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1093/jjco/hyq181 Advance Access Publication 11 October 2010
Clinical Features and Prognosis of a Unilateral Fibroadenoma of the Breast in a 16-Month-Old Female
Aiping Shi 1, Sijie Li 1, Ning Xu 2, Gang Nie 1, Xingliang Li 1, Tianwei Zhang 3 and Zhimin Fan 1,*
Department of Breast Surgery, The First Hospital of Jilin University, 2Department of Urology, The First Hospital of Jilin University, Changchun 130021, and 3Department of Breast Surgery, The Second Farm Hospital, Heilongjiang Province, Haerbin 150088, China *For reprints and all correspondence: Zhimin Fan, Department of Breast Surgery, The First Hospital of Jilin University, 71 Xinmin Street, Changchun 130021, China. E-mail: email@example.com
Received May 15, 2010; accepted August 26, 2010
Downloaded from http://jjco.oxfordjournals.org/ by guest on April 19, 2012
Fibroadenoma of the breast is a common benign disease, occurring mainly in females younger than 30 years of age. Infant ﬁbroadenoma is extremely rare. Here, we report on a 16-month-old female with a 6 month history of unilateral progressive breast enlargement. Upon clinical evaluation, a palpable mass was observed in the upper and outer quarter of the right breast. The single tumor was solid and well circumscribed. Various clinical examinations were performed, including determination of hormone levels, ultrasound, mammography, magnetic resonance imaging, as well as the collection of a ﬁne needle aspiration. The results showed that the sex hormones were present at normal levels. The size of the tumor was approximately 3 Â 3 Â 3 cm. Enlarged lymph nodes were not detected in the axillary region or any other regions. The tumor was removed surgically and ﬁbroadenoma was diagnosed postoperatively. The patient was followed up for 38 months and no tumor recurrence was observed. Key words: breast pathology – breast surgery – ﬁbroadenoma – infant mastectomy
The human breast is composed of fat tissue embedded with glandular tissue and a supporting ﬁbrous tissue, also referred to as the stroma. Normal breast development starts during embryogenesis with the formation of the mammary ridge. In newborns, breast tissue can be enlarged during a short period after birth due to exposure to maternal estrogen. However, this is a transient situation and will reverse until the onset of puberty. Enlarged infant breast masses are rare. Diagnosis and proper treatment are important, but there is little knowledge on this subject. Fibroadenoma of the breast is the second most common tumor after breast cancer in young female adults, but is rarely observed in infancy. As a benign tumor, ﬁbroadenoma is composed of both stromal and epithelial elements of the breast. It can be diagnosed by a clinical approach of physical examination, ultrasound
mammography, ﬁne needle aspiration (FNA) and core needle biopsy. Surgical resection is the common therapeutic approach.
The patient was a 16-month-old female with a 6 month history of unilateral progressive breast enlargement caused by a solid swelling. The infant’s grandmother had a history of breast cancer. The infant was born by uncomplicated vaginal delivery and had otherwise been in good condition. There was no history of hormone therapy in the mother during pregnancy or during the breastfeeding period. Breastfeeding was carried out until 12 months of age. At presentation, a 3 Â 3 Â 3 cm solid tissue mass was palpable in the upper and outer quarter of right breast. The tumor was solid and well circumscribed.
# The Author (2010). Published by Oxford University Press. All rights reserved.
Figure 2. In the FNA. without any microcalciﬁcation (Fig. As shown in Fig. The MRI images indicated a non-uniform tissue. with high density and a well-deﬁned border. having some areas with low signal. Figure 3. Promoting prolactin-releasing hormone (PRL). (B) T2WI.org/ by guest on April 19. 3. This analysis showed an irregular solidity in the tissue and lower echo than in the surrounding tissue. 2). estradiol (ESTRDL). 1.Jpn J Clin Oncol 2011. Swollen lymph nodes were not found in right axillary. The primary diagnosis was ﬁbroadenoma and cystosarcoma. There were no signs of metastasis in the lungs or the liver. Magnetic resonance imaging (MRI) analysis revealed a triangular lesion with smooth borders. There were neither enlarged lymph nodes detected in the axillary regions. Downloaded from http://jjco. The estrogen receptor (ER) and the progesterone receptor (PR) status by immunohistochemistry analysis indicated that approximately 90% of the cells expressed ER (Fig. follicle-stimulating hormone-releasing hormone (FSH-RF) levels were normal. Histology revealed an obvious ﬁbroadenoma morphology. 2012 Figure 1. Ultrasound image of the tumor.oxfordjournals.41(2) 261 Progesterone. T1-weighted signal (A) was similar to the muscle signal (top) and T2-weighted imaging (B) had a slightly higher signal than that of the fat tissue and water. testosterone and luteinizing hormonereleasing hormone (LHRH) levels were slightly decreased. Circulation in this area was determined to be low. MRI image of the tumor. Mammography image of the tumor. Ultrasound imaging revealed a solid tissue mass of about 3 Â 3 Â 3 cm as demonstrated in Fig. nor were there any found elsewhere in the body. Mammography revealed a spherical solid tissue mass. The patient underwent surgical resection of the tissue mass under general anesthesia. a large number of benign tumor cells were observed agglutinating and forming clusters. The tumor was well encapsulated and macroscopic evaluation of the tumor revealed a rough and uniform surface (Figs 4 and 5). (A) T1WI. 6) and .
