Fine-needle aspiration of breast masses. A review of its role in diagnosis and management in adolescent patients

Idiopathic fibroadenoma in an elderly man

A fibroadenoma within the male breast remains a rarely diagnosed entity. Though it was once believed that a fibroadenoma could not exist within a male breast, this has now been demonstrated as incorrect by several reported cases. Most have been in individuals with gynecomastia. There are only a handful of reported cases of men with a diagnosed fibroadenoma in the absence of gynecomastia. We describe a man in his 80s with a left breast fibroadenoma and no features of gynecomastia or hormonal alterations. Based on our findings, we suggest that for men of all ages presenting with a breast lesion, a fibroadenoma remains a possible diagnosis.

Management of patient presenting with breast fibroadenoma and medullary thyroid cancer in a young male: A case report and review of the literature

Introduction and importance

Fibroadenoma of the male breast is a rarely diagnosed lesion that often occurs concurrently with gynecomastia and the intake of medications that alter sex hormone levels. Herein, we report the first case of fibroadenoma of the male breast, presenting with medullary thyroid cancer. In addition, we reviewed the current management strategies for fibroadenoma of the male breast in the literature.

Case presentation

A 25-year-old male patient presented to our surgical unit with medullary thyroid cancer (MTC). The physical examination revealed an unnoticed lump in his left breast. We delayed the planned thyroid surgery to determine whether the breast mass was associated with metastasis from MTC. We performed pathological tests from excised breast mass and confirmed the diagnosis of fibroadenoma. After confirming the benign nature of the breast mass, the patient underwent total thyroidectomy with selective neck dissection for MTC.

Clinical discussion

Fibroadenoma of the male breast was diagnosed based on clinical presentation and histopathological findings. Fibroadenoma of the male breast is a rarely diagnosed lesion: and is often associated with gynecomastia and altered serum sex hormone level. The presentation of this case without those concurrences is even rarer, as revealed in our case. The management for suspected fibroadenoma of the male breast presented with MTC should include delaying the thyroid surgery to rule out the presence of malignancy and metastasis.

Conclusion

The finding indicates that fibroadenoma can be considered a differential diagnosis in the male breast even in the absence of those concurrences. The timely diagnosis and orderly management of fibroadenoma of the male breast and MTC could help to improve the patient outcome.

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Fibroadenoma of the male breast is a rarely diagnosed lesion.

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This lesion is often associated with gynecomastia and altered serum sex hormone.

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Histopathological exam is essential in the diagnostic process of this rare case.

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Developmental mechanism of fibroadenoma of the male breast is a matter of scrutiny.

Breast pathology in adolescence

OBJECTIVE

Description of breast pathology in adolescents.

METHODS

A retrospective descriptive study of adolescents who were referred to the Gynecology consultation of a tertiary pediatric hospital for suspected breast pathology, in the period from the 1st June 2011 to the 30th December 2018.

RESULTS

One hundred and two female adolescents (11 to 18 years old) with suspected breast pathology were referred (6% of the motives for consultation), with confirmation in 58 (56.9%), who were included in the study. The reasons for referral were breast masses (66%), anomalies in breast size or symmetry (29%) and infection (5%). Of breast masses, the most frequent diagnosis was fibroadenoma (76%), followed by fibro-cystic pathology (18%). In most cases, a conservative approach was chosen, with clinical and imaging surveillance. Surgery was required in 29% of these cases. Anomalies in breast size and symmetry were observed in 17 adolescents. Two adolescents were submitted to symmetrization, after 18 years of age. Infectious and inflammatory pathology occurred in three cases: two mastitis and one retroareolar cyst. The approach consisted mainly of antibiotherapy. There were no cases of malignant breast disease.

CONCLUSION

Lumps or breast masses are the most frequent breast pathology in adolescence, and in the majority of cases surveillance was recommended, as they are a mere sign of hormonal oscillations at this age. Objective examination and/or breast ultrasound are usually enough to make the diagnosis. The approach must be mainly conservative, since malignancy is extremely rare in this age group.

A clinical approach to benign breast lesions in female adolescents

The female breast undergoes two phases of growth and differentiation. The first occurs during fetal life and results in the formation of simple branched ducts, which are able to respond to the hormonal stimuli of maternal origin. The second period of growth occurs at puberty, when the ducts elongate, divide, and form terminal duct lobular units. Breast pathology during adolescence is usually benign and therefore management has to be mostly conservative. Familiarity with the spectrum of breast pathology in this age group is essential. Ultrasound is the imaging modality of choice. Open surgical biopsies can damage the developing breast and therefore availability and expertise with fine needle aspiration biopsy can circumvent this problem. (www.actabiomedica.it)

Biopsy versus conservative management of sonographically benign-appearing solid breast masses in adolescents

OBJECTIVES

To determine whether the size of palpable solid breast masses in adolescents at initial sonography and their growth at follow-up sonography could be used to decide between conservative management and tissue biopsy.

