A case report and a literature review of double mammary pseudoangiomatous stromal hyperplasia associated with galactoma during pregnancy

Pseudoangiomatous stromal hyperplasia (PASH) is a benign interstitial hyperplasia of the breast that usually occurs in premenopausal or perimenopausal women. It is usually characterized by localized lesions or clear boundary masses, and diffuse double breast enlargement is rare. PASH is considered a hormone-dependent disease that is commonly progesterone related. There are no imaging characteristics, and both benign and suspicious malignant signs can be seen. The definitive diagnosis of PASH depends on a pathological diagnosis, and it is necessary to be vigilant in distinguishing between benign and malignant tumors with similar breast histopathology. Here, we report the case of a 23-year-old multipara patient with bilateral diffuse pseudoangiomatous stromal hyperplasia of the breast during pregnancy who presented with macromastia and reviewed the literature to further understand the clinical features, pathological diagnosis, differential diagnosis, treatment and prognosis of pseudoangiomatous stromal hyperplasia of the breast.

Tumoral pseudoangiomatous stromal hyperplasia (PASH) of the male breast: A systematic analysis

<b><br>Aim:</b> The study was conducted to systematically analyze the recent peer-reviewed literature related to tumoral pseudoangiomatous stromal hyperplasia (PASH) in males.</br> <b><br>Materials and methods:</b> Articles published in peer-reviewed journals of repute from 2012 to 2023 were evaluated for eight variables: 1) the age of the patient, 2) clinical presentation, 3) laterality (unilateral or bilateral), 4) associated breast disorder, 5) the presence of systemic co-morbidity, 6) imaging modalities aiding diagnosis, 7) treatment, and 8) recurrence.</br> <b><br>Results:</b> There were 10 patients ranging in age from 1 year to 67 years (mean: 34.5 years). In 8 cases (80%), there were breast lumps; in 2 cases (20%), there were axillary lumps at presentation. Pain was not a prominent symptom. Six patients (60%) had another breast disorder at presentation and 3 (30%) had significant systemic co-morbidities, including diabetes and renal insufficiency. The greatest dimension of the lumps ranged from 2 cm to 12 cm, with 80% of the lumps being below 5 cm in size. Imaging modalities utilized in evaluation included breast ultrasound (USG), mammograms, computerized tomography (CT), and magnetic resonance imaging (MRI). All the cases were treated surgically, and the final diagnosis was made only after the analysis of the surgical specimen. Recurrence was recorded in 2 (20%) cases.</br> <b><br>Conclusions:</b> Tumoral PASH is a benign myofibroblastic proliferation disorder rarely reported in males. This condition should be considered a differential diagnosis of breast or axillary lumps, and an evaluation should be initiated accordingly. The recommended course of treatment is adequate surgical excision with regular clinical and radiological follow-up.</br>.

Giant juvenile fibroadenomas with and without prominent pseudoangiomatous stromal hyperplasia (PASH)-like change: clinicopathological and molecular characteristics

AIMS

Juvenile fibroadenomas (JFA) are biphasic fibroepithelial lesions (FEL) usually occurring in adolescent female patients. Giant (G) JFA, like other FEL, may exhibit prominent pseudoangiomatous stromal hyperplasia (PASH)-like change. We sought to determine clinicopathological and molecular characteristics of GJFA with and without PASH.

