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May Month: 2013

UNUSUALVARIANTSOFFIBROADENOMABREAST
RiddhiJaiswal1,UrvasheeDwivedi2,SonalGhaoghave3.
CORRESPONDINGAUTHOR:
RiddhiJaiswal,
DepartmentofPathology,
KingGeorgesmedicaluniversity,chowk,
Lucknow226003.
Email:riddhiadvay@gmail.com
ABSTRACT:UNUSUALVARIANTSOFFIBROADENOMABREASTDIAGNOSEDONCYTOLOGY
Fibroadenomasarecommonbenignbreasttumoursthatdisplayacharacteristicmorphology,althoughseveralepithelialandstromalvariationsexist
which may pose a diagnostic difficulty. We are discussing a case series of four cases of benign fibroadenoma with morphological variations as
observed on cytology smears in the department of Pathology, KGMU, Lucknow, UP. Juvenile fibroadenoma constitutes only 4% of the total
fibroadenomaswithincidenceof0.5%peryear.
Anotherveryrarehistologicalfindingisthepresenceofmultinucleatedgiantcellsthroughoutthestromaofabenignfibroadenoma,morecommonly
foundincidentallywithintheinterlobularstromaofbreasttissue.
Similarlyapocrinemetaplasiahasbeenfoundtobe28%inacaseseries(ArnoKuijperet.al)of396casesoffibroadenoma.
Itisimportanttoidentifythesevariantsastheymaybemisinterpretedasmalignancy.
KEYWORDS:Fibroadenoma,variants,cytology

