Pseudoangiomatous Stromal Hyperplasia Research Articles

Novel Pseudoangiomatous Stromal Hyperplasia Mass in a Breast Hamartoma: A Case Report

Breast fibroadenolipomas, otherwise known as hamartomas, are a relatively rare finding in regard to the occurrence of breast masses. Breast hamartomas make up approximately 4.8% of benign breast tumors in women. Breast hamartomas are uncommon, and our case presents with a 4.7 cm hamartoma with a focal, irregular mass inside of it which was histologically confirmed as pseudoangiomatous stromal hyperplasia (PASH). PASH is a benign mesenchymal lesion of the breast that is characterized by dense collagenous stroma forming “pseudoangiomatous” capillary-like spaces lined by spindle cells. [1] A rare condition overall, PASH is predominately discovered in premenopausal women, with fewer than 1,500 cases of PASH documented in literature [1]. Therefore, our case presentation describes a combination of two relatively rare phenomena within one palpable breast mass. Due to the absence of symptoms, the patient was scheduled for interval follow up to monitor the breast hamartoma for interval change in size, and definitive treatment by elective surgical excision was offered if accompanying symptoms developed.

Giant Pseudoangiomatous Hyperplasia of the Breast Stroma: About A Complicated Case of Gigantomastia

Pseudoangiomatous stromal hyperplasia (PASH) is a lesion that is often discovered incidentally in breast biopsies performed for benign or malignant lesions of the breast. More rarely, it may present as a palpable lesion. The term "Pseudoangiomatous" has been proposed to underline its particular histological aspect simulating a vascular proliferation. We report a case of PASH in a 42-year-old female patient presenting as a recurrent lesion that resulted in a considerable and rapid increase in breast volume (135 x 100 x 97mm) requiring a large lumpectomy with muscular-fat remodeling. Angiosarcoma and fibroadenoma remain the main differential diagnoses. Anatomopathological examination allows us to eliminate them, in particular through immunohistochemistry.

PSEUDOANGIOMATOUS STROMAL HYPERPLASIA,BENIGN PROLIFERATIVE BREAST DISEASE - A RARE CASE DIAGNOSED ON HISTOPATHOLOGY

Introduction: Pseudoangiomatous stromal hyperplasia (PASH) is a benign mesenchymal proliferative lesion of the breast. Case Report: A 25years old female present in surgery department with complain of right breast lump since 2 months. FNAC : Phyllodes tumor USG: Phyllodes tumor, more likely BIRADS category III Discussion: Pseudoangiomatous stromal hyperplasia is a rare but benign breast lesion presenting mostly in premenopausal women. It may be found incidentally in routine biopsy performed in benign or malignant disease of the breast.

Pseudoangiomatous Stromal Hyperplasia: Radiologic-Pathologic Correlation.

Pseudoangiomatous stromal hyperplasia (PASH) is a benign mesenchymal proliferative lesion of the breast. PASH is postulated to be hormonally induced and predominantly occurs in premenopausal women and postmenopausal women on menopausal hormone therapy. Clinical presentation varies from screen-detected lesions to palpable masses. Imaging findings of PASH are nonspecific. The most common mammographic findings are an oval or round circumscribed non-calcified mass or developing asymmetry. On US, PASH is often seen as an oval hypoechoic mass that may be circumscribed and can have an echogenic rim, or, when manifest as mammographic asymmetry, US may show a corresponding non-mass focal area of echogenic tissue. Limited studies have investigated the MRI appearance, with PASH most often manifesting as non-mass enhancement, or, less often, as an oval or irregular mass with persistent kinetics. Histopathologically, PASH can be mistaken for a fibroadenoma or phyllodes tumor and has features overlapping low-grade angiosarcoma. Assessment of radiologic-pathologic concordance is particularly important as PASH is often an incidental finding, adjacent to the targeted lesion at histopathology. Surgical excision or repeat core-needle biopsy is necessary for discordant suspicious cases. After a benign, concordant diagnosis of PASH, the patient may resume routine screening.

