Pseudoangiomatous Stromal Hyperplasia Research Articles

Hiperplasia estromal seudoangiomatosa. Una lesión de la mama infrecuente y de presentación variable

Pseudoangiomatous stromal hyperplasia is a rare benign mammary lesion. It is characterised by an overgrowth of fibrous connective tissue that produces numerous spaces resembling vascular structures. This lesion usually affects women of reproductive age but has been described in patients aged between 12 and 75 years. It may appear as an incidental finding in histological analysis after surgery for benign or malignant disease, either as a painless breast tumour, simulating a fibroadenoma, or as a gigantomastia or deformity that becomes more evident on comparison with the contralateral breast. Percutaneous ultrasound-guided biopsy allows definitive identification of the type of lesion and exclusion of malignant disease, such as low-grade angiosarcoma. Treatment is surgical and includes both surgical removal of the lesion and mastectomy with prosthetic reconstruction. We describe a series of three cases with different clinical presentations and treatment. The first case was a radiological and histopathological finding related to a breast deformity and asymmetry, while the remaining two cases presented as a palpable, single and painless breast tumour.

How to manage pseudoangiomatous stromal hyperplasia: our clinical experience

Background/aim: Pseudoangiomatous stromal hyperplasia (PASH) is a rare and benign mesenchymal proliferative breast lesion. Our aim is to review the clinical and radiological features of PASH and define a standard approach for its diagnosis and management. Materials and methods: Clinical records of 35 consecutive patients with PASH were retrospectively reviewed between 2009 and 2015. Patients with clinically or radiologically detected mass and patients who underwent biopsy for other indications and were diagnosed incidentally were included in the study. Results: There were 34 female patients and one male patient with gynecomastia. Twenty-three patients had palpable masses, and 16 of them were diagnosed as PASH with a median size of 3.1 cm. PASH did not show any specific features in radiological imaging. Core needle biopsy was performed for 3 patients before surgical excision; however, the lesions had not been diagnosed as PASH. In pathological examination, lesions associated with PASH showed nonproliferative changes in 14 patients, proliferative changes without atypia in 17, one phyllodes tumor, one in situ tumor, and one invasive cancer. Conclusion: Imaging findings of PASH are nonspecific. It is difficult to give a true prognostic diagnosis through pathological evaluation of big masses with core needle biopsy. We recommend surgical excision, especially for big lesions with suspicious features.

Anogenital mammary-like glands and related lesions. Part 1. Benign tumors and tumor-like disorders

Anogenital mammary-like glands represent a normal anatomic constituent of the anogenital area and may give rise to many benign and malignant tumors that morphologically mimic similar breast diseases. The literature review is complemented by a description of 286 cases of benign tumors and tumor-like processes in the mammary-like glands. The paper presents the clinical and morphological characteristics of papillary hidradenoma, fibroadenoma, benign phyllodes tumor, lactating adenoma, sclerosing adenosis, pseudoangiomatous stromal hyperplasia, etc.

Pseudoangiomatous stromal hyperplasia: rare case in an 11-year-old girl

A Revista Brasileira de Cirurgia Plástica é o órgão oficial de divulgação da Sociedade Brasileira de Cirurgia Plástica (SBCP), tem como objetivo registrar a produção científica em Cirurgia Plástica, fomentar o estudo, aperfeiçoamento e atualização dos profissionais da especialidade.

Giant nodular pseudoangiomatous stromal hyperplasia of the breast with fbroadenomatoid myxoid changes: a potential pitfall in the differential diagnosis of phyllodes tumor

ABSTRACT A 21-year old woman presented with a 17-cm left breast mass. Physical examination and ultrasound revealed the mass to be well-circumscribed, homogeneous and freely mobile, suggestive of giant fibroadenoma or phyllodes tumor. The mass was surgically excised and initially interpreted as benign phyllodes tumor. Subsequent slide review established the diagnosis of nodular pseudoangiomatous stromal hyperplasia (PASH) associated with fibroadenomatoid areas and myxoid stromal changes. This case illustrates the difficulty encountered in recognizing nodular PASH. A thorough discussion of the histopathologic differential diagnosis of nodular PASH is provided.

Does Identifying Whether Pseudoangiomatous Stromal Hyperplasia (PASH) Is Focal or Diffuse on Core Biopsy Correlate With a PASH Nodule on Excision?

