as predominantly cystic masses with solidcomponents, or predominantly solid masses with cysticcomponents (6). Predominantly cystic lesions includesimple cysts, traumatic and postoperative fuid collections,abscess, galactocele, cystic papilloma and cystic papillarycarcinoma. Complex breast cysts, that are deined as cysts

with thick walls, thick septa, intracystic masses, or otherdiscrete solid components, include both benign lesions,such as ibrocystic changes, intraductal or intracysticpapilloma without atypia, ibroadenoma; atypical or high-risk lesions, such as atypical ductal hyperplasia, atypicalpapilloma; and malignant lesions, such as ductal carcinomain situ, invasive ductal and invasive lobular carcinoma(6,7). Clinical, imaging, and pathologic correlation issigniicant in these lesions or appropriate management othe patient. According to Berg et al, presence o a discretesolid component in a complex cystic mass, or presence othick wall or thick septations in an otherwise cystic lesion,

without antecedent trauma or evidence o inection shouldsuggest possible malignancy and require biopsy. Tey haveound in their series that 23% o patients with such complexcystic lesions had a diagnosis o malignancy pathologically(8).

Histologically, simple cysts can be divided into two groupsaccording to their cell lining and electrolyte content:epithelial cell-lined cysts and cysts lined with cells thathave apocrine metaplasia. Te latter group, which ischaracterized by fuid low in sodium and high in potassiumhas a tendency to recur aer aspiration more commonly

than do epithelial cell-lined cysts (6). Galactoceles arecysts that contain milky fuid. Tey develop in women whoare pregnant, lactating, or have stopped lactating withinthe last 2 to 3 years. Histologically, these cysts are usuallylined by cuboidal or fat epithelial cells with cytoplasmic

vacuolization due to lipid accumulation (1,6). Papillarylesions, on the other hand, are characterized by branchingronds o ibrovascular stroma protruding into the lumen,

lined by epithelial and myoepithelial cells (1). Te presenceor absence o myoepithelial cells distinguishes benign rommalignant papillary lesions.

Various studies have reported that ibroadenomas donot have increased risk or developing breast carcinoma,unless the tumor or the surrounding breast parenchymashows prolierative changes, or the patient has a amilyhistory o breast cancer (2,9). Dupont et al. have reportedthat the relative risk o developing breast carcinoma was3.1 or women who had complex ibroadenoma, and thatthe risk had increased to 3.7 i the patient had complexibroadenoma and a amily history o breast carcinoma (2).Our patient, who did not have a amily history o breastcancer, is well and ree o disease or recurrences aer 17months o ollow-up.

In conclusion, dierential diagnosis o cystic lesions o the

breast may be diicult both clinically and radiologically.Pathologic examination o the lesion is usually necessaryin order to highlight the nature o the lesion. Cysticibroadenoma, although rarely seen, should be consideredin the dierential diagnosis o cystic lesions o the breast,that includes cystic papilloma and ibrocystic changes.

REFERENCES

1. Rosen PP: Fibroepithelial neoplasms. In Rosen PP. (Ed): RosensBreast Pathology. 3rd ed., Philadelphia, Lippincott Williams &Wilkins, 2009, 187-201

2. Dupont WD, Page DL, Parl FF, Vnencak-Jones CL, PlummerWD Jr, Rados MS, Schuyler PA: Long-term risk o breast cancerin women with ibroadenoma. N Engl J Med 1994, 331:10-15

3. Pinder SE, Mulligan AM, OMalley FP: Fibroepithelial lesions,including ibroadenoma and phyllodes tumor. In OMalleyFP, Pinder SE, Goldblum JR. (Eds): Breast Pathology. 1st ed.,Philadelphia, Churchill Livingstone Elsevier, 2006, 109-115

4. Menet E, Wager I, Babin M, Magnin G, Babin P: Multiple vulvarcystic and papillary ibroadenomas. J Gynecol Obstet Biol Reprod1999, 28:830-832

5. Gerridzen RG, McDonald MW, Mai K: An unusual pelvic mass:cystic ibroadenoma o the prostate. Can J Urol 1995, 2:172-174

6. Cardenosa G: Cysts, cystic lesions, and papillary lesions.Ultrasound Clin 2007, 1:617-629

7. Doshi DJ, March DE, Crisi GM, Coughlin BF: Complex cystic

breast masses: diagnostic approach and imaging-pathologiccorrelation. Radiographics 2007, 27:53-648. Berg WA, Campassi CI, Iofe OB: Cystic lesions o the breast:

sonographic-pathologic correlation. Radiology 2003, 227:183-191

9. Hutchinson WB, Tomas DB, Hamlin WB, Roth GJ, PetersonAV, Williams B: Risk o breast cancer in women with benignbreast disease. J Natl Cancer Inst 1980, 65:13-20