556 Case Report: Diagnosis of Bilateral PASH (Pseudoangiomatous Stromal Hyperplasia) in an 11-Year-Old Female

Abstract PASH (Pseudoangiomatous stromal hyperplasia) is a rare pathological finding, defined as a benign mesenchymal proliferative lesion of the breast, presenting more frequently in premenopausal women. Although benign, differentiation from low grade Angiosarcoma due to their histological similarities. Management guidelines for PASH remain primitive due to the rarity in diagnosis and reporting of such cases. We present a very interesting case of an 11-year-old female assessed for her rapidly enlarging breasts. Initial management entailed right breast reduction Mammoplasty due to the presumed diagnosis of Macromastia. Histopathological assessment of the specimen initially reported the presence of Fibroadenoma. However, re-assessment by a senior Pathologist subsequently diagnosed the lesion as Pseudoangiomatous Stromal Hyperplasia (PASH). Further MRI imaging of both breasts revealed multiple, large, bilateral lesions. All identified bilateral breast lesions were excised, with a cumulative weight of 1.6 Kg, combined with WISE pattern reduction of the right breast overlying skin was carried out in due course. There has been no previous reporting of PASH in an 11-year-old female, which itself is a rare condition. Further studies on PASH are recommended to reduce the risk unnecessary surgical management of such cases due to misdiagnosis.

Spindle Cell Lesions of the Breast: A Diagnostic Algorithm.

Spindle cell lesions of the breast represent a broad spectrum of entities, ranging from nonneoplastic reactive conditions to high-grade malignant tumors. The wide range makes breast spindle cell lesions a diagnostic pitfall. To review the classification of spindle cell lesions of the breast, including clinical features, morphologic characteristics, and the role of immunohistochemistry as well as molecular tools in assisting the differential diagnosis. A diagnostic algorithm will be proposed. Literature and personal experience are the sources for this study. Spindle cell lesions of the breast can be classified as biphasic or monophasic, with the former including both spindle cell and epithelial components, and the latter including only spindle cell elements. Each category is further subclassified as low or high grade. In the biphasic low-grade group, fibroadenoma and benign phyllodes tumor are the most common lesions. Other uncommon lesions include hamartoma, adenomyoepithelioma, and pseudoangiomatous stromal hyperplasia. In the biphasic high-grade group, borderline/malignant phyllodes tumor and biphasic metaplastic carcinoma are the main lesions to consider. In the monophasic low-grade group, reactive spindle cell nodule, nodular fasciitis, myofibroblastoma, fibromatosis, and fibromatosis-like metaplastic carcinoma have to be considered. In the monophasic high-grade group, the possible lesions are monophasic spindle cell metaplastic carcinoma, primary breast sarcoma, and metastases. Awareness of the clinical history and careful evaluation of any epithelial differentiation (with a large immunohistochemical panel) are crucial in the distinction.

Unknown Case: 74-year-old Woman With a Developing Asymmetry Within a Breast Hamartoma.

A 74-year-old female with a known mammary hamartoma in the inner right breast presented with a palpable lump in the left breast. Bilateral diagnostic mammogram (Figure 1) and targeted US (Figure 2) were performed. On diagnostic imaging, the left breast workup was negative. Incidentally noted was a developing asymmetry within the known right breast hamartoma in the lower inner right breast (Figure 1). Targeted diagnostic US showed a circumscribed solid lesion with mixed hyperechoic and hypoechoic components, consistent with the known hamartoma at 4 o’clock in the right breast. Within this hamartoma, there was a distinct 5-mm hypoechoic mass (Figure 2). Since breast hamartomas are a subtype of fibroepithelial lesion, they contain breast epithelium, collagenous stroma, and adipose tissue. The differential diagnosis for a breast mass within a hamartoma therefore includes lesions of epithelial origin, such as invasive ductal or lobular carcinoma, high-risk lesions, cysts, or lesions of stromal origin, such as pseudoangiomatous stromal hyperplasia. Lipid-rich carcinoma could be considered, although the long history of a stable fat-containing circumcised mass (presumed hamartoma) makes this rare entity less likely.