Pseudoangiomatous stromal hyperplasia (PASH) diagnosed on core needle biopsy is generally excised. As a consequence, PASH as an incidental finding, may lead to unnecessary excisions. This study categorized PASH in biopsies as diffuse versus focal to determine if this correlates with the presence of a mass. In a 10-year period, 253 biopsies were identified and 159 met inclusion criteria. Of these, 47 biopsies had excisions. Biopsies and excisions were classified as diffuse, involving 2 adjacent lobules, or focal PASH in a single lobule or noncontiguous lobules. The diffuse or focal category on biopsy was correlated to the category on excision. Fibroadenomas with PASH were defined as concordant with diffuse PASH on biopsy. The category was correlated to the presence/absence of a mass determined from radiographic/clinical data for the 159 biopsies. The biopsies were classified as diffuse (105, 66%) and focal (54, 34%). A total of 67% of biopsies with focal PASH showed either focal or no PASH on excision. Diffuse PASH on biopsy, had diffuse PASH in 93% of excisions. Concordance of this classification between biopsy and excision, using a Fisher's exact test (2-tailed P value is <.0001), is statistically significant. A mass was present in 102/105 (97%) of biopsies with diffuse PASH. In biopsies with focal PASH, 78% had a mass lesion. Classification of diffuse versus focal PASH on biopsy was concordant with findings on excision. We found that diffuse PASH on biopsy showed strong correlation with a mass lesion. Quantifying PASH may assist with clinical-pathologic correlation and reduce unnecessary excisions.

Abstract: Approach to Management Using Evidence Based Medicine: Proliferative Breast Lesions Among Reduction Mammoplasty Specimens

INTRODUCTION: Given the reported lifetime estimate of 1 in 8 women becoming diagnosed with breast carcinoma, it is standard perioperative practice for excised tissue obtained from routine reduction mammoplasty procedures to be sent for pathology review. 1 On average, an estimated 0.2–1.1% of all reduction mammoplasty specimens reviewed by pathology is diagnosed with occult malignancy.2–5 On occasion, atypical proliferative lesion of variable malignancy potential is also reported, which may become an area of concern given the management of such lesions may be unfamiliar to plastic surgeons. We aimed to provide a review of commonly diagnosed proliferative lesions identified in routine reduction mammoplasty specimens and the best supporting evidence for their subsequent management. METHODS: Retrospective literature review using a PubMed search of all English-language articles published between 1990 and 2016 containing the phrases (“reduction mammoplasty”, “breast reduction”, “proliferative”, “atypical”, “hyperplasia”, “ductal”, “epithelial”, “lobular”, “stromal” and “meshchymal”) was completed. A total of 210 publications were generated after initial screening with 10 articles ultimately incorporated after comprehensive review. RESULTS: Commonly encountered proliferative lesions among reduction mammoplasty specimens include pseudoangiomatous stromal hyperplasia (PASH), atypical lobular hyperplasia (ALH), atypical ductal hyperplasia (ADH) and flat epithelial atypia (FEA). PASH and FEA with no concomitant atypical ductal or lobular lesions confers no risk of subsequent malignancy and routine standard of care is recommended. ADH and ALH confer a four-fivefold increased risk of subsequent breast carcinoma with increased risk among high risk individuals.2 For this patient cohort, current management strategies recommend referral to a breast program, biannual clinical exam, yearly mammography with breast MRI, genetic testing for BRCA 1/2 gene mutation with or without chemoprevention in higher risk individuals. CONCLUSION: Our review provides important findings by highlighting the most frequently encountered atypical proliferative lesions among routine reduction mammoplasty specimens as well as current evidence supporting management strategies. DISCLOSURE/FINANCIAL SUPPORT:The authors report no financial disclosure REFERENCES: 1. American Cancer Society. Breast Cancer Facts & Figures 2013–2014. Atlanta: American Cancer Society, Inc. 2013 2. Clark CJ, Whang S, Paige KT. Incidence of precancerous lesions in breast reduction tissue: a pathologic review of 562 consecutive patients. Plast Reconstr Surg. 2009;124(4):1033–1039. doi:10.1097/PRS.0b013e3181b45801. 3. Desouki MM, Li Z, Hameed O, Fadare O, Zhao C. Incidental atypical proliferative lesions in reduction mammoplasty specimens: Analysis of 2498 cases from 2 tertiary women’s health centers. Hum Pathol. 2013;44(9):1877–1881. doi:10.1016/j.humpath.2013.02.015. 4. Pitanguy I, Torres E, Salgado F, Viana GAP. Breast pathology and reduction mammaplasty. Plast Reconstr Surg. 2005;115(3):729–734; discussion 735. doi:10.1097/01.PRS.0000152683.62899.50 5. Slezak S, Bluebond-Langner R. Occult carcinoma in 866 reduction mammaplasties: preserving the choice of lumpectomy. Plast Reconstr Surg. 2011;127(2):525–530. doi:10.1097/PRS.0b013e3181fed5dc.

