|Year : 2018 | Volume
| Issue : 2 | Page : 95-97
Giant fibroadenoma in postmenopausal female
Vandana Verma Ahluwalia, Prerna Singh Saharan, Ankita Chauhan
Department of Radiodiagnosis, Sarojini Naidu Medical College, Agra, Uttar Pradesh, India
|Date of Web Publication||11-Oct-2018|
Dr. Vandana Verma Ahluwalia
Department of Radiodiagnosis, Sarojini Naidu Medical College, Agra - 282 002, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Giant fibroadenoma, with an overall incidence of <4%, is an uncommon variant of fibroadenoma. It is common in adolescent age group but sporadic in the elderly. The important differential is phyllodes tumor of the breast which also presents as rapidly enlarging mass. We herein report a case of a middle-aged woman with an unusually large fibroadenoma in the right breast and vascular calcification in the left breast.
Keywords: Breast arterial calcification, elderly female, giant fibroadenoma, microcalcification
|How to cite this article:|
Ahluwalia VV, Saharan PS, Chauhan A. Giant fibroadenoma in postmenopausal female. J Mahatma Gandhi Inst Med Sci 2018;23:95-7
| Introduction|| |
Fibroadenomas are the most common solid breast lesions found in women of all age groups. They present as firm, mobile, painless, easily palpable breast nodules. Various names describe these lesions such as the age-related term “juvenile fibroadenoma” and the size-related term “giant fibroadenoma.” Juvenile fibroadenoma may be multiple. Giant fibroadenoma is disproportionally large compared to the rest of the breast, with a diameter of more than or equal to 5 cm., Giant fibroadenomas are rare in presentation, with an incidence of <4% of all fibroadenomas.
| Case Report|| |
A 55-year-old woman presented with gradual, insidious enlargement of the right breast for more than 5 years with rapid increase and heaviness for 3 months. There was no history of nipple discharge, trauma, and surgery. She attained menopause 5 years back, and her family history was negative for breast cancer. There is no history of diabetes and hypertension, and laboratory parameters are insignificant. No history of hormone replacement therapy or medication was noted.
Local examination demonstrated pendulous enlargement of breast extending up to the infraumbilical region. A large lobulated lump could be palpated in right breast. It was nontender, firm in consistency, freely mobile within the breast tissue, and free from the chest wall. There was no lump in the left breast and either axilla.
Chest radiograph revealed diffusely enlarged (>10cm) fibroadenomatous right breast with scattered calcifications within. [Figure 1].
|Figure 1: (a) Chest radiograph with a magnified view (b) reveals enlarged lobulated pendulous breast outline extending till mid abdomen with amorphous macrocalcification scattered within isodense. No pleuroparenchymal or ribcage abnormality was seen|
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Digital mammography [Figure 2] showed a massive radiodense mass deforming the breast contour and ultimately replacing the breast parenchyma. Visualization of multiple scattered amorphous popcorn calcifications throughout the mass suggests benign calcification changes secondary to degenerating fibroadenoma. The left breast mammogram shows predominately fatty breast component without any focal abnormality. Multiple serpentine vascular calcifications in the left breast are likely breast arterial calcifications (BACs). The BAC presents as serpiginous, linear, and plaque-like calcifications or parallel, “tram track” pattern along vessel wall, which when seen in the breast tends to be peripheral and superficial.
|Figure 2: MLO (a) and CC (b) mammogram are showing large hyperdense mass replacing the parenchyma in the right breast with amorphous calcification. Vascular calcifications in the left breast|
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Ultrasonogram [Figure 3] showed well-encapsulated multilobulated hypoechoic lesion in the right breast without any vascularity. There was no evidence of cystic changes suggesting against phyllodes tumor (PT). The left breast showed predominantly hypoechoic parenchyma.
|Figure 3: Ultrasonographic correlation reveals multiple discrete and some coalescing heterogeneous hypoechoic lesions with well-encapsulated echogenic rim irregular echogenic capsule foci with acoustic reverberation shadowing|
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The patient underwent mastectomy, and diagnosis of fibroadenoma was confirmed on histopathology of excised breast tissue.
| Discussion|| |
Fibroadenoma is a benign breast disease having abnormal growth of the glandular and fibrous tissue. It is common in women of reproductive age group, and our patient was in 5 years postmenopausal phase.
They are of varying number and size in all quadrants of the breast. Fibroadenomas more than 5 cm in diameter (about 4% of the total) are known as giant fibroadenomas; however, this is not a universally accepted terminology. When found in an adolescent girl, it is more appropriate to call it a juvenile fibroadenoma.
Giant fibroadenoma lesions are rapidly growing masses, causing breast asymmetry, overlying skin distortion, and stretching of the nipple. Postmenstrual changes may result in regression, calcification, or both. Degenerating fibroadenoma shows coarse calcification.