METHODS AND RESULTS

Archives were searched for cases of GJFA (1985-2020). All were stained for androgen receptor (AR), beta-catenin, CD34 and progesterone receptor (PR). Cases were sequenced using a custom 16-gene panel - MED12 (exons 1 and 2), TERT promoter (-124C>T and -146Ctable>T), SETD2, KMT2D, RARA (exons 5-9), FLNA, NF1, PIK3CA (exons 10, 11 and 21), EGFR, RB1, BCOR, TP53, PTEN, ERBB4, IGF1R and MAP3K1. Twenty-seven GJFA from 21 female patients aged 10.1-25.2 years were identified. Size ranged from 5.2 to 21 cm. Two patients had multiple, bilateral and later recurrent GJFA. Thirteen (48%) cases showed prominent PASH-like stroma. All were positive for stromal CD34, negative for AR and beta-catenin and one case showed focal PR expression. Sequencing showed MAP3K1 and SETD2 mutations in 17 samples, with KMT2D, TP53 and BCOR aberrations in 10 (45%), 10 (45%) and seven (32%) cases, respectively. Tumours with a PASH-like pattern had higher prevalence of SETD2 (P = 0.004) and TP53 (P = 0.029) mutations, while those without PASH had more RB1 mutations (P = 0.043). MED12 mutation was identified in one case. TERT promoter mutation was observed in four (18%), including two recurrences.

CONCLUSIONS

Gene mutations along more advanced phases of the proposed FEL pathogenetic pathway in GJFA are unusual, and suggest a mechanism for more aggressive growth in these tumours.

Pseudoangiomatous stromal hyperplasia of the breast: Clinical evaluation

BACKGROUND

Pseudoangiomatous stromal hyperplasia is a rare benign breast stromal proliferative lesion of the breast. Clinical presentation ranges from rapidly growing mass to incidental identification in routine screening. This difference in manifestation and its rarity makes it difficult to be a standard treatment protocol. Therefore, we aimed to share our clinical experience in Pseudoangiomatous stromal hyperplasia.

METHODS

The files of patients who underwent core biopsy or surgical excision due to a breast mass and resulted in pseudoangiomatous stromal hyperplasia between January 2013 and December 2021 were included in the study.

RESULTS

17 patients with a median age of 37 (22-68) were found Pseudoangiomatous stromal hyperplasia confirmed by surgical excision or core biopsy. Chosen treatment option was observation in 8 patients (47.1%), while surgical excision was used in 9 (52.9%) patients. The mean follow-up period was 55.24 ± 26.72 (13-102) months. None of the patients observed the Malignant transformation during the follow-up period.

CONCLUSION

For Pseudoangiomatous Stromal Hyperplasia of the breast, surgical excision with clean margins or close follow-up after diagnosis confirmation by tissue biopsy is sufficient. Pseudoangiomatous Stromal Hyperplasia is not a risk factor for developing breast cancer.

Bilateral axillary pseudoangiomatous stromal hyperplasia in a premenopausal woman: A case report with imaging findings

Pseudoangiomatous stromal hyperplasia is a benign proliferative mesenchymal lesion of the breast. To date, only a few cases of axillary pseudoangiomatous stromal hyperplasia with imaging findings have been reported in the literature. Herein, we report a rare case of pseudoangiomatous stromal hyperplasia in both axillae in a previously healthy 46-year-old woman and describe the imaging findings, including ultrasonography and computed tomography findings.

MRI features of pseudoangiomatous stromal hyperplasia with histopathological correlation

Pseudoangiomatous stromal hyperplasia (PASH), a rare, noncancerous lesion, is often an incidental finding on magnetic resonance imaging (MRI)-guided biopsy analysis of other breast lesions. We sought to describe the characteristics of PASH on MRI and identify the extent to which these characteristics are correlated with the amount of PASH in the pathology specimens. We identified 69 patients who underwent MRI-guided biopsies yielding a final pathological diagnosis of PASH between 2008 and 2015. We analyzed pre-biopsy MRI scans to document the appearance of the lesions of interest. All biopsy samples were classified as having ≤50% PASH or ≥51% PASH present on the pathological specimen. On MRI, 9 lesions (13%) appeared as foci, 19 (28%) appeared as masses with either washout or persistent kinetics, and 41 (59%) appeared as regions of nonmass enhancement. Of this latter group, 33 lesions (80%) showed persistent kinetic features. Masses, foci, and regions of nonmass enhancement did not significantly correlate with the percentage of PASH present in the biopsy specimens (P ≥ .05). Our findings suggest that PASH has a wide-ranging appearance on MRI but most commonly appears as a region of nonmass enhancement with persistent kinetic features. Our finding that most specimens had ≤50% PASH supports the notion that PASH is usually an incidental finding. We did not identify a definitive imaging characteristic that reliably identifies PASH.