Pseudoangiomatous Stromal Hyperplasia in Core Needle Biopsies of Breast Specimens.

Pseudoangiomatous stromal hyperplasia (PASH) is a benign lesion of myofibroblasts that is composed of a network of slit-like channels that resemble vascular spaces. The aims of this study were to document the frequency of PASH in core needle biopsy specimens (CNBS) of the breast, to describe which histopathologic findings coexist with PASH and to examine any endothelial cell differentiation. We reevaluated hematoxylin and eosin-stained sections of all CNBS that were obtained during a 1-year period. First, we performed CD34 and CD31 immunostainings to highlight the areas of PASH, then performed D2-40/podoplanin (lymphatic endothelial marker) and Fli-1 (vascular endothelial cell marker) immunostains. The total number of CNBS was 412. Areas of PASH were noted in 37 of the 412 cases (9%), with a mean age of 38.5 years. The lesions that were described in association with PASH were "benign breast parenchyma with stromal fibrosis" (17/37; 46%), "fibroepithelial tumors" (17/37; 46%), "columnar cell changes (CCC)" (2/37; 5%), and "invasive carcinoma" (1/37; 3%). There were 2 cases of CCC within the foci of PASH (direct contact with PASH), and 8 additional cases of CCC that coexisted in the same specimen but were not in direct contact. There was no staining for D2-40 or Fli-1 within PASH foci. PASH lesions occurred with a frequency of 9% in CNBS and were mostly in association with benign breast lesions in premenopausal women. CCC was determined as an accompanying epithelial lesion within or near PASH areas. No obvious immunopositivity compatible with endothelial cell differentiation was revealed.

Pseudoangiomatous Stromal Hyperplasia Presenting as Rapidly Growing Bilateral Breast Enlargement Refractory to Surgical Excision.

Pseudoangiomatous stromal hyperplasia (PASH) is a benign proliferative mesenchymal lesion of the breast. PASH presents as a palpable or mammographically detectable mass or is an incidental microscopic finding in up to 23% of breast biopsies. Its pathogenesis is unclear but may involve hormonal factors, as recently postulated. Its clinical, cytological, and radiological characteristics resemble those of other benign tumors, including low-grade angiosarcomas and phyllodes tumors. Because of its uncertain pathogenesis, PASH is usually treated via surgical excision, with post-excision recurrence rates ranging from 7% to 22% [1]. Although several cases of PASH have been recently reported, cases of PASH involving large, rapidly growing lesions refractory to surgical incision are rare [2]. In this study, we report our experience with a case of PASH that presented as rapidly growing bilateral breast enlargement refractory to surgical excision. We also review the pertinent literature, including the clinical and histopathological features, pathogenesis, imaging findings, treatment, and prognosis of PASH.

Pseudoangiomatous Stromal Hyperplasia on Core Needle Biopsy Does Not Require Surgical Excision