METHODS

This retrospective study included 37 adolescent female patients with 45 palpable benign-appearing solid breast masses on initial sonography. They were grouped as follows: group I, masses undergoing follow-up sonography with subsequent biopsy (n = 9); group II, masses undergoing biopsy without follow-up sonography (n = 13); and group III, masses undergoing follow-up sonography without biopsy (n = 23). The largest dimension, volume, volume change per month, and change in the sonographic appearance were analyzed to predict the need for biopsy. A combination of a largest dimension greater than 3 cm and volume change per month greater than 16% was used to assess the need for biopsy. Sonograms of 22 masses were correlated with histopathologic diagnoses.

RESULTS

None of the masses that underwent follow-up sonography showed changes in their sonographic appearance. All masses that underwent biopsy were benign on histopathologic analysis. There was no significant difference in the largest dimension among the groups at initial sonography or between groups I and III at follow-up sonography. The volume change was smaller for fibroadenomas (n = 7; mean, 22.67%) than benign phyllodes tumors (n = 2; mean, 45.30%) in group I, but the difference was not significant (P = .384). However, the volume change for groups I and III showed a significant difference (P = .026). Neither size greater than 3 cm nor volume change greater than 16% predicted pathologic outcomes.

CONCLUSIONS

If the combined criteria for assessing benignity of palpable breast masses had been used, biopsy could have been reduced by 89% in group I and deemed not necessary in 96% of group III breast masses.

Ultrasonic elastography features of phyllodes tumors of the breast: a clinical research

The purpose of this study was to analyze the ultrasonic elastography features of phyllodes tumors of the breast comparing with fibroadenomas. A retrospective database was queried for the patients diagnosed as phyllodes tumors and fibroadenomas at Sun Yat-sen Memorial Hospital from January 2008 to August 2012. Three hundred and fifty lesions from 323 consecutive patients were included in the study. All the cases were examined by conventional ultrasonography and ultrasound elastography. Ultrasound elastography was used to calculate strain ratio of the lesions with bilateral breast tissue at the same depth as reference. There were 36 phyllodes tumors (27 benign, 8 borderline, 1 malignant) and 314 fibroadenomas (158 the pericanalicular type, 103 the intracanalicular type, 53 other special types). The strain ratio for phyllodes tumors (3.19±2.33) was significantly higher than for fibroadenomas (1.69±0.88) (p<0.05). The Spearman^.s correlation coefficient between strain ratio of ultrasound elastography and pathological groups was significant, with a value of 0.17 (p<0.05). Ultrasound elastography could provide additional information to differentiate phyllodes tumors from fibroadenoma in breast.

Juvenile fibroadenoma of the breast: Treatment and literature review

It is uncommon to find palpable breast masses in young patients. Generally, such masses are benign. Juvenile fibroadenoma is the most frequent benign tumour of the breast. The present report describes a case involving a 17-year-old girl with unilateral right breast hypertrophy, for whom resection and breast reduction was effectively achieved.Resection was combined with an aesthetically pleasing outcome through breast reduction, via a wise pattern of reduction with a superior pedicle.While young patients rarely present with breast masses, the consideration of fibroadenoma in these cases is always warranted. The disconcerting appearance of the breasts for adolescents afflicted by such benign masses underscores the importance of achieving aesthetically optimal outcomes and attaining adequate tumour resection for diagnostic purposes through pathological specimens. In the present case, the young patient underwent a procedure that fulfilled both of these valuable goals through careful pre-operative planning, pedicle selection and skin resection patterns.

Breast fibroadenomas in the pediatric population: common and uncommon sonographic findings

BACKGROUND

Sonography is usually requested to evaluate palpable pediatric breast lumps, and solid masses are almost always fibroadenomas. Lack of familiarity with the findings of fibroadenomas can lead to diagnostic uncertainty and sometimes unnecessary biopsy and excision. We sought to review the spectrum of sonographic findings in our cases of pathology proven pediatric fibroadenomas.

OBJECTIVE

The purpose of this retrospective study was to describe the sonographic appearances of pathologically proven pediatric breast fibroadenomas.

MATERIALS AND METHODS

A query of the Department of Radiology database at our institution was performed for all patients younger than 19 years who underwent breast US from January 2001 to June 2009. A total of 332 patients were identified: 282 girls (85%) and 50 boys (15%). Ninety-one girls and no boys had a solid breast mass based on US findings. Forty-three children had a total of 49 pathologically proven breast masses with the diagnoses of fibroadenoma (44), hamartoma (1), non-Hodgkin lymphoma (1), tubular adenoma (1), pseudoangiomatous stromal hyperplasia (1) and lactation changes (1). Reviews of medical records, histological results and sonographic examinations of all pathology-proven fibroadenomas were performed. US findings were characterized according to location, multiplicity, size, shape, echogenicity and homogeneity, definition of margins, posterior acoustic features and Doppler vascularity.