Management of recurrent bilateral multifocal pseudoangiomatous stromal hyperplasia (PASH)

Pseudoangiomatous stromal hyperplasia (PASH) is a benign hyperplastic condition of the breast that can lead to macromastia. The standard treatment for PASH is focal excision or rarely reduction mammoplasty. We present a rare case of postpartum bilateral rapid breast enlargement and axillary growth that was refractory to reduction mammoplasty. Ultimately, the patient required bilateral mastectomy and two-stage implant-based breast reconstruction. This more extensive form along with its management represents one of the few reported cases in the literature. The decision to pursue bilateral mastectomy was undertaken after exhausting more conservative options. Excellent aesthetic outcome and pain relief was obtained following definitive extirpative and reconstructive surgery.

Breast Imaging Chameleon: Pseudoangiomatous Stromal Hyperplasia Presenting as Breast Malignancy

Pseudoangiomatous stromal hyperplasia (PASH) is a benign mesenchymal proliferative lesion of the breast, often an incidental finding on breast biopsy specimens and rarely presents as a palpable lump. The case being reported is interesting as a lactating female presented with gross left breast enlargement due to a huge firm mass with skin thickening and palpable left axillary lymph nodes. A provisional diagnosis of left breast malignancy was made and the patient extensively worked up with ultrasound, CT scan, bone scan and core biopsy. The histopathology, however, revealed PASH of the breast. There was no invasive or in situ malignancy. The patient was successfully managed conservatively.

Pseudoangiomatous Stromal Hyperplasia of the Breast: A Rare Finding in a Male Patient

Pseudoangiomatous stromal hyperplasia (PASH) in male patients is a rare condition that represents a hormonally-induced proliferation of mesenchymal tissue of the breast. This benign pathology is often undiagnosed due to many reasons. When PASH presents as a breast mass, it appears innocent, developing as a smooth and well-circumscribed tumor. Furthermore, it does not elicit suspicious findings on imaging. These points often halt further investigation of many breast abnormalities. Breast masses are statistically most likely to be gynecomastia when they arise in men. However, they are important to investigate because, although rare, breast cancer can occur in men. Furthermore, the benign conditions of the breast that commonly affect women can also impact male patients. It is oftentimes overlooked that men too can experience hormonal stimulation of the breast tissue. The following case describes this rare but important instance of a male patient diagnosed with PASH following a previous diagnosis of infiltrative ductal carcinoma in situ of the contralateral breast.

Atypical pseudoangiomatous stromal hyperplasia showing rapid growth of the breast: Report of a case

Pseudoangiomatous stromal hyperplasia (PASH) of the breast is a benign lesion manifesting as myofibroblastic proliferation and anastomosing slit-like spaces. Atypical PASH is an extremely rare lesion characterized by cytological alteration of myofibroblast, presenting as myofibroblastic sarcoma arising from PASH. To our knowledge, only one other case has been reported since the first report of Rosen. We present a case of atypical PASH. A 39-year-old female presented with a round, elastic hard, painless mass in the left breast. Mammography and ultrasonography revealed no definitive sign of malignancy. Core needle biopsy report was suggestive of atypical PASH. Five months later, the mass had grown rapidly with pain. Considering the clinicopathological features, excision was performed. Pathological examination revealed the spindle cells proliferation in collagenous stroma. The spindle cell involved the adipose tissue and lobules and lined peudoangiomatous spaces. These cells exhibited marked cytological atypia and mitotic activity. Immunohistochemically, these spindle cells were positive for SMA, CD10, and bcl-2, and negative for podoplanin, p63, CD31, ERG and cytokeratins. The final diagnosis was atypical PASH. She is tumor-free on 12 months follow-up. The nature of atypical PASH remains unknown. Further studies are required for a clear definition, a new histological entity and diagnostic criteria.