Pseudoangiomatous stromal hyperplasia (PASH) is an uncommon, benign localized fibrotic lesion. Historically, PASH has been difficult to differentiate from angiosarcoma. This difficulty has led to recommendations of surgical excision. We sought to identify the incidence of upgraded pathology to atypia or malignancy on surgical excisional biopsy after identification of PASH on core needle biopsy (CNB). A 5-year retrospective review at a single institution was conducted including all cases of PASH confirmed on CNB. The data set was divided into patients who underwent excisional biopsy and those followed only by imaging. Primary end points included the incidence of subsequent malignancy or high-risk pathology on histologic analysis or the presentation of suspicious imaging. Thirty-seven patients were reviewed, 19 (51.4%) underwent surgical excision and 18 (48.6%) were followed with imaging alone. A palpable mass was noted in 36.8 per cent of patients in the excisional group versus 5.6 per cent in the imaging group (P = 0.02). The median follow-up for the excisional and imaging groups were 43 and 35 months, respectively (P = 0.85). The 95 per cent confidence interval for the presence of malignancy was 0 to 9.4 per cent. Although further characterization of PASH is needed, our data support using CNB with follow-up imaging as a safe alternative to excisional biopsy in the absence of symptoms or other clinical factors. However, further research in this area is needed.

Myoid hamartoma breast with pseudo angiomatous stromal hyperplasia: a case report and review of literature

Hamartomas of the breast, also known as fibroadenolipomas, lipofibroadenomas or adenolipomas are benign lesions with low risk of recurrences. Hamartomas account for between 0.04 and 1.15% of all benign breast tumours in females. Myoid hamartoma of the breast (MHB) with Pseudo Angiomatous Stromal Hyperplasia (PASH) is an extremely rare lesion. These cases will be misdiagnosed preoperatively. Histopathology only gives definitive diagnosis. Sixteen year old girl admitted with a mass of two months duration in the left breast in which reduction mammoplasty was done two years back. Ultra sonogram of the left breast revealed a well circumscribed 10cm x 6 cm x 3cm mass with echogenic and isoechoic areas. A core needle biopsy was done and reported as fibro adenoma of the left breast. Excision of the mass with adequate margins was done. The histopathology report of the resected mass showed myoid hamartoma breast with pseudo angiomatous stromal hyperplasia (PASH). So far there is no literature report about myoid hamartoma breast with pseudo angiomatous stromal hyperplasia (PASH) in an already reduction mammoplasty done patient. We present this case for its rarity and also to stress the importance of immunohistochemical studies in benign breast lesions.

Bilateral Simultaneous Pseudoangiomatous Stromal Hyperplasia of the Breasts and Axillae: Imaging Findings with Pathological and Clinical Correlation.

Pseudoangiomatous stromal hyperplasia (PASH) of the breast is a pathology that is usually diagnosed by accident during pathological examination of other breast lesions. PASH is an uncommon and benign tumoral lesion of the mammary stroma that can be pathologically mistaken for other tumours, such as phyllodes, fibroadenoma, and sometimes even angiosarcoma. We report the case of a 45-year-old woman with complaints of huge bilateral breast enlargement. This is a rare case of PASH presenting with gigantomastia and involving bilateral breasts and axillae simultaneously. Mammography, ultrasonography, and MRI features are illustrated with histopathological correlation.

A Clinicopathological Study of Benign Phyllodes Tumour of Breast with Emphasis on Unusual Features

Benign Phyllodes Tumours (PTs) are rare fibroepithelial neoplasms that resemble fibroadenoma. But unlike fibroadenoma, benign PT can recur and both stromal & epithelial components can progress to malignancy. Contrary to earlier belief that benign PT is a stromal neoplasm and possibly arises from fibroadenoma, more recent molecular studies have suggested that both stroma and epithelium can become neoplastic. Sometimes, benign PT can occur synchronously with fibroadenoma. Here histomorphologic analysis of eleven cases of benign PT are presented including some unusual features. Eleven cases of benign PT diagnosed between Dec 2014 and Jan 2016 in the Department of Pathology were studied. The demographic and clinicopathological features were analysed. The most common age group affected was 20-30 years (range: 13-45). Clinical features included pain, lump and bleeding from nipple. The tumour size varied from 2.5-18 cm in diameter. H&E stained sections showed secondary changes (haemorrhage, myxoid, change, cystic degeneration), epithelial hyperplasia (8), squamous & columnar metaplasia (1), benign tubular adenoma like areas (1), Ductal Carcinoma In Situ (DCIS) (1), Invasive Ductal Carcinoma (IDC) (1), Pseudoangiomatous Stromal Hyperplasia (PASH) (1), histologic infarction (2), tumour necrosis (1) and synchronous fibroadenoma (1). Unusual histologic features included atypical ductal hyperplasia, DCIS, IDC, synchronous fibroadenoma and tubular adenoma like areas arising within benign PT. This study shows a spectrum of hyperplastic, metaplastic, dysplastic, benign, in-situ-malignancy and even invasive ductal malignancy occurring in benign PT. Therefore adequate and extensive sampling is recommended for accurate diagnosis.