RESULTS

The vast majority of solid breast masses in girls are histologically benign. Fibroadenomas accounted for 91% of the pathologically proven solid breast masses. Common findings on US imaging are an oval shape, hypoechoic echo pattern, posterior acoustic enhancement and internal Doppler signal. Lobulations were found in 57% of the masses. Less common findings are absent internal vascular flow and complex echo pattern, while isoechoic echo pattern, posterior shadowing and angular margins are rare or unusual.

CONCLUSION

Fibroadenomas represent the most common solid mass in the breasts of girls. Sonographic appearances are usually characteristic and do not significantly differ from those found in adults. The radiologist must be aware of common and uncommon sonographic appearances of fibroadenomas in the pediatric age group and should be cautious when recommending histological confirmation based on imaging findings, as breast malignancy is extremely rare.

From the archives of the AFIP: breast masses in children and adolescents: radiologic-pathologic correlation

The spectrum of breast lesions in children and adolescents varies markedly from that for adults, with the former lesions being overwhelmingly benign. A breast mass in a young boy or girl may arise from normal and abnormal breast development. Other causes of masses include infection, trauma, and cyst formation. After onset of puberty, most cases of breast enlargement arise from benign fibroadenoma in girls and gynecomastia in boys. These conditions have specific imaging appearances, although juvenile (often giant) fibroadenoma cannot be distinguished from phyllodes tumor, which can be benign or malignant. In children, both conditions usually appear as well-circumscribed, hypoechoic masses at sonography and show diffuse enhancement except for nonenhancing septations at magnetic resonance imaging. A diagnosis of juvenile papillomatosis (a benign lesion) portends later development of breast cancer, and patients with this condition should be closely monitored. Malignant lesions of the breast in children are rare. The most common malignant lesions are metastases and are usually associated with widespread disease. The most common primary breast malignancy is malignant phyllodes tumor. Primary breast carcinoma is exceedingly rare in the pediatric age group, but its imaging appearance in children is the same as seen in adults and is different from that of almost all benign lesions. In girls, diagnostic interventions may injure the developing breast and cause subsequent disfigurement. Given this risk and the low prevalence of malignant disease in this population, a prudent course should be followed in the diagnosis of breast lesions. Imaging findings are very helpful for selecting patients for further diagnostic procedures. Although malignancy is rare, lesions with suspicious imaging findings or progressive growth should be subjected to cytologic or histologic examination.

Giant fibroadenoma of the breast in adolescents: report of 2 cases

Giant fibroadenoma (GF) is an uncommon variant of fibroadenomas that represent the most frequent breast lesion in adolescents and young women. The authors present 2 cases of GF of the breast in girls aged 12 and 14 years, and the respective diagnostic workup and conservative surgical treatment. Giant fibroadenomas are benign tumors, but their rapid growth and large size together with their rarity may determine difficulties in the clinical approach. Moreover, GF must be excised in all cases to exclude a phyllodes tumor and to prevent later deformity.

Surgical breast lesions in adolescent females

PURPOSE

Breast diseases in teenage girls are fortunately uncommon, with most presenting masses being benign. The aim of this study was to evaluate the histopathological results of breast lesions excised from adolescent females less than 19 years of age.

METHODS

The authors reviewed the medical and pathology records at the University Hospital of Vienna, Department of Obstetrics and Gynaecology, between 1993 and 2006, retrospectively. All data included the patient age, age of menarche, pregnancy, hormonal contraception, family history of breast cancer, size of the breast lesion and its histopathology following surgery.

RESULTS

Thirty-seven female patients with an average age of 16 years (ranging 12-18 years) were operated on for breast tumor and/or discharge. All tumors were palpable. Six patients had bilateral breast masses; thus, 43 breast lesions were evaluated following surgical excision. Surprisingly, breast cancer was found in two cases. Both patients were diagnosed with a noninvasive ductal carcinoma in situ (DCIS) within a fibroadenoma at the age of 16. These are the first reported cases of DCIS found in this young age group. As breast neoplasm was found in two cases, a malignancy rate of 4.7% was observed. The most common histologies were fibroadenoma (n=27) and fibrocystic disease (n=4).

CONCLUSION

The incidence of primary breast cancer in adolescent women is low. However, our experience shows the need for compulsory excision of all breast masses and highlighting the importance of histopathological evaluation of all breast tumors including adolescents.

Can hamartoma of the breast be distinguished from fibroadenoma using fine-needle aspiration cytology?

