Diffuse pseudo angiomatous stromal hyperplasia of breast - A case report Poster No.: C-0011 Congress: ECR 2011 Type: Scientific Exhibit Authors: S. L. Penukonda, B. Dev; CHENNAI, TN/IN Keywords: Breast, Ultrasound, Mammography DOI: 10.1594/ecr2011/C-0011 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. www.myesr.org Page 1 of 19
Purpose To present a rare case of diffuse pseudo angiomatous stromal hyperplasia involving the whole breast. Page 2 of 19
Methods and Materials A 36 year old female presented with gradually enlaging left breast over the period of 1 year. The swelling was painless. No abnormal nipple discharge. On clinical examination the left breast was diffusely enlarged and shows dilated veins on the skin. on palpation the breast was soft rubbery consistency with no tenderness and no discret lump palpated. Digital mammogram of both breasts performed in two standard mediolateral oblique and craniocaudal views followed by ultrasound examination of both breasts. Subsequently patient was operated and histopathology obtained. Patient followed up for one year. No recurrence observed. Page 3 of 19
Results Digital mammogram done in two views showed enlarged left breast with diffusely increased homogenous density.(fig.1 on page 5 and Fig.2 on page 5) Right breast appeared normal.(fig.12 on page 15) Ultrasound scan of the left breast performed with high frequency(8-12mhz) linear transducer showed increased paranchymal thickness and paranchymal heterogeneity. Normal fat globules and fibroglandular tissue could not be seen. (Fig.3 on page 6 and Fig.4 on page 7) This pattern is noted all over the left breast. No focal nodules seen. Ultrasound of the right breast showed normal mixed fatty and fibroglandular pattern (Fig.5 on page 8) Imaging diagnosis of possible phylloids tumor was given. Patient was operated and the entire left breast specimen (Fig.6 on page 9 and Fig.7 on page 10)was sent for histopathological examination. Histology showed extensive proliferation of spindle cells lining the interlacing areas of vascular like channels.(fig.8 on page 11 and Fig.9 on page 12) There is no evidence of mitosis. Spindles cells were positive for CD 34 staining (Fig.10 on page 13) Review of ultrasound images showed thin slit like anechoic areas within the proliferated stroma possibly representing histologically identified pseudovascular channels (Fig.11 on page 14) Color doppler showed minimal vascularity within the proliferated stroma. Page 4 of 19
Images for this section: Fig. 0: Mediolateral view of the left breast shows diffusely increased density with no obvious discret nodules or microcalcifications Page 5 of 19
Fig. 0: Craniocaudal view of the left breast with diffusely increased density. No discret nodules or microcalcifications seen. Page 6 of 19
Fig. 0: Ultrasound of the all four quadrants of the left breast shows diffuse thickening of breast paranchyma with loss of normal fibroglandular and fatty echotexture Page 7 of 19
Fig. 0: Zoomed out image of the left breast shows thickend paranchyma with altered echotexture. Page 8 of 19
Fig. 0: Ultrasound of the right breast for comparison Page 9 of 19
Fig. 0: Excised specimen of left breast shows grey white mass with vascular congestion on the surface Page 10 of 19
Fig. 0: Cut surface of the specimen which shows firm, homogenous grey white surface Page 11 of 19
Fig. 0: Histological specimen x4 H&E stain, Bland spindle cells appear to be lining the slit like spaces with interspersed collagen Page 12 of 19
Fig. 0: High power view showing slit like spaces. spindle cells and collagen. x 40. H&E stain Note the absence of atypia and mitosis Page 13 of 19
Fig. 0: CD 34 stain decorating the spindle cells. x 10, Immunohistochemistry Page 14 of 19
Fig. 0: Retrospective review of the ultrasound image of the left breast shows thin vascular like channels which donot show any color flow. The hypertrophic paranchyma shows minimal vascularity Page 15 of 19
Fig. 0: Craniocaudal view of the right breast for comparison Page 16 of 19
Conclusion Cinical and radiological signs of diffuse enlargement of the entire left breast with proliferation of stromal tissue with typical histological faetures of PASH as mentioned above makes this case extremely rare rather unique in involving the entire breast tissue. To the best of our knowledge this is the first case of diffuse PASH reported in females involving the entire breast. Page 17 of 19
References 1) What is this breast mass a mammogram detected? VOL 63, NO 1/JANUARY 2007 Contemporary Surgery 2007 Quadrant HealthCom Inc. Timothy Judge, MD; Moo Hwang, MD; James Harris, MD Department of Surgery, Dwight D. Eisenhower Army Medical Center, Fort Gordon, GA 2) American Journal of Roentgenology, Vol 166, 349-352, Copyright 1996 by American Roentgen Ray Society Pseudoangiomatous stromal hyperplasia: mammographic and sonographic appearances MR Polger, CM Denison, S Lester and JE Meyer Department of Radiology, Brigham and Women's Hospital, Boston, MA 02115, USA. 3) Diagnosis of Pseudoangiomatous Stromal Hyperplasia of the Breast: Ultrasonography Findings and Different Biopsy Methods Yonsei Med J. 2008 October 31; 49(5): 757-764. Published online 2008 October 31. doi: 10.3349/ymj.2008.49.5.757. Yoon Jung Choi, 1 Eun Young Ko, 2 and Shinho Kook 1 Page 18 of 19
Personal Information Primary author - Dr. Penukonda suvarna latha, DNB, FRCR. Assistant professor of radiology, Sriramachandra medical college, Porur, Chennai, TN, India-600116. Presently working in the department of Diagnostic Imaging, KK women's and childrens' hospital, 100 Bukit timah road, Singapore Co -authors 1) Dr. Bhawna Dev, Professor of radiology, Sriramachandra medical college, Porur, Chennai, TN, India-600116. 2) Dr. J.Thanka, Professor of pathology, Sriramachandra medical college, Porur, Chennai, TN, India-600116. 3) Dr. S.Rajendran, Professor of pathology, Sriramachandra medical college, Porur, Chennai, TN, India-600116. Page 19 of 19