Bilateral Diffuse Pseudoangiomatous Stromal Hyperplasia Necessitating Mastectomy.

Pseudoangiomatous stromal hyperplasia (PASH) is an uncommon, benign breast lesion often diagnosed incidentally and frequently mistaken for fibroadenoma given similar radiographic appearance. Histopathology classically reveals diffuse, dense fibrous stromal background with a complex network of spindle cells forming slit-like spaces, giving it the appearance of angiomatous proliferation. Surgical excision is generally not necessary. Here we present two unusual cases of PASH: an adolescent patient with bilateral rapid onset of symptoms, and a premenopausal patient with bilateral, diffuse, recurrent PASH. Both required mastectomy. We aim to highlight the variable nature of presentation and briefly review current management options.

Giant Pseudoangiomatous Stromal Hyperplasia of the Adolescent Breast: A Case Report with Emphasis on Image Findings and Literature Review

Giant Pseudoangiomatous Stromal Hyperplasia of the Adolescent Breast: A Case Report with Emphasis on Image Findings and Literature Review

The Relationship of Pseudoangiomatous Stromal Hyperplasia (PASH)-Like Appearance in Invasive Breast Carcinomas with PASH Areas in Non-Tumoral Breast Parenchyma as Well as on Axillary Lymph Node Involvement.

The aim of this study were to determine the relationship of pseudoangiomatous stromal hyperplasia (PASH)-like appearance in invasive breast carcinomas (IBCs) with PASH foci in the non-tumoral breast parenchyma as well as axillary lymph node involvement. In this study, 200 consecutive cases with IBC were re-examined. Cases with and without PASH-like appearance in IBC were determined. Each case was assessed regarding the presence of accompanying PASH foci (CD34+, CD31-) in the non-tumoral areas in addition to other clinicopathological parameters. PASH-like appearance within the IBC was present in 22 of the 200 cases (11%) and absent in 178 (89%). The presence of PASH foci in the non-tumoral breast parenchyma was significantly more common in IBC with PASH-like appearance compared to the group without such areas. However, there was no significant difference between the groups regarding other clinicopathological parameters (age, tumor size, nuclear and histological grade, Estrogen receptor/Progesterone receptor status, HER2 status, and Ki-67 proliferation index), lymphovascular invasion (LVI), and axillary lymph node involvement. There was no significant difference between the two groups regarding the histopathological findings observed in the non-tumoral areas. PASH-like appearance within IBC was found to be associated with higher rate of PASH foci in the non-tumoral breast parenchyma. However, such cases do not show a difference as regards LVI and axillary lymph node metastasis.

English

Gigantomastia is a rare breast disease with massive bilateral enlargement of breast causing physical and psychosocial disability for the patient. Diffuse pseudoangiomatous stromal hyperplasia causing gigantomastia is a very rare presentation. We present a case of 45-year-old female with bilateral gigantomastia and cyclical mastalgia, who underwent bilateral mastectomy, postoperatively diagnosed with pseudoangiomatous hyperplasia. Gigantomastia is a rare condition characterised by excessive breast tissue growth resulting in massive enlargement of both breast. An arbitrary definition for gigantomastia is breast size more than 1.5 kg or when the breast tissue comprises 3 % or more of patients total body weight. Gigantomastia is accompanied by skin ulceration, postural problems, back pain, traction nerve injury and social stigmata. It is physically and psychosocially disabling for the patient. The aetiopathogenesis of gigantomastia is poorly understood, but generally classified as idiopathic, drug induced (penicillamine, cyclosporine) and due to hormonal imbalance (gestational and pubertal).1 Pseudoangiomatous stromal hyperplasia (PASH) is a benign mesenchymal proliferative disease of the breast which is usually an incidental finding accompanying other breast pathology like fibroadenoma, fibrocystic disease, breast cancer, gynaecomastia etc. It was first described by Vuitch, Erlandson and rosen (1986). Ibrahim et al. reported the occurrence of incidental microscopic PASH in breast specimens as around 23 %.2 Around 200 cases of PASH presenting as a tumoral palpable mass is there in literature. Another very rare and under recognised presentation is as diffuse PASH with bilateral or unilateral massive breast enlargement. Here we report a case of diffuse PASH with gigantomastia and a review of literature.