Step by step approach to rare breast lesions containing spindle cells.

Differential diagnosis of spindle cell lesions of breast is challenging for certain reasons. The most important reason is the presence of cytological atypia and mitosis in all three conditions: reactive, benign, and malignant. Patients diagnosed with benign and malignant tumor/tumor-like lesions that had spindle cell components following the histopathological examination were included in the study. The patients’ medical records were accessed to obtain the clinical history, follow-up notes, and radiological findings. Following histopathological, immunohistochemical, and clinical evaluations, the patients were diagnosed as follows: pseudoangiomatous stromal hyperplasia (PASH), bilateral desmoid-type fibromatosis (FM), adenomyoepithelioma (AME), myofibroblastoma (MFB), malignant phyllodes tumor (MF), high-grade AS, post-chemotherapy osteosarcoma (OS) + Paget’s disease, and metaplastic carcinoma (MC). An algorithmic approach should be used in the diagnosis; cellular structure, presence and grade of atypia, growth pattern, mitotic activity, immunohistochemical staining, and clinical and radiological features should be evaluated together. Detection of some molecular changes can be useful in differential diagnosis.

Breast MR biopsy: Pathological and radiological correlation.

To identify pathological features for sample analysis of magnetic resonance imaging-guided vaccum-assisted breast biopsy (MRIgVaBB) to optimize radio pathological correlation and identify discordant benign result. Databases of two centres were queried to identify MRIgVaBB performed between January 2009 and February 2013. A cohort of 197 women (mean age: 54.5years (24-77)) with 208 lesions was identified. We retrospectively analyzed all prebiopsy MRI examinations according to the new BI-RADS lexicon, and all biopsy samples to describe the lesion of interest, its interface with the surrounding breast tissue and other associated features. The malignancy rate was 26.0% (54/208) with an underestimation rate of 15.67% (5/32). A visible interface at pathology between a biopsied lesion and the surrounding breast tissue was more frequently identified in mass enhancement compared to NME or focus (p = 0.0003). Regional NME was correlated with a high degree of fibrosis (p = 0.001) and the presence of PASH (p = 0.0007). Linear or segmental NME was correlated with the presence of periductal mastitis (p = 0.0003). The description of a visible interface between the target lesion and the surrounding tissue is crucial to confirm the correct targeting of an MR mass or a NME. • Pathological interface correlated with magnetic resonance mass and focal non-mass enhancement (NME). • Linear or segmental NME correlated with mastitis or ductal carcinoma in situ. • Fibrosis and pseudoangiomatous stromal hyperplasia (PASH) are correlated with regional NME.

Treatment of Pseudoangiomatous Stromal Hyperplasia of the Breast: Implant-Based Reconstruction with a Vascularized Dermal Sling.

Pseudoangiomatous stromal hyperplasia (PASH) of the breast is a benign mesenchymal lesion with incidental histologic findings. Surgical excision is recommended as the treatment of choice for PASH, although the recurrence rates after excision range from 15% to 22%. A 46-year-old-female presented with a six-month history of bilateral breast enlargement and painful sensation mimicking inflammatory carcinoma. Imaging studies demonstrated innumerable enhancing nodules in both breasts. Due to the growth of the lesions and progressive clinical symptoms, bilateral subcutaneous mastectomy was performed. Grossly, the specimens were round and well-circumscribed, and the histologic examination revealed PASH. After mastectomy, we created a pocket with the pectoralis major muscle and a lower skin flap, which was deepithelized. Anatomical mammary implants were inserted, and the nipple areolar complex was transferred to a new position as a free graft. The aesthetic result was satisfactory after twelve months of follow-up.

Ultrasound of pediatric breast masses: what to do with lumps and bumps.

