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Year : 2014 | Volume : 2 | Issue : 1 | Page : 47 - 48  


Case Reports
Fibroadenoma with Spontaneous Infarction: An Unusual Case.

Divyagna Thatikonda1, Indira Velagandla2, Mahesh Kumar Kandukuri3, Sudhir kumar Vujhini4

1Asst. Professor, 2Professor and Head, 3Asst. Professor, 4Assosciate professor, Dept. of Pathology, Malla Reddy Institute of Medical Sciences, Suraram, Hyderabad, Andhra Pradesh.

Abstract:

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. Spontaneous infarction is an uncommon complication of fibro adenoma of the breast. Although infarction following fine needle aspiration (FNA) has been reported in the literature, infarction encountering on first time aspiration is very rare. Lack of knowledge of this entity may lead to a false diagnosis of inflammatory lesion like mastitis and carcinoma on cytology smears. In young patients with breast lumps, if the aspirated material is necrotic, the probable diagnosis of spontaneous infarction should always be kept in mind. Viable fibroadenomatous tissue should be searched for in the FNA smears.

Key words: Fibroadenoma, Infarction, Breast tumors

Corresponding Author: Dr. Divyagna T, Dept. of Pathology, MallaReddy Institute of Medical Sciences, Suraram, Hyderabad, Andhra Pradesh E mail : t.divyagna@yahooo.com

Introduction

Fibroadenomas are the most common benign neoplasms of the breast usually affecting adolescents and young women, they can occur at any age in premenopausal women. Clinically, fibroadenoma presents as a palpable mass and may occasionally be mistaken for inflammatory lesions due to pain and tenderness or for malignancy due to hardness, fixation to the surrounding tissue or bloody nipple discharge [1, 2, 3]

Infarction in benign breast lesions is rare and may occur in various conditions, including fibroadenomas. Infarction within a fibroadenoma was first described by Delarue and Redon in 1949 and may occur during pregnancy, lactation, trauma or following fine needle aspiration biopsy (FNA). [4-6] Spontaneous infarction is an infrequent complication of fibroadenoma and only a few cases (0.5–1.5%) are described in the available literature. [2-6]

Here, we report one such rare case of spontaneous infarction of fibroadenoma in a 16-year-old adolescent girl with no etiologic factors.

Case report

A 16-year-old girl presented with a lump in her right breast since one month. The lump was slowly increasing in size. The patient had no history of pain, trauma or any other previous breast disease.

On examination, a 3x2 cm, firm, non tender well-circumscribed mass was palpated in the upper outer quadrant of the right breast. On ultrasound, the mass was oval, well circumscribed with smooth and sharp margins, and a homogeneous texture with a diagnosis of fibroadenoma.

On cytology, the smears showed occasional clusters of ductal cells with bland nuclear features, plenty of bare nuclei and necrotic debris over a hemorrhagic background. Considering clinical and cytological features a diagnosis of “benign breast disease- Fibroadenoma with? Necrosis” was given.

Grossly, the specimen showed a well-encapsulated tumor mass measuring 3.5x3x1.5 cu.cm. Cut-surface was pale, gray-brown, glistening and semi viscous and showing slit-like spaces. Histologically, the lesion showed well encapsulated mass with stroma and ducts showing coagulative necrosis; occasional viable ducts noted. Several congested large vessels were seen at the periphery of the tumor along with inflammatory cell infiltrate. The histological diagnosis given was “infracted fibroadenoma with secondary inflammation”

Discussion

Fibroadenoma is the third most common lesion of the breast following fibrocystic changes and carcinoma, and constitutes about 20% of all benign breast lumps. Only 0.5% of all fibroadenomas show partial or complete infarction, especially during pregnancy and lactation. The most characteristic features of spontaneous infarction in fibroadenoma is its association with pregnancy and breast-feeding. The pathophysiology of the necrosis is related to relative vascular failure, which would be more easily explained in periods of high metabolic activity in the breast, such as during pregnancy or breastfeeding.