Concurrent giant tumoral pseudoangiomatous stromal hyperplasia necessitating bilateral mastectomy

Pseudoangiomatous stromal hyperplasia (PASH) is an uncommon benign mesenchymal tumor of the breast. Majority occur as diffuse lesions, and diagnosis is often incidental or in a background of other breast pathologies. Bilaterality with multiple tumoral masses in giant breasts is a rarity. We report a 34-year-old nonlactating female with 2-year history of rapid progressive painless bilateral enlargement of the breasts following surgical excision of ill-defined breast lumps which were not subjected to histopathological evaluation a year earlier. Examination revealed bilateral nontender giant breasts extending to the umbilical area with masses which were not attached to overlying skin, Grade 2 pressure ulcers on the lateral posterior breast aspects bilaterally and peau d'orange. There were no other palpable masses or lymph nodes. A clinical assessment of bilateral gigantomastia was made. Bilateral mastectomy revealed giant PASH which was confirmed with positive immunohistochemical reactivity for CD34 and vimentin. No other breast pathologies were seen with extensive sectioning. Diffuse multiple breast lesions with incomplete excision are associated with rapid growth in PASH as seen in this case. The presence of concurrent bilateral giant tumoral masses without any underlying breast pathology is a novelty. The mainstay of treatment in this case is mastectomy despite its benign nature.

[Fibroepithelial tumors of the anogenital mammary-like glands]

Mammary-like glands are a normal anatomical component of the anogenital region. The tumors occurring in them morphologically mimic the similar diseases of the breast. The paper presents a case of vulvar fibroadenoma with leaf-like outgrowths and apocrine metaplasia in a 38-year-old female patient. It describes the clinical and morphological characteristics of fibroadenomas and benign phyllodes tumors in the anogenital region.

Pseudoangiomatous Stromal Hyperplasia in Core Needle Biopsies of Breast Specimens

BACKGROUND

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.

MATERIALS AND METHODS

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.

RESULTS

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.

CONCLUSION

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.

A Case Report: Pseudoangiomatous Stromal Hyperplasia Tumor Presenting as a Palpable Mass

We report a case of woman with a palpable lump on her left breast. On mammography, a huge mass located between the inner and the outer inferior breast quadrants of the left breast was found. The ultrasound examination realized later revealed a heterogeneous mass with smooth and lobulated borders. An MRI was also performed, showing an oval mass with heterogeneous areas of enhancement. Finally, a core biopsy under sonographic guidance revealed a pseudoangiomatous stromal hyperplasia of the breast.

Nodule-Forming Pseudoangiomatous Stromal Hyperplasia of the Breast: Report of Three Cases

Pseudoangiomatous stromal hyperplasia (PASH) is a benign proliferative entity of mammary stroma. It is generally found as an incidental finding. It may rarely present as a palpable nodule. Three patients, who were 29, 45, and 58 years of age, were referred to our clinic with nodule and pain in the breast. The physical examinations and ultrasound findings of all three patients were consistent with fibroadenoma. Core biopsies were performed and reported as "benign breast parenchyma including stromal fibrosis." PASH areas were noted in one case. The excision specimens were observed as solid nodular masses with smooth external surfaces and white in colour. Microscopically, well-demarcated hyalinized stroma, including slit-like pseudovascular spaces lined by bland spindle cells, was observed. Immunohistochemically, these cells showed positive staining for CD34 and negative staining for CD31. Nodule-forming PASH mostly confuses with fibroadenoma with respect to clinical examination and radiological findings. Definite diagnosis requires histopathological verification. Differential diagnosis should be made with low grade angiosarcoma, fibroepithelial tumors, and myofibroblastoma.

