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Breast Imaging Case of the Day

¹ Departments of Radiological Sciences (D.C.)
² Internal Medicine (M.P.)
³ Pathology (S.E.C.), University of California, Irvine Medical Center, 101 The City Drive, Orange, CA 92868-3298

Index Terms: Breast neoplasms, 00.3112 • Drugs, effects, 00.64 • Fibroadenoma, 00.3112

	HISTORY

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A 28-year-old woman with immunosuppression from cyclosporin A and steroid therapy began noticing increasing breast size 1 year after undergoing renal transplantation for idiopathic end-stage renal disease. The patient had no previous history of breast signs or symptoms. During the next year, her breast size "doubled" bilaterally and multiple, slightly tender breast masses were palpated. At initial clinical examination, the breast masses were 1–3 cm in diameter. Over the next 6 months, many of the masses doubled or tripled in size. Mammography and ultrasonography were performed.

	FINDINGS

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Craniocaudal mammography demonstrated numerous circumscribed masses bilaterally (Fig 1). Ultrasonography revealed multiple bilateral, sharply circumscribed hypoechoic masses surrounded by highly echogenic stroma (Fig 2). Ultrasound-assisted core biopsy was performed for diagnosis.

View larger version (95K): [in this window] [in a new window] [Download PPT slide]   Figure 1a.  Craniocaudal mammograms of the right (a) and left (b) breasts demonstrate multiple large, scattered, circumscribed masses bilaterally.

View larger version (108K): [in this window] [in a new window] [Download PPT slide]   Figure 1b.  Craniocaudal mammograms of the right (a) and left (b) breasts demonstrate multiple large, scattered, circumscribed masses bilaterally.

View larger version (139K): [in this window] [in a new window] [Download PPT slide]   Figure 2.  Ultrasonogram of the right breast demonstrates representative large, well-circumscribed hypoechoic masses against a background of echogenic stroma.

	DISCUSSION

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Fibroadenoma is a benign tumor that arises from the epithelium and stroma of the terminal duct lobular unit and is the most common breast tumor in adolescent girls and young women (1). In most cases, the fibroadenoma is solitary and is palpated by the patient. Multiple fibroadenomas occur in about 15% of affected patients (1). The majority of fibroadenomas are less than 3 cm in diameter; only about 10% of fibroadenomas are greater than 4 cm (2). Fibroadenomas more than 5 cm in diameter or weighing more than 500 grams are known as giant fibroadenomas (3–5). Giant fibroadenomas are the most common cause of massive breast enlargement in young females (4).

Multiple giant fibroadenomas are rare; to our knowledge, only 22 cases have been reported (4). Multiple giant fibroadenomas occur mainly in adolescent black girls (4–7). These lesions commonly recur after excision or are replaced by newly arising lesions and may result in massive breast enlargement and deformity bilaterally, sometimes requiring mastectomy (3,5,7).

The giant fibroadenomas seen in adolescent girls tend to be of the juvenile type, with prominent stromal cellularity, ductal hyperplasia, and stromal collagenation (5,7,8). In our patient, the giant fibroadenomas were of the adult type and did not demonstrate these proliferative changes.

A total of 12 cases of multiple fibroadenomas in association with cyclosporin A therapy were described by Baildam et al (9) and Rolles and Calne (10). The size of the fibroadenomas was not specified, but most of the lesions were palpable. Unlike the present case, none of these 12 cases involved giant fibroadenomas. In the study by Baildam et al (9), fibroadenomas were seen in 13 of 29 women with renal transplants who had undergone cyclosporin A therapy. Ten cases involved multiple lesions, and in five cases, the lesions were bilateral. There were no abnormal breast findings in 10 women treated with steroids and azathioprine alone. In one of the two cases reported by Rolles and Calne (10), there was resolution of the masses after cessation of cyclosporin A therapy. In none of the reported cases was there an inexorable increase in lesion size necessitating mastectomy.

Various mechanisms for the association of cyclosporin A with multiple fibroadenomas have been suggested, including effect on fibroblasts (some fibroblasts have cyclosporin receptors), effect on hypothalamic-pituitary axis (demonstrated in rats), and, less likely, resolution of uremia (9).

Multiple giant fibroadenomas manifest as well-defined round, oval, or lobulated masses at mammography. At ultrasonography, well-defined, homogeneously hypoechoic solid masses embedded in a highly echogenic stroma (as seen in this case) have been reported (4,11). A single supplying vessel has been described at Doppler sonography (4). In one previously reported case, T1- and T2-weighted magnetic resonance (MR) imaging showed well-circumscribed, encapsulated masses with low signal intensity (4). Dynamic contrast material–enhanced MR imaging demonstrated rapid enhancement within 1 minute, so that malignancy could not be excluded.