INTRODUCTION: Breast masses are uncommon in childhood. The majority of them are related to inflammation (infection or abscess) or benign
tumors as fibroadenomas. Juvenile fibroadenoma is a rare clinical entity comprising 4% of the total fibroadenomas, of which giant juvenile
fibroadenomaconstitutesonly0.5%.1Similarlyfibroadenomawithapocrinemetaplasiaandmultinucleatedstromalgiantcellsoccurrarelyintheage
group found in our series. We are presenting a series of 4 cases of fibroadenoma with these morphological variations each with case history,
radiologicalandcytologicalfindings.
CASEHISTORY
CASENO.1:A11yearoldfemalepatient(premenarchal)presentedwithlumpinleftbreastforadurationof4monthsincreasingprogressivelyin
size and not associated with pain. Family history, history of trauma, nipple discharge, fever, anorexia, or weight loss were absent. On local
examinationslightlytender,huge,nodularmassinleftbreastwasseen,whichwasfirminconsistency(Fig1).Theoverlyingskinwastenseand
shinywithprominentsuperficialveins.Leftbreastlumpmeasured10x8cmandwasnotfixedtounderlyingstructures.Therewasnodischarge
fromthenipple,andaxillarylymphadenopathywasabsent.Routinehematologicalandbiochemicalexaminationswerewithinnormallimits.ChestX
raywasnormal.Ultrasonographywascarriedoutwhichshowedheterogenousparenchymalpatternsuggestiveoffibroadenoma.
Cytologicalfindingsshowedcellularsmearswithlargemonolayeredsheetsandclustersofbenignepithelialandmyoepithelialcellsinabackgroundof
haemorrhage.Individualepithelialandmyoepithelialcellswereuniformroundtoovalwithblandnucleusandsmallamountofcytoplasm.Fairnumber
ofbarebipolarnucleiwerealsoseeninbackground.Mitoticactivitywasabsent.
BasedoncytologicalfindingsfinaldiagnosisofGiantjuvenilefibroadenomaofleftbreastwasgiven.
CASENO.2
A 17year old female patient presented with a lump in right breast for a duration of one and half years. Swelling was increasing gradually and
progressivelyinsizeassociatedwithmildpainandonandofffever.Menstrualandclinicalhistorywereunremarkable.Onlocalexaminationasingle
mobilefirmswellingwithwelldefinedmarginswasnoticedinrightbreastmeasuringabout1.5x1cm.Ultrasonographyconfirmedthepresenceofa2
cmsolidmassintherightupperquadrant.
Cytological findings showed cellular smears with monolayered sheets of benign ductal epithelial cells and myoepithelial cells which were round to
oval,haduniformroundnucleuswithblandchromatinmoderateeosinophiliccytoplasm.Fairno.ofcystmacrophages,barebipolarnucleiandfew
multinucleated giant cells were also seen in background.(Fig 2) Based on cytological findings a final diagnosis of benign fibroadenoma with
multinucleatedstromalgiantcellswasgiven.
CASENO.3
A19yearoldfemalepatientpresentedwithlumpinleftbreastforadurationof8monthsincreasingslowlyinsizeandnotassociatedwithpain.
Familyhistory,historyoftrauma,nippledischarge,fever,anorexia,orweightlosswereabsent.Onexaminationitwasabout2.5x2cmsinsize,
slightlytendertotouch,freelymobilewithnormaloverlyingskinnormal.
Cytology smears were cellular and show benign ductal epithelial cells arranged in large monolayered sheets and clusters in haemmorhagic
backgroundalongwithbarebipolarnucleiofmyoepithelialcells.SheetsofapocrinecellshavingroundnucleusandabundantEosinophilicgranular
cytoplasmwerealsoseen(Fig3)Basedonthecytologicalfeaturesdiagnosisoffibroadenomawithapocrinechangeswasgiven.
CASENO4:
A44yearfemalepatientpresentedwithbilateralbreastlumpsince89months.Theywerefirmandfreelymobilegraduallyprogressinginsizeand
notassociatedwithpain,discharge,fever,weightloss,anorexiaandanyotherlumpinaxilla.Onexamination1.5x1cmlumpwasfoundinrightand
0.5x0.8cminleftbreastonultrasound.Guidedsmearsfrombothrightandleftbreastwererichlycellularandshowedtypicalcytologicalfeaturesof
fibroadenomaalongwithnumerousstromalfragments(Fig4).Basedonthesefeatures,diagnosisoffibroadenomawithbenignphylloidesfeatures
breastwasgiven.
DISCUSSION:Juvenilefibroadenomaofthebreastisdefinedascircumscribed,oftenlarge,breastmassusuallyoccurringinadolescentfemales
withstromalandepithelialhypercellularitybutlackingtheleaflikegrowthpatternofphyllodestumors.Diagnosticcriteriaforjuvenilefibroadenomaare
1,2
Circumscribedandrarelymultiple
Biphasic stromal and epithelial process in which pericanalicular pattern is most common and lacks leaflike growth pattern in uniformly
hypercellularstroma.Fibroticareasmaybepresent
Lackofatypicalfeaturesinstromalikeperiductalincreaseincellularity,stromalovergrowth,cytologicatypia,andmitoticrate>3/hpf
Frequentepithelialandmyoepithelialhyperplasia