Infarction of fibroadenoma associated with thrombo-occlusive vascular changes in the feeding vessels was documented in the literature. Our case did not show any evidence of thrombo-occlusive vascular changes. Infarction following fine needle aspiration has been reported in the literature. [5, 6] However, this fails to explain the infarction of fibroadenomas in young patients, where there is no increase in metabolic demand or demonstrable thrombo-occlusive vascular changes or no history of previous FNAC as in our case.

On clinical examination, an infarcted fibroadenoma is likely to be mistaken for an inflammatory lesion because of rapid enlargement with pain and tenderness, or for carcinoma because of fixation of the mass and lymphadenopathy. [6] Our case had no history of pain, was an unmarried adolescent girl and the lump was freely mobile.

On fine needle aspiration cytology, infarcted fibroadenoma needs to be differentiated from mastitis, duct ectasia, and even carcinoma. On frozen section and histological examination, these lesions are confused with carcinoma because of necrosis and ghost epithelial cells. [6] Microscopic examination of the sections taken from the peripheral grey white area of the breast mass usually show features of a classic fibroadenoma whereas sections taken from the central brownish area show extensive necrosis. Ghost architecture of the epithelial fronds with focal glandular outlines, extravasated red cells, karyorrhectic debris, macrophages and mixed inflammatory cells may be seen. Reticulin stains show preserved reticulin network.

Sometimes infarction may lead to an increase in size, fixation of the mass to adjacent soft tissues with peripheral reactive changes and axillary lymphadenopathy. The clinical findings will increase the suspicion of malignancy. The presence of necrotic ductal and glandular outlines, which may bear a superficial resemblance to adenocarcinoma, may also create confusion. Preservation of the architecture and the presence of benign viable tissues, most often at the periphery of the tumor is usually sufficient evidence of the benign nature of the neoplasm. However, the presence of partial or complete necrosis with evidence of recent hemorrhage obscure the nature of pathology and apparent infiltration of fat may mimic carcinoma. As the reticulin network is usually preserved in infarcted fibroadenoma, reticulin stain is useful as an additional feature that helps in the diagnosis. Sections taken from the periphery of the mass usually reveal viable fibroadenomatous tissue. [6]

We conclude that spontaneous infarction is a rare event in breast fibroadenomas and may not be associated with any known risk factor. The presence of necrosis on cytology, core biopsy or intra-operative frozen section should be cautiously interpreted and is not itself a sign of malignancy. [5] This case is presented because of its rarity and to discuss the diagnostic difficulties which it possesses.

 

References:

  1. Liu H, Yeh ML, Lin KJ, Huang CK, Hung CM, Chen YS. Bloody nipple discharge in an adolescent girl: unusual presentation of juvenile fibroadenoma. Pediatr Neonatol. 2010;51(3):190–2
  2. Oh YJ, Choi SH, Chung SY, Yang I, Woo JY, Lee MJ. Spontaneously infarcted fibroadenoma mimicking breast cancer. J Ultrasound Med. 2009;28(10):1421–3.
  3. Rajesh Singh Laishram. Spontaneous Infarction of Fibroadenoma of the Breast in a Young Girl Mimicking Carcinoma. Iranian J Pathology 2010;5(4):212-5
  4. Fowler CL. Spontaneous infarction of fibroadenoma in an adolescent girl. Pediatr Radiol. 2004;34(12):988–90.
  5. Skenderi F, Krakonja F, Vranic S. Infarcted fibroadenoma of the breast: report of two new cases with review of the literature. Diagn Pathol. 2013 Feb 27;8:38.
  6. Toy H, Esen HH, Sonmez FC, Kucukkartallar T. Spontaneous Infarction in a Fibroadenoma of the Breast. Breast Care (Basel) 2011;6(1):54–55. 

Figure 1: necrotic tissue (arrows) and viable benign ductal epithelial cells (400x). Inset oil immersion1000x

 

 

Fig. 2: Cut section of fibroadenoma with glistening surface.