Fibroadenomas and cysts may be indistinguishable at both physical examination and mammography. Once cysts are excluded with ultrasonography, the differential diagnosis of multiple large, circumscribed masses includes giant fibroadenomas, phyllodes tumors, and (particularly in immunosuppressed patients) lymphoma.

Mammographic differentiation of giant fibroadenomas from phyllodes tumors is not possible because all these lesions, benign or malignant, may manifest as smooth, sharply defined round or lobulated masses (12). At ultrasonography, the presence of clefts or cysts in a well-defined solid mass would favor the diagnosis of phyllodes tumor; however, this finding is not pathognomonic (12) and biopsy is mandatory.

The mean age of patients with fibroadenomas is 30 years; in contrast, that of patients with phyllodes tumors is about 45 years (1,2). However, phyllodes tumors may also occur in adolescent girls and young women. Furthermore, these lesions are usually unilateral, although they may be bilateral (5).

The presence of fibroadenomas is considered a slight risk factor for breast cancer (13). To our knowledge, no malignant degeneration has been reported in patients with multiple giant fibroadenomas. In contrast, phyllodes tumors may undergo malignant degeneration in a small percentage of cases (12).

In this case, results of ultrasound-assisted core needle biopsy helped confirm the diagnosis. The patient subsequently underwent bilateral subcutaneous mastectomy and reconstruction (Figs 3, 4).

View larger version (103K): [in this window] [in a new window] [Download PPT slide]   Figure 3.  Photograph of resected tissue from the right breast demonstrates multiple circumscribed masses 2–9 cm in diameter.

View larger version (169K): [in this window] [in a new window] [Download PPT slide]   Figure 4.  Photomicrograph (original magnification, x80; hematoxylin-eosin stain) of a fibroadenoma shows a proliferation of sparsely cellular, mainly fibrous stroma and glandular elements with slitlike lumens ("intracanalicular pattern"), features that are diagnostic for fibroadenoma.

	Footnotes

 
Address reprint requests to D.C.

From the 1998 RSNA scientific assembly.

Received for publication September 30, 1998. Revision received October 7, 1998. November 6, 1998. Accepted for publication November 6, 1998.

	References

Top HISTORY FINDINGS DISCUSSION References

 

1. Rosen PP. Rosen's breast pathology Philadelphia, Pa: Lippincott-Raven, 1997; 143-175.
2. Foster ME, Garrahan N, Williams S. Fibroadenoma of the breast: a clinical and pathological study. J R Coll Surg Edinb 1988; 33:16-19.[Medline]
3. Kuusk U. Multiple giant fibroadenomas in an adolescent female breast. Can J Surg 1988; 31:133-134.[Medline]
4. Schneider B, Laubenberger J, Kommoss F, Madjar H, Grone K, Langer M. Multiple giant fibroadenomas: clinical presentation and radiologic findings. Gynecol Obstet Invest 1997; 43:278-280.[Medline]
5. Musio F, Mozingo D, Otchy DP. Multiple giant fibroadenoma. Am Surg 1991; 57:438-441.[Medline]
6. Hart J, Lafield LJ, Trumbull WE, Brayton D, Barker WF, Giuliano AE. Practical aspects in the diagnosis and management of cystosarcoma phyllodes. Arch Surg 1988; 123:1079-1083.[Abstract]
7. Fekete P, Petrek J, Majmudar B, Someren A, Sandberg W. Fibroadenomas with stromal cellularity: a clinicopathologic study of 21 patients. Arch Pathol Lab Med 1987; 111:427-432.[Medline]
8. Pike AM, Oberman HA. Juvenile (cellular) adenofibromas: a clinicopathologic study. Am J Surg Pathol 1985; 9:730-736.[Medline]
9. Baildam A, Higgins RM, Hurley E, et al. Cyclosporin A and multiple fibroadenomas of the breast. Br J Surg 1996; 83:1755-1757.[Medline]
10. Rolles K, Calne RY. Two cases of benign lumps after treatment with cyclosporin A (letter). Lancet 1980; ii:795.
11. Fornage BD, Lorigan JC, Andry E. Fibroadenoma of the breast: sonographic appearance. Radiology 1989; 172:671-675.[Abstract/Free Full Text]
12. Czum JM, Sanders LM, Titus JM, Kalisher L. Breast imaging case of the day. RadioGraphics 1997; 17:548-551.[Medline]
13. Dupont WD, Page DL, Parl FF, et al. Long-term risk of breast cancer in women with fibroadenoma. N Engl J Med 1994; 331:10-15.[Abstract/Free Full Text]

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This Article Figures Only Full Text (PDF) Submit a response Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Cyrlak, D. Articles by Carpenter, S. E. Search for Related Content PubMed PubMed Citation Articles by Cyrlak, D. Articles by Carpenter, S. E. Related Collections Breast (Imaging and Interventional) Mammography