The approach to breast masses in children differs from that in adults in many ways, including the differential diagnostic considerations, imaging algorithm and appropriateness of biopsy as a means of further characterization. Most pediatric breast masses are benign, either related to breast development or benign neoplastic processes. Biopsy is rarely needed and can damage the developing breast; thus radiologists must be familiar with the imaging appearance of common entities so that biopsies are judiciously recommended. The purpose of this article is to describe the imaging appearances of the normally developing pediatric breast as well as illustrate the imaging findings of a spectrum of diseases, including those that are benign (fibroadenoma, juvenile papillomatosis, pseudoangiomatous stromal hyperplasia, gynecomastia, abscess and fat necrosis), malignant (breast carcinoma and metastases), and have variable malignant potential (phyllodes tumor).

Large pseudoangiomatous stromal hyperplasia complicated with gynecomastia and lobular differentiation in a male breast.

Pseudoangiomatous stromal hyperplasia (PASH) is a benign lesion often observed in parts of the mammary stroma in a variety of breast diseases. It is characterized by stromal myofibroblastic proliferation that possesses irregularly anastomosing slit-like pseudovascular spaces lined by a layer of spindle cells. PASH commonly occurs in premenopausal women; however, it has also been observed in men with gynecomastia. Although tumor-forming lesions are rare, we report on a case with a large PASH in a male breast complicated with gynecomastia. Imaging showed a tumor with a diameter of >10 cm in the left breast, and aspiration cytology revealed a benign lesion. Since the tumor was large and gradually increased in size, a simple mastectomy was performed. The tumorous lesion was diagnosed as PASH based on the pathological and immunohistological findings. It was complicated by gynecomastia with acinar and lobular formation, which resembled female mammary gland secretory activity that is observed during lactation.

English

Introduction: Hamartoma of the breast is a rare entity, frequently underdiagnosed by pathologists. It is a benign tumour-like nodule with overgrowth of mature cells that normally occur in the affected part. Patients present at an average of 45 yrs. with a unilateral, well defined, painless mass or enlargement; incidence being 0.1% to 0.7%. The aim of our study was to investigate clinical and histopathological features of breast hamartomas. Materials and Methods: Eighteen cases of breast hamartomas operated our hospital, between Jan. 2005 to Dec. 2012 were included in this study. The clinicopathological features and follow up data were analysed in all the cases. Results: All cases in our study were female patients with age group ranged between 23-40 yrs. All patients presented with unilateral breast masses. Clinically majority of patients were suspected to have fibroadenoma with only 2 cases suspected to be cystosarcoma phyllodes. Lumpectomy was performed in all the cases. Grossly all tumors were well circumscribed, grey white, lenticular masses with some showing cystic changes, myxoid areas and nodular areas. The maximum dimension of the tumors ranged from 4 to 16 cms. Microscopically, all hamartomas demonstrated good demarcation with fibrous tissue condensation and hyalinisation. Epitheliosis, apocrine metaplasia, pseudo angiomatous stromal hyperplasia, atrophy and cystically dilated ducts were among the major microscopic features observed. No recurrence or malignant components were noted in our case series. Conclusion : The diagnosis of hamartoma is difficult as no specific diagnostic histological features are present. The presence of fibrous tissue within the lobules, or fibrous tissue and fat in the stroma, with or without pseudoangiomatous changes, should alert the pathologist to the possibility of a hamartoma. The role of FNAC and needle core biopsy is limited. Coincidental malignancy can occur in hamartomas and hence the importance of its diagnosis.

Bilateral diffuse pseudoangiomatous stromal hyperplasia (PASH) causing gigantomastia in a 33-year-old pregnant woman: case report

Pseudoangiomatous stromal hyperplasia (PASH) is a benign proliferation of mammary stroma mostly described as incidental microscopic finding. It can clinically manifest as a palpable, well circumscribed breast mass or in rare cases as a diffuse bilateral process causing massive breast enlargement. The most postulated theory for aetiology of this condition is hormonal stimulation of mammary miofibroblast, particularly by progesterone. The definite diagnosis of PASH is based on typical pathological findings like stromal hyperplasia and empty slitlike channels positive for myofibroblastic and negative for endothelial markers. The main clinical differential diagnosis is a fibroadedoma or phylloid tumour and histologically a low grade angiosarcoma. There are less than 200 cases of tumorous PASH and less than 20 of diffuse PASH reported so far. Here we present a case report of huge diffuse PASH, that is, to our knowledge, first one in a pregnant woman.