In an attempt to determine if it is possible to distinguish hamartoma of the breast from fibroadenoma using fine-needle aspiration cytology, we reviewed the cytological slides of 13 histopathologically confirmed cases of hamartoma of the breast and compared them with the cytological features of 13 histologically confirmed fibroadenomas. In each case, we studied the epithelial and stromal features. Cytologic characteristics were retrospectively evaluated in a semiquantitative manner. In conclusion, the finding of intact lobular units and a relative paucity of stroma may suggest the diagnosis of hamartoma.

Pathologic breast conditions in childhood and adolescence: evaluation by sonographic diagnosis

OBJECTIVE

The growing awareness of female breast cancer has led to increased sensitivity toward pathologic breast conditions in children and adolescents. Thus, approximately 15% of patients in child and adolescent gynecology are referred for the first time because of conspicuous features of the breast such as pain, palpable masses, and other findings on visual inspection. The aim of this study was to analyze the underlying diagnoses and diseases and determine the status of breast sonography in the diagnostic process.

METHODS

The study population consisted of 62 female patients between 8 weeks and 20 years of age (1997-2002) who were examined clinically, followed by standardized sonography (7.5-13 MHz, conventional B-mode panoramic sonography). Presumed diagnoses were confirmed by biopsy in some patients (n = 16) and by follow-up with clinical examination and sonography in most cases (n = 46).

RESULTS

The clinical and sonographic evaluation confirmed 4 main groups of diagnoses: benign tumors (15), developmental disturbances (14), cystic changes (11), and inherent defects (7). In the remaining cases, the findings were no abnormality (9), nipple discharge without evidence of pathologic or morphologic correlates (3), abscesses (2), and epidermoid cyst (1).

CONCLUSIONS

Knowledge of regular breast development and its variants is essential for the physician. Given knowledge of the sonographic appearance of physiologic breast development and specific lesions, breast sonography is most helpful in identifying and characterizing abnormalities and guiding further investigation.

Breast hamartoma: fine-needle aspiration cytologic finding

BACKGROUND

Breast hamartoma is an unusual, well-circumscribed, tumor-like mass entering into the differential diagnosis of benign breast disease. To the authors' knowledge, the cytology of these lesions has not been well described. Although fine-needle aspiration is a well established procedure for the detection of breast carcinoma, its utility in classifying benign breast disease is less clear.

METHODS

Fine-needle aspirates from eight patients with histologically proven hamartomas were reviewed. None of the cases had a preoperative fine-needle aspiration diagnosis of hamartoma. Cytologic characteristics were retrospectively evaluated in a semiquantitative manner and compared with the histologic findings.

RESULTS

The aspirates were moderately cellular and contained sheets of both bland ductal cells and lobular units. Adipose tissue was present in varying amounts. Bipolar stromal nuclei were readily apparent, whereas intact stromal fragments were less prominent. Cytologic atypia was uniformly absent.

CONCLUSIONS

The cytology of breast hamartomas shows considerable overlap with other benign breast disease and is unlikely to be interpreted as malignant. The findings of intact lobular units and a relative paucity of stroma in an aspirate from a well circumscribed breast lesion may suggest the diagnosis of hamartoma.

Fine-needle aspiration cytology for diagnosis and management of palpable breast mass

BACKGROUND

The present study aims to clarify the use, in a developing country, of fine-needle aspiration cytology (FNA) instead of open biopsy as a cost-saving, reliable initial diagnostic and management tool for patients with breast mass.

METHODS

A prospective study of 60 patients (71 breast masses) was carried out. The accuracy of physical diagnosis of the mass was compared with that obtained by FNA. The cytological results were analysed with the clinical profiles and pathological results.

RESULTS

Physical examination was unreliable for the diagnosis of breast cyst (61.1% positive predictive value, 73.6% negative predictive value), which accounted for 35% of breast masses studied. Aspiration alone determined the diagnosis and management in 39% of masses. For solid breast masses benign cytological results (class I, II) were proved to be reliable (100% positive predictive value), as were malignant cytological results (class V; 100% positive predictive value). Inadequate cytology was reported for five masses (11.9%).

CONCLUSIONS

Fine-needle aspiration should be routinely performed in all patients with breast masses. This would facilitate prompt diagnosis and treatment in one-third of patients with breast cyst, and the benign cytological result could facilitate definite management in the majority of patients with a low risk of malignancy. This could save cost, time and patient anxiety. For the patients with a high clinical suspicion of breast cancer, the positive cytological result could reliably confirm the diagnosis, while the equivocal result could be combined with mammography or open biopsy. Considering the ease, simplicity and low cost, FNA may be suitable for developing countries where other non-invasive procedures are unavailable or difficult to obtain, and it could replace open biopsy, which is still commonly done.