Malignant transformation of fibroadenomas

Transcription

1 Malignant transformation of fibroadenomas Poster No.: C-2503 Congress: ECR 2013 Type: Educational Exhibit Authors: L. N. Elias, M. A. Rudner, L. M. Yano, P. C. Moraes, Y Chang, M. B. D. G. Funari, M. Corpa ; São Paulo, SP/BR, Sao Paulo/BR Keywords: Breast, Mammography, Ultrasound, Biopsy, Cancer, Image registration, Patterns of Care DOI: /ecr2013/C-2503 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 36

2 Learning objectives Review and illustrate the imaging findings associated with malignant transformation of fibroadenomas. Page 2 of 36

3 Background Fibroadenomas are the most common solid benign masses of the breast and are frequently classified as probably benign on imaging exams. Lesions classified as BI RADS 3 have a low (< 2%) probability of being malignant and short-interval follow-up monitors lesions for changes at a more frequent interval than regular screening. Although rare, malignant transformation of fibroademas is a possibility. Deschenes et al reported finding carcinoma within fibroadenomas in 0.02% of patients in a screened population. Diaz et al reported the features of 105 carcinomas arising within fibroadenomas. The mean age of the patients was 44 years and carcinoma in situ was the predominant type of malignancy (95%) found, lobular and ductal subtypes occurring with equal frequency. Carcinomas arising within a fibroadenoma have the same biological behavior as those arising independently and, therefore, their management should follow the general principles of therapy for the in situ or infiltrative breast cancers. Page 3 of 36

4 Imaging findings OR Procedure details Fibroadenomas are usually characterized as circumscribed solid masses at both mammography and ultrasound. When they are associated with coarse dense calcifications, they can be safely classified as BI-RADS 2. In cases of noncalcified masses, BI-RADS 3 is the proper classification and the few cancers occurring in this category can be identi#ed through interval progression at follow-up imaging. New calcifications in a preexisting mass, mass growth or margin modification during follow up are suspicious for malignancy and could also indicate malignant transformation in a fibroadenoma. In light of that, radiologists should be aware of any change that occur during the follow up of lesions classified as BI-RADS 3, because it may be the only indicative sign of malignization in a pre-existing fibroadenoma. Workup of lesions should include coned-down-compression and/or magnification views and ultrasound evaluation in cases of masses. This careful evaluation of mass margins and of the morphologic features of calcifications can help distinguish a malignant lesion from a probably benign finding. Cases of malignant transformation of fibroadenomas diagnosed at our institution will be displayed. These patients underwent mammography, ultrasound and histological investigation. The decision to perform percutaneous biopsy was based on ACR BI RADS criteria. Page 4 of 36

5 Images for this section: Fig. 1: Case 1: Female, 52 years old with clinical history of two benign biopsies on the right breast (fibroadenomas) in Actual mammogram showed an ill-defined mass in the posterior third of the junction of the upper quadrants of the right breast, associated with coarse and heterogeneous calcifications. The finding was classified as BI-RADS 4 and histopathological study was recommended. Page 5 of 36

6 Fig. 2: Vacuum assisted biopsy specimen shows typical fibroadenoma findings. Page 6 of 36

7 Fig. 3: Post biopsy follow up showed mass growth and also increase in the number of calcification. Histopathological study was recommended again. Page 7 of 36

8 Fig. 4: Comparative craniocaudal views show the evolution of the ill-defined mass in the right breast. Page 8 of 36

9 Fig. 5: Comparative mediolateral oblique views show the increase in size and in number of calcifications of the right breast mass. Page 9 of 36

10 Fig. 6: Comparison between the focal spot compressions of the right ill-defined mass. Page 10 of 36

11 Fig. 7: Ultrasound showed an ill-defined mass (Fig A) and was used to guide the percutaneous vacuum-assisted biopsy (Fig B). The histophatological result was invasive ductal carcinoma associated with fibroadenoma. Page 11 of 36

12 Fig. 8: Surgical specimen shows invasive ductal carcinoma Page 12 of 36

13 Fig. 9: Case 2: Female, 50 years old, screening mammogram showed an ill-defined mass associated with pleomorphic calcifications in the anterior third of the junction of the outer quadrants of the left breast. Page 13 of 36

14 Fig. 10: Prior mammogram from another facility was available for comparison demonstrating the appearance of the calcifications within the mass. Page 14 of 36

15 Fig. 11: Comparative mediolateral oblique views. Note the new calcifications within the mass. Page 15 of 36

16 Fig. 12: Figure A - Ultrasound showed this lobulated and ill-defined mass with calcifications within it, corresponding to the mammographic finding and was used to guide the biopsy. A post biopsy clip was deployed next to the mass (yellow arrow). Figure B X-Ray of the specimens confirmed the presence of calcifications. Page 16 of 36