The typical sonographic appearance of a fibroadenoma is a well-circumscribed, round or oval macrolobulated, compressible, mobile, nontender mass with relatively uniform hypoechogenicity. Rarely, sonography may reveal heterogeneity in echotexture, due to necrosis or dystrophic calcification, a finding which is more common in older women., Ovoid lesions could have a horizontal or parallel growth pattern wherein its long axis runs parallel to the chest wall.,, During a Doppler ultrasound evaluation, these lesions may demonstrate some central vascularity or no vascularity. A fibroadenoma on mammography will appear as a round-to-oval, well-defined, macrolobulated mass. Calcification appears as small, peripheral, punctate densities that coalesce into popcorn-like calcifications.
Vascular calcification or BAC seen on mammography are called Mönckeberg calcifications and involve the middle layer of the arteries. They appear as serpiginous, linear, and plaque-like calcifications and are typical calcifications which are easily recognized; however, atypical vascular calcification may mimic malignancy. BAC reported as a risk factor for coronary artery disease (CAD) independent of age; hence, radiologists should report the presence of BAC.
Histologically, giant fibroadenoma has more cellularity and less of lobular components compared to simple fibroadenomas. It shows no features of malignant transformation.
Differential diagnosis of solitary or multiple giant masses includes a wide variety of breast conditions such as PT, virginal hypertrophy, hamartoma, lipoma, cyst, abscess, and carcinoma. Distinguishing these entities is essential for treatment as some of the lesions are treated by mastectomy, but some may require only local excision, aspiration, or conservative management.,
PT of the breast is an uncommon fibroepithelial tumor with epithelial and highly cellular stromal components. Although occurring in all age groups, they are common in women over 35 years of age but rare in an adolescent. They do not show calcifications. Virginal breast hypertrophy is rapid, often asymmetrical and distressing enlargement of one or both breast. Giant lipoma can also lead to unilateral breast hypertrophy, presenting as a soft mobile mass on palpation.
Surgical excision using a circumareolar incision is preferred in patients older than 35 years and those with large tumors to avoid missing an occult malignancy within the fibroadenoma. However, young women could be managed conservatively or followed up.
| Conclusion|| |
The rapid growth and large size of a giant fibroadenoma together determine the difficulties in the clinical approach. This case is unusual in the presentation for its enormous size with progressive enlargement in a postmenopausal patient even without any documented estrogen therapy. Conservative breast surgery is the treatment of choice for these tumors owing to their benign nature. Mammogram report should mention vascular calcification as it is an independent risk factor for CAD irrespective of age group.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Rattan K, Kumar S, Dhull AK, Kaushal V, Kaur P. Giant fibroadenoma mimicking phyllodes tumor in a young female: A cytological dilemma. Internet J Third World Med 2008;6:2.
Raganoonan C, Fairbairn JK, Williams S, Hughes LE. Giant breast tumours of adolescence. Aust N
Z J Surg 1987;57:243-7.
Bauer BS, Jones KM, Talbot CW. Mammary masses in the adolescent female. Surg Gynecol Obstet 1987;165:63-5.
Sklair-Levy M, Sella T, Alweiss T, Craciun I, Libson E, Mally B, et al.
Incidence and management of complex fibroadenomas. AJR Am J Roentgenol 2008;190:214-8.
Cole-Beuglet C, Soriano RZ, Kurtz AB, Goldberg BB. Fibroadenoma of the breast: Sonomammography correlated with pathology in 122 patients. AJR Am J Roentgenol 1983;140:369-75.
Kronemer KA, Rhee K, Siegel MJ, Sievert L, Hildebolt CF. Gray scale sonography of breast masses in adolescent girls. J Ultrasound Med 2001;20:491-6.
Goel NB, Knight TE, Pandey S, Riddick-Young M, de Paredes ES, Trivedi A, et al.
Fibrous lesions of the breast: Imaging-pathologic correlation. Radiographics 2005;25:1547-59.
Duhn V, D'Orsi ET, Johnson S, D'Orsi CJ, Adams AL, O'Neill WC, et al.
Breast arterial calcification: A marker of medial vascular calcification in chronic kidney disease. Clin J Am Soc Nephrol 2011;6:377-82.
Muttarak M, Chaiwun B. Imaging of giant breast masses with pathological correlation. Singapore Med J 2004;45:132-9.
Uygur F, Yigitler C. Rare juvenile giant fibroadenoma. J Br Health 2009;5:164-6.
Wurdinger S, Herzog AB, Fischer DR, Marx C, Raabe G, Schneider A, et al.
Differentiation of phyllodes breast tumors from fibroadenomas on MRI. AJR Am J Roentgenol 2005;185:1317-21.
[Figure 1], [Figure 2], [Figure 3]