Pseudoangiomatous Stromal Hyperplasia: A Rare Cause of Breast Lump in a Premenopausal Female

Abstract

A 26-year-old female presented to the gynaecology Outpatient Department (OPD) with complaint of infertility. She was admitted and was being worked up for the same. Incidentally, a left breast lump was found for which she was referred to surgery OPD. Patient gave a history of lump being present since one year, which had gradually increased in size. She did not have any family history of similar lump in breast. She was married since three years and had not conceived till presentation. Patient gave history of irregular menstrual cycle associated with pain in abdomen on and off since four years. Magnetic Resonance Imaging (MRI) pelvis was done which was suggestive of bilateral multicystic ovarian lesion with haemorrhage within-chocolate cysts/endometriomas.On examination, a well defined lump of around 10 cm x 8 cm x 6 cm size was palpable in the left breast below the nipple areola complex. It was mobile, firm and non tender on palpation. Patient did not have any axillary lymphadenopathy. Rest of the physical examination were unremarkable. Provisional diagnosis on clinical examination was either a giant fibroadenoma or a phylloides tumour.On investigation, biochemical parameters were within normal limits. Ultrasonography (USG) of left breast showed a large, oval, hypoechoic lesion measuring 12.8 cm x 4.9 cm in size, wider than taller with smooth margins, in upper outer quadrant of right breast. It appeared benign.Core needle biopsy of the lump was performed and the histopathology report showed few benign acini in sclerosed stroma, suggestive of benign breast tissue.Patient underwent wide local excision of the lump using an inframammary incision [Table/ Fig-1], which revealed a 15 cm x 12 cm x 6 cm well encapsulated, smooth lump, with regular margins, weighing 600 grams in the left breast [Table/ Fig-2]. Procedure was uneventful, subcutaneous drain was placed after closure, and patient was discharged after removal of subcutaneous drain after three days.Patient was regularly followed up after excision for six months and had no significant complaints. Histopathology, report of the lump revealed mammary hamartoma with PASH with no evidence of malignancy [Table/ Fig-3-5]. DISCUSSIONPASH of the breast is a rare condition typically found incidentally. It typically occurs in pre-menopausal women but is also reported to be found in 24-47% of men with gynaecomastia [1]. Histologically, it resembles a low grade angiosarcoma or a phylloides tumour, from which it needs to be differentiated. Most of the patients are asymptomatic and are found to have a palpable, mobile, firm, painless lump in the breast while presenting with some other chief complaint, as in this case.The differential diagnosis include fibroadenoma, especially in a young patient and a phylloides tumour in older women [ AbSTRACTPseudoangiomatous Stromal Hyperplasia (PASH) of the breast is a rare benign proliferating breast condition. We report a case of a 26-year-old female who was being worked up for infertility and was incidentally noted to have a well defined l...

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“…However, there have been many cases where PASH was managed by observation as an acceptable treatment without any notable long term sequelae. Kareem et al states that excision may not be necessary if the mass is less than two centimeters or when found on core needle biopsies [ 7 ]. These lesions can be subsequently followed with serial imaging and may even be treated medically with tamoxifen [ 8 ].…”

The effect of hormones on an uncommon breast disorder pseudoangiomatous stromal hyperplasia: a case report and literature review

“…Pseudoangiomatous stromal hyperplasia (PASH) is an uncommon benign breast condition first described in 1986 [ 1 ]. With few reported cases to date, the lesion usually manifests as a palpable lump with similar characteristics to fibroadenomas; however, PASH is also frequently found incidentally on biopsies performed for other reasons [ 2 ].…”

“…PASH itself is a benign entity and is not associated with an increased incidence of malignancy. However, PASH can coexist with malignant lesions; suspicious imaging findings should prompt further investigation [ 1 ] and close follow-up. Surgical excision may not be indicated in patients diagnosed with PASH on core biopsy.…”

“…Excision is indicated for tumors with a suspicious radiologic or clinical appearance [ 6 ]. Following excision, PASH may recur, and recurrence rates from 5–22% have been reported [ 1 ].…”

Pseudoangiomatous stromal hyperplasia presenting as a tumor

“…In pseudoangiomatous hyperplasia, the fine needle aspiration findings are nonspecific and core biopsy has superior diagnostic accuracy ( 10 ) . However, in some cases, the appropriate histopathological diagnosis is made only after excision of the lesion ( 11 ) .…”