A case of a giant pseudoangiomatous stromal hyperplasia of the breast: magnetic resonance imaging findings

Pseudoangiomatous stromal hyperplasia (PASH) of the breast is a benign myofibroblastic process. We present the case of a 17-year-old girl who underwent diagnostic work-up due to an enlargement of her left breast. She was submitted to ultrasounds and magnetic resonance imaging (MRI) which depicted a 14 cm lesion in her left breast. The patient was later operated and histology revealed PASH. Although PASH may range from 0.6–12 cm, a few lesions over 12 cm have been described, the largest being 20 cm. Large series present mammographic and ultrasonographic features of PASH in the literature, but little has been reported on the MR characteristics of PASH up to today. Signal on the T1-weighted image (T1WI) and T2-weighted image (T2WI) may vary. Curves generated from dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) studies are mainly type I or less frequently type II. There are no reports about diffusion-weighted imaging and corresponding apparent diffusion coefficient (ADC) values for PASH in the literature. ADC values in our case lie within the range of values reported for other benign breast lesions. The presence of slit-like spaces within the lesion on MR imaging along with DCE-MRI type I curve and ADC values consistent with a benign lesion may favour the diagnosis of PASH. Tissue biopsy is necessary, however for the final diagnosis. This case report will further contribute to the understanding of MR imaging features of PASH, especially in cases where mammography is not indicated.

Columnar cell lesions and pseudoangiomatous hyperplasia like stroma: is there an epithelial-stromal interaction?

The significance of association between cancer and its microenvironment has been increasingly recognized. It has been shown in animal models that interaction between neoplastic epithelial cells and adjacent stroma can modulate tumor behavior. Carcinoma associated stromal cells can transform normal epithelial cells into neoplastic cells. In breast, columnar cell lesions are non-obligate precursors of low grade ductal carcinoma in situ. Columnar cell lesions can be seen intimately associated with PASH-like-stroma, a lesion we termed as CCPLS. Our aim is to investigate epithelial-stromal interactions in CCPLS and compare them to PASH without columnar cell lesions in breast core needle biopsies. Normal terminal duct lobular unit (TDLU) epithelium was seen in association with columnar cell lesions as well as PASH. Eight (8) cases of each category were examined by a panel of immunostains: CD117 (C-kit), CD34, CD105, bFGF, AR, ER-beta, MIB-1. We observed a markedly decreased expression of c-kit in columnar cell lesions compared to TDLU-epithelium. CD105 showed a quantitative increase in activated vessels in CCPLS compared to PASH. A subset of CCPLS and PASH were androgen receptor positive. A strong nuclear positivity for ER-beta is observed in the epithelium and stroma of all CCPLS cases. We conclude that (1) activated blood vessels predominate in CCPLS; (2) A molecular alteration is signified by c-kit loss in columnar cell lesions; (3) ER-beta and androgen receptor positivity indicate CCPLS are hormonally responsive lesions. Our study suggests an intimate vascular and hormone dependent epithelial-stromal interaction exists in CCPLS lesions.

Diagnosis of pseudoangiomatous stromal hyperplasia of the breast: ultrasonography findings and different biopsy methods

PURPOSE

Pseudoangiomatous stromal hyperplasia (PASH) of the breast is a rare, benign condition that can be mistaken as a fibroadenoma on an ultrasound examination or as a low-grade angiosarcoma on a histological examination. The objective of this study was to evaluate the ultrasound features and to present biopsy methods to correctly identify PASH.

PATIENTS AND METHODS

We retrospectively reviewed the data of 55 women who were diagnosed with PASH of the breast. Ultrasound features were evaluated according to the Breast Imaging Reporting and Data System (BI-RADS; American College of Radiology). The diagnostic ability of different biopsy methods such as core needle biopsy, vacuum-assisted biopsy and excisional biopsy were analyzed with the final histopathological results of surgical specimens.

RESULTS

PASH presented as a circumscribed solid mass, with hypoechoic texture with or without heterogeneity, and a parallel orientation. The features of small, internal cysts or vascular channels and no calcifications can be used to differentiate the lesions from fibroadenomas. A core needle biopsy misdiagnosed PASH in 13 cases out of 28 cases and vacuum-assisted biopsy correctly identified PASH in all 3 cases.

CONCLUSION

Ultrasound features of PASH should be noted when performing a biopsy. For inconclusive cases of PASH, an excisional biopsy followed by an initial core biopsy should be performed.