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Mostpatientsageis1020yearsasinourcase(11years)withameanageof15years.
Thedifferentialsofjuvenilefibroadenomaincludelowgradephyllodestumor,virginalhypertrophy,andrarelylipoma,hamartoma,breastabscess,
macrocyst,adenocarcinoma,andpseudoangiomatousstromalhyperplasia.Giantjuvenilefibroadenomaisabenigntumor,andtotalexcisionofthe
lumpwithconservationofnippleandareolaistheoptimaltreatment
In 1979 Rosen first described the presence of Multinucleated Stromal Giant Cells (MSGCs) in the breast, as an incidental finding in breast
specimensfrom14patientswithbreastcarcinomaandconcludedthatthesecellsrepresentedanonneoplasticandpossiblyreparativeprocess3.
All the patients were in perimenopausal age group (4050 years). However, our case showed presence of multinucleated stromal giant cells in a
teenagepatientwithbenignbreastdisease.ItwasfurthersuggestedthatVimentin/CD34positivefibroblastofmammarystromacouldbetheresultof
differentiationfromapluripotentialmesenchymalprecursorcellwiththepotentialtodifferentiatetowardseveralmesenchymallines.4,5Thedifferential
diagnosisincludesthemalignantphyllodestumourandbreastspindlecelltumour.6
Fibroadenoma of the breast is associated with an elevated risk for invasive breast cancer, especially in case of complex changes and epithelial
proliferationsinadjacenttissue.7Dupontetal8foundthatthecumulativeriskofinvasivebreastcarcinomainwomenwithcomplexfibroadenomas
(having one or more of the socalled complex features: epithelial calcifications, apocrine metaplasia), was 3.1 times that of women in the general
population,comparedwitharelativeriskof1.89timesinwomenwithnoncomplexfibroadenomas.KuijperAetal9performedastudyon396cases
offibroadenomaandfoundthatapocrinemetaplasiawasthemostfrequentcomplexfeature(28.0%).
Fibroadenomas and phyllodes tumors may have similar cytological appearances and identical clinical and radiological appearance. However, a
detailedstudyofcellularityofstromalfragments,andtheproportionofspindlecellsinthebackgroundareimportantfeaturesthatmaybehelpfulin
differentiation.10
CONCLUSION:.FineNeedleAspirationisanimportanttoolinraisinganalarmtothemanylookalikes(foreg.Apocrinemetaplasiaandapocrine
carcinoma)seeninthecomplexpathologyofthebreast,hencethesmearsmustbescreenedsignificantly.
REFERENCES:
1. D. B. Nikumbh, S. R. Desai, P. S. Madan, N. J. Patil, and J. V. Wader Bilateral Giant Juvenile Fibroadenomas of Breasts: A Case Report
PathologyResearchInternationalVolume2011(2011),ArticleID482046,4pages
2.A.BoothroydandH.Carty,Breastmassesinchildhoodandadolescence.Apresentationof17casesandareviewoftheliterature,Pediatric
Radiology,vol.24,no.2,pp.8184,1994.
3. Helen M Heneghan1, Sean T Martin1, Mary Casey2, Igdam Tobbia3, Fadel Benani3 and Kevin M Barry A diagnostic dilemma in breast
pathologybenignfibroadenomawithmultinucleatedstromalgiantcells,DiagnosticPathology2008,3:33
4.RosenP:MultinucleatedmammarystromalgiantcellsAbenignlesionthatsimulatesinvasivecarcinoma.Cancer1979,44(4):13051308
5. Berean K, Tron VA, Churg A, Clement PB: Mammary fibroadenoma with multinucleated stromal giant cells.American Journal of Surgical
Pathology1986,10(11):823827
6.KeeneyGL,RykaA,ReynoldsC:Benigntumoursofthebreastwithmultinucleatedstromalgiantcells.VirchowsArchiv:aninternationaljournal
ofpathology2001,439(6):76877
7.ArnoKuijper,EllenC.M.Mommers,ElskenvanderWall,andPaulJ.vanDiestHistopathologyofFibroadenomaoftheBreast:AmJClinPathol
2001115:736742
8.DupontWD,PageDL,ParlFF,etal.Longtermriskofbreastcancerinwomenwithfibroadenoma.NEnglJMed1994331:1015
9.KuijperA,ECMMommersECM,vanderWallE,vanDiestPJ.HistopathologyofFibroadenomaoftheBreast.AmJClinPathol2001115:73674
10.DusenberyD,FrableWJ.Fineneedleaspirationcytologyofphyllodestumor.Potentialdiagnosticpitfalls.ActaCytol.199236:21521.SimiV,
Moretti D, Iacconi P, Arganini M, Roncella M, Miccoli P, et al. Fine needle aspiration cytopathology of phyllodes tumor. Differential diagnosis with
fibroadenoma.ActaCytol.198832:636

Picture1:grossimageofgiantfibroadenoma

Picture2:fibroadenomawithstromalgiantcells.

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