Upstaging of Fibroepithelial Lesions: A Single-Institution Experience.

Fibroepithelial lesions of the breast (FEL) are heterogeneous lesions ranging from fibroadenomas (FA) to phyllodes tumors (PT). FEL with cellular stroma are diagnostic challenges on core needle biopsy (CNB) as it is difficult to distinguish cellular FA from PT. The purpose of this study was to determine the features of FEL on CNB that may be predictive of PT, the upstage rate to PT after excision, and the outcomes of those who did not undergo excision. Overall, 305 patients with FEL on CNB between 2009 and 2019 were identified from a prospectively maintained institutional database. Presentation, imaging, and pathology were evaluated. Mean age at diagnosis was 43.8years. Pathology on CNB included 97 cases of FEL favoring FA, 19 cases of FEL favoring PT, 3 cases of FEL versus pseudoangiomatous stromal hyperplasia, and 186 cases of FEL not otherwise specified. Following CNB, 96 (31.5%) patients were observed, 158 (51.8%) patients had an excisional biopsy, 48 (15.7%) patients underwent segmental mastectomy, and 3 (1.0%) patients underwent a mastectomy. The upgrade rate from FEL on CNB to PT upon excision was 25.8%. PT on final pathology was more commonly seen when the CNB identified stromal overgrowth, necrosis, and diagnosis of FEL favoring PT. On multivariable analysis, a final diagnosis of PT was associated with age >50years, larger tumor size >2cm, stromal overgrowth, and ≥1 mitoses/10 high power fields (HPF) on CNB. Patients who were observed had smaller tumors compared with those who underwent excision. In this 10-year single-institution experience of FEL, the upstage rate to PT was 25.8%. Excision of FEL is recommended. Furthermore, the observation of lesions appeared to be safe in select cases, specifically in patients with smaller tumor size.

Випадок псевдоангіоматозної стромальної гіперплазії

Псевдоангіоматозна стромальна гіперплазія (PASH) — це рідкісне доброякісне фіброзне ураження, в основі якого лежить патологічне розростання мезенхімальної тканини з клітинною вистілкою, що імітує судини. В статті наведено випадок PASH у жінки 25 років з історією спостереження.

Myofibroblastic stromal hyperplasia of the breast

Myofibroblastic stromal hyperplasia (MSH) is the proposed name for a benign spindle cell proliferation of the mammary stroma, which often raises clinical and radiographic concern for a mass or a malignant process. Ten cases were retrieved from the files of our institution. All presented as a mammographic abnormality. Patients ranged in age from 24 to 67 years. Seven were <50 years old. The salient histopathologic aspect was the proliferation of benign appearing spindle cell within the intralobular stroma. The most common pattern was a diffuse proliferation of compact spindle cells with areas of perilobular/periductal accentuation. Mitotic activity and atypia were not seen. Tumor cells were positive for CD34 and SMA and negative for estrogen receptor, Beta-catenin, and p63. Only one of the cases demonstrated an associated lesion that explained the mammographic abnormality. Follow-up was available for four cases and was uneventful. MSH has overlapping features with the fascicular pattern of PASH and is likely related to pseudoangiomatous stromal hyperplasia (PASH) but differs in that does not demonstrate pseudovascular structures and it predominantly involves perilobular stroma. Recognition of this pattern will avoid discordant radiologic pathologic findings and unnecessary surgery/repeat biopsies.

Breast hamartoma: reassessment of an under-recognised breast lesion.