17 Fig. 13: The result was ductal carcinoma in situ (DCIS) associated with fibroadenoma. Within typical fibroadenoma general architecture, the clefts are expanded by highly atypical epithelial cells, with coarse calcifications. Page 17 of 36

18 Fig. 14: In high power magnification, the nuclei are hyperchromatic with prominent nucleoli. Page 18 of 36

19 Fig. 15: Case 3: Female, 62 years old, screening mammogram. The craniocaudal view showed a new oval, isodense mass with obscured margins in the posterior third of the inner lower quadrant of the right breast. Page 19 of 36

20 Fig. 16: Mediolateral oblique, mediolateral and focal compression views showing the same mass. Page 20 of 36

21 Fig. 17: Comparative craniocaudal views show the new mass in the right breast. Page 21 of 36

22 Fig. 18: Comparative mediolateral oblique views depicting the new mass. Fig. 19: An oval, ill-defined and hypoechoic mass was seen on ultrasound (Fig A) and percutaneous vacuum-assisted biopsy was performed (Fig B).The histophatological result was DCIS in complex fibroadenoma. Page 22 of 36

23 Fig. 20: At low power magnification, typical fibroadenoma architecture. One of the clefts showing a subtle monotounous epithelial proliferation. Page 23 of 36

24 Fig. 22: At higher power the proliferation is monotonous, with rigid arcs and regular secondary lumens. Page 24 of 36

25 Fig. 21: Detail of the subtle monotounous epithelial proliferation. Page 25 of 36

26 Fig. 23: Case 4: Female, 51 years old, prior right lumpectomy and radiation therapy three years ago. Mammography demonstrated no evidence of malignancy. Page 26 of 36

27 Fig. 24: Screening ultrasound demonstrated a new mass with probably benign features (oval, isoechoic and circumscribed) in the right upper outer quadrant. Percutaneous biopsy was performed and resulted in lobular carcinoma in situ associated with fibroadenoma. Page 27 of 36

28 Fig. 25: Low power magnification view discloses typical fibroadenoma. In the upper right, the ducts look filled and expanded. Page 28 of 36

29 Fig. 26: In higher power, the ducts are expanded by a monotonous proliferation of discohesive vacuolated cells with low grade atipia. Page 29 of 36

30 Fig. 27: Immunostain for E-cadherin is negative in the neoplastic cells. Page 30 of 36

31 Fig. 28: Case 5 : Female, 31 years old with family history of breast cancer. First screening mammogram shows heterogeneously dense breast with no mammographic evidence of malignancy. Page 31 of 36

32 Fig. 29: Screening ultrasonography revealed a solid, irregular, hypoechoic and ill-defined mass in the lower outer quadrant of the left breast. Biopsy was recommended and the result was DCIS within fibroadenoma. Page 32 of 36

33 Fig. 30: Staging MRI depicted a segmental, heterogeneous and asymmetric enhancement in the lower outer quadrant corresponding to the previously biopsied mass. Page 33 of 36

34 Conclusion Fibroadenomas are benign breast tumors that manifest on imaging exams as probably benign masses. Although they are not expected to change during follow up, interval progression could be the only indicator of malignant transformation and should prompt the recommendation for biopsy. Page 34 of 36

35 References Baker KS, Maonsees BS, Diaz NM, Destouet JM, McDivitt RW: Carcinoma within fibroadenomas: mammographic features. Radiology 1990, 176(2): Diaz NM, Palmer JO, McDivitt RW. Carcinoma arising within fibroadenomas of the breast. A clinicopathologic study of 105 patients. Am J Clin Pathol May ;95(5): Dupont WD, Page DL, Parl FF, Vnencak-Jones CL, Plummer WD Jr, Rados MS, et al. Long-term risk of breast cancer in women with fibroadenoma. N Engl J Med. 1994; 331(1): El-Wakeel H, Umpleby HC. Systematic review of fibroadenoma as a risk factor for breast cancer. Breast. 2003; 12(5): Borecky N, Rickard M. Preoperative diagnosis of carcinoma within fibroadenoma on screening mammograms. J Med Imaging Radiat Oncol 2008;52:64-7 Sklair-Levi M, Sella T, Alweiss T, Craciun I, Libson E, Mally B. Incidence and Management of Complex Fibroadenomas. AJR. 2008; 190(1): Page 35 of 36

36 Personal Information Albert Einstein Hospital- HIAE Department of Radiology Av. Albert Einstein, 627 Morumbi - São Paulo/SP - Brazil CEP: Paula de Camargo Moraes, MD, PhD Chief, Breast Imaging Service HIAE moraespc@gmail.com Page 36 of 36