Giant tumour of the breast

Clinical History

A 12-year-old black girl presented with a rapid growing mass in the left breast associated with an ulcerated nipple and bloody discharge. Her clinical and family histories and laboratory analysis were irrelevant. Her left breast was tender, warm, doubled in volume, with several palpable lumps.

Imaging Findings

Ultrasound showed an oval, relatively homogeneous and well-defined hypoechoic mass, with a partially lobulated contour, difficult to measure accurately due to its big dimension, but at least 12 cm large. There were no suspicious lymph nodes.
Magnetic Resonance imaging showed a big, well-defined left breast mass, with lobulated margins and several internal lobules. It had intermediate signal in T1. T2 weighted MR imaging reveals an almost isointense lesion with irregular hypointense central section and with some patchy hyperintense areas. T1 weighted fat suppressed post-gadolinium MR images showed persistent and heterogeneous enhancement pattern over time. The mass strongly enhances but there are non-enhancing septations. The right breast was normal. The MR imaging findings suggested a benign breast mass.

Discussion

Pathological breast conditions are rare in adolescence and ultrasonography is the modality of choice for identifying and characterizing parenchymal abnormalities and guiding further management [1]. Bloody discharge is found usually in ductal ectasia, chronic cystic mastitis and intraductal papiloma [1], entities usually not associated with an enlarging mass [2]. .
Breast primary neoplasms are rare in adolescents and if they are regular, well circumscribed and wider than tall in ultrasound, it favours benignity. Fibroadenoma is the most common benign neoplastic lesion in children and adolescents [3] and ultrasound and MR findings suggested this entity.
A large and solitary rapid growing breast mass in an adolescent is most likely benign, but in 25% of cases it could be malignant [2]. The malignant entities that present as a palpable enlarging breast mass are usually angiosarcoma and metastasis [4]. On MR, angiosarcomas usually show heterogeneous architecture with cystic cavities, and areas of hemorrhage or venous lakes [5]. Enhancement depends on tumor grade and it can be progressive in low grade tumors or it can show rapid wash-out in high grade tumors. In oncologic patients metastasis to the breast should be a consideration.
The core biopsy result of pseudoangiomatous hyperplasia (PASH) raised suspicion about the final diagnosis. In fact PASH sometimes presents as a mass and the clinical and radiological features resemble those of fibroadenoma [5, 6] . On the other hand, microscopic foci of PASH have been demonstrated in association with several entities like fibrocystic changes, fibroadenoma, phyllodes tumor, lymphoma and invasive carcinoma [4]. . Nevertheless it is mandatory to differentiate PASH from low grade angiosarcoma [6].
Surgical removal of the breast with breast reconstruction afterwards was performed, attending to the symptoms, youth of the patient and aesthetic result. The breast specimen result confirmed a giant juvenile fibroadenoma with several microscopic foci of PASH. The age of the patient, clinical presentation and ultrasound and MR imaging features suggested fibroadenoma from the beginning, but only the pathological examination of the tumor allowed confirmation of the diagnosis.

Differential Diagnosis List

Final Diagnosis

Giant juvenile fibroadenoma

URL:	https://www.eurorad.org/case/9585
DOI:	10.1594/EURORAD/CASE.9585
ISSN:	1563-4086