Breast hamartomas are an under-recognised lesion because they lack a distinctive microscopic appearance. Microscopic diagnosis can often conclude 'no significant lesion' or 'normal breast tissue', leading to repeated biopsies and diagnostic delay. We describe the histological, immunohistochemical and radiological features of breast hamartomas with the aim of identifying specific signs to facilitate their diagnosis and to differentiate them from normal breast and fibroepithelial lesions. Forty-seven breast hamartomas were reassessed (histological diagnosis and imaging features). An immunohistochemical study [oestrogen receptor (ER), progesterone receptor (PR), CD34, high-mobility group A2 (HMGA2)] was performed. On breast imaging, hamartomas most often presented as probably benign solid masses with circumscribed margins and variable densities. Histologically, breast hamartomas resembled normal breast, although their stromal component was predominant, separating randomly scattered epithelial elements with areas of pure collagenous stroma. Pseudoangiomatous stromal hyperplasia (PASH) was present in 93.6% of cases and CD34 antibody highlighted intralobular, perilobular and interlobular distribution of CD34-positive fibroblasts. By comparison, CD34 was mainly expressed in the intralobular normal breast tissue stroma. Hamartoma stromal cells expressed HMGA2, ER and PR in 79%, 66% and 76.3% of our cases, respectively, compared to 7.7%, 23% and 19% in normal breast tissue, respectively (P < 0.0001; P = 0.0005; P < 0.0001). After ascertaining that core needle biopsy is effectively intralesional, breast hamartomas can be diagnosed with confidence by taking into account the presence of stromal changes, PASH, interlobular distribution of CD34-positive fibroblasts, HMGA2 and hormonal receptor stromal expression.

Primary Breast Tumors with Mesenchymal Morphology.

Overview Mesenchymal tumors of the breast are rare. Few epithelial tumors also have mesenchymal components. It is crucial to identify these as per histogenesis. This can be facilitated by markers of epithelial–mesenchymal transition (EMT). Objectives The aim of this study was to categorize the breast lesions with mesenchymal morphology and to study EMT on immunohistochemistry (IHC). Materials and Methods This is a retrospective study of 5-year duration from January 2015 to December 2019. Inclusion criteria: all breast lesions showing mesenchymal/nonepithelial morphology, complete or partial, on histology. Exclusion criteria: Mammary carcinomas without any mesenchymal/nonepithelial morphology, fibroadenomas, and lymphomas. Demographics, clinical, gross examination, histology, and IHC findings of selected cases were reviewed and recorded. Three additional markers p53, E-cadherin, and β-catenin were performed. Statistical Analysis Used Frequency calculation for each variable (IHC). Results Thirteen (2.5%) out of total 510 breast specimens showed mesenchymal histology. Of these, five (38.5%) were metaplastic breast carcinomas (MBC), four (31%) were phyllodes tumor (PT), and one (7.7%) case each of malignant peripheral nerve sheath tumor, primary stromal sarcoma of breast, pseudoangiomatous stromal hyperplasia, and myofibroblastoma. Loss of E-cadherin was seen in 4/5 (80%) MBCs and was retained in ductal component of PTs. p53 was not expressed in any of the tumors except 3/5 (60%) MBCs. β-Catenin was aberrant in all MBCs. Conclusions Primary breast tumors with mesenchymal morphology present a spectrum ranging from benign mesenchymal, fibroepithelial neoplasms to malignant tumors of mesenchymal and epithelial origin. Loss of E-cadherin, expression of p53, and aberrant expression of β-catenin are suggestive of EMT and molecular heterogeneity of MBCs.

Gynaecomastia-like hyperplasia of axillary ectopic breast tissue – a case report

Aim: To highlight the incidental finding of gynaecomastia-like hyperplasia of axillary ectopic breast tissue in a female patient, with review of the literature. Case report: A 36 year old multiparous female presented for surgical management of right axillary ectopic breast tissue on a background history of a previously excised right lower quadrant breast lesion one year prior that showed a 29mm grade 3 invasive breast carcinoma of no special type with triple negative immunophenotype. The sentinel nodes were uninvolved and excision margins were clear. She underwent neoadjuvant chemotherapy and local radiotherapy. There was no radiological or clinical evidence of recurrence at the one year mark. Excised axillary fibroadipose tissue histologically showed benign breast ducts without lobules demonstrating occasional micropapillary hyperplasia, as well as stromal pseudoangiomatous stromal hyperplasia (PASH). There was no evidence of in-situ or invasive malignancy. The overall appearance was that of gynaecomastia-like hyperplasia. Discussion: Gynaecomastia-like hyperplasia is a rare finding in breast specimens in female patients. It is exceedingly rare in ectopic breast tissue, with only a single case report in the literature to date. The spectrum of histologic changes are characteristic, although the pathogenesis is poorly understood due to the rare nature of this process.

Psödoanjiyomatöz stromal hiperplazinin shear dalga elastografi bulguları

Pseudoangiomatous stromal hyperplasia (PASH) is a benign entity defined in 1987. Conventional breast imaging methods, including mammography, ultrasonography, and magnetic resonance imaging findings have been published in the literature before. Sonoelastography (SE) is an imaging method that allows us to evaluate tissue stiffness in vivo. Many studies have shown that SE increases the specificity of B-mode US in the discrimination of benign-malignant lesions. In this case report, it was shown that PASH is of high stiffness in shear wave elastography evaluation. To our best knowledge, this is the first case presenting SWE findings of PASH in the published literature.

Excision of giant pseudoangiomatous stromal hyperplasia and its surgical challenges.

Excision of giant pseudoangiomatous stromal hyperplasia and its surgical challenges.

Abstract PS3-20: Rapid beside diagnosis of breast core needle biopsies using stimulated raman histology

Abstract Image-guided core needle biopsy plays a central role in the diagnosis and management of a wide range of breast lesions. After collection, tissue cylinders are transported from a biopsy suite to a pathology laboratory for analysis. The existing workflow for microscopic diagnosis of tissue specimens precludes the option of using histologic data to inform clinical decision-making at the time of biopsy. Here, we introduce stimulated Raman histology (SRH), a rapid label-free optical imaging method that enables microscopic imaging of unprocessed breast biopsy specimens in the biopsy suite within minutes of sample collection. SRH has been thoroughly validated for use in the detection and diagnosis of brain tumors but its use has not been validated in breast lesions. In our study, we collected core needle biopsy specimens and allocated a 2mm portion of the tissue sample for SRH imaging. Each specimen was imaged with SRH and subsequently fixed in formalin, embedded, stained and sectioned in a conventional manner. A board-certified breast pathologist first analyzed the diagnostic features of the imaged specimens with SRH and then with conventional H&amp;E-stained sections. In a pilot series of six patients, we found that SRH could differentiate between lesions that can mimic cancer such as a radial scar from neoplastic ones like invasive ductal carcinoma. SRH also demonstrated histologic differences between a benign tumor like a fibroadenoma and a malignant tumor like an invasive ductal carcinoma. We also observed diagnostic differences amongst benign processes such as radial scar and pseudoangiomatous stromal hyperplasia. Importantly, we showed that SRH is non-consumptive and the imaged tissue can be used for downstream histologic and immunohistochemical analysis. Our data provide proof of concept that SRH can reveal the diagnostic features of tissue collected in breast core needle biopsies, supporting further validation of this technology. Ultimately, we envision the use of SRH to create new, efficient workflows for managing patients with breast lesions, especially those in which fine needle aspiration is of limited value, and where rapid diagnosis of tissue biopsies could streamline care and increase patient satisfaction. Citation Format: Daniel Avram Orringer, Thomas Chen, Steve Pastore, Farbod Darvishian, Hildegard Toth, Freya Schnabel. Rapid beside diagnosis of breast core needle biopsies using stimulated raman histology [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS3-20.