mechanisms that trigger onset of infant breast ﬁbroadenoma are not clear.org/ by guest on April 19. Downloaded from http://jjco. thyroxine and insulin.262 Fibroadenoma of breast in 16-month-old female Figure 4. Infant mammary hyperplasia normally fades away within 3 to 6 months after birth. . CONCLUSION To date.oxfordjournals. However. breast tissue remains in a static state until the onset of puberty. The normal undeveloped breast is composed of glandular tissue and a supporting ﬁbrous tissue known as the stroma. (A) The excised tumor specimen and (B) macroscopic examination of the tumor mass. In females beyond the neonatal period. premature thelarche and precocious puberty are the most likely causes of early breast enlargement (3). 2012 Figure 5. 10% showed PR expression (Fig. Figure 7. 7).2). The patient was clinically followed up for 38 months (until October 2009) and no tumor recurrence was observed. Immunohistochemical detection of estrogen receptor expression (100 Â ). Normal breast development starts with the formation of the mammary ridge during embryogenesis. estrogen. Only two other papers have reported on this abnormality in Korea and Spain (1. Hematoxylin and eosin stained histological preparation of the tumor (100 Â ). Afterwards. such as progesterone. The glandular tissue produces milk and is composed Figure 6. no case reports exist of infant ﬁbroadenoma occurring in China. adrenal and pituitary hormones. Juvenile mammary ﬁbroadenoma may be related to local mammary tissue reacting to a rise in the estrogen level or to the expression of higher levels of estrogen receptors (4). Breast development occurs under the inﬂuence of several physiologic factors. Immunohistochemical detection of progesterone receptor expression (100 Â ).
For treatment planning purposes. Groups of alveoli form lobules. The ﬁnal cosmetic result is important when planning the surgical excision process. West et al. Secretory breast cancer ( juvenile breast carcinoma) is a rare type of breast cancer ﬁrst reported in pediatric patients in 1966. Using the methods mentioned above. well-encapsulated mass with a deﬁned border. and in our opinion the tumor was more likely to be a benign lesion. All of these elements led us to perform surgery in order to make an accurate diagnosis and to treat the patient accordingly. the patient is expected to have no apparent scar. In this present case. such as gynecomastia. The goal of any technique that seeks to image the breast is to extend the capability of physical examination to provide more information about subtle abnormalities. ﬁbroadenoma must be distinguished from malignant tumors. careful physical examination. FNA is highly speciﬁc in the diagnosis of breast masses as they are speciﬁcally targeted by the extraction method for ex vivo analysis. and the tumor displayed remarkably rapid growth. 2012 . the great majority of patients in the USA are treated by excisional biopsy to remove the tumor and establish the diagnosis. the esthetic result and its psychological implications were considered. reported on 74 children and adolescents who presented with palpable breast masses between 1980 and 1993. such as secretory breast cancer and cystosarcoma. we could not completely exclude the possibility of cystosarcoma. formation of new ducts by branching and elongation of existing ducts and the formation of lobular units (5). it is necessary to perform preoperative cytology of the mass to clearly deﬁne the amount of tissue involved and necessary for removal (9). Core needle biopsy is not a proper method for children.oxfordjournals. The tumor was properly removed by an incision near the areola and the tumor was excised completely with the intact capsule. and it is important to differentiate benign lesions from malignant ones to pursue the proper course of treatment.Jpn J Clin Oncol 2011. However. it is easy to differentiate ﬁbroadenoma from other breast diseases. which drain into ducts. MRI is also an appropriate technique used to detect recurrences (8). especially in distinguishing solid from cystic masses (7). which occurs in female adolescents. a non-surgical post-operative treatment approach with careful screening and close follow-up was considered. we attempted to remove all of the tumors while preserving as much of the normal tissue. different approaches exist regarding the treatment of ﬁbroadenoma.org/ by guest on April 19. Ultrasound is a very useful tool in examining benign breast diseases. Mammography also is a common means by which experts may distinguish benign lesions from malignant tumors by observing microcalciﬁcation and mass modality (6). the child had a history of breast cancer in her family. particularly for small lesions in dense or augmented breasts. MRI is not a common examination for breast cancer patients. Because malignant tumors are rare in children. but distant metastases have been reported (10. In the current case. We should pay attention to the fact that a large number of carcinoma and cystosarcoma have been misdiagnosed as ﬁbroadenoma prior to operation. In different countries. Downloaded from http://jjco. Fibroadenoma is a benign tumor composed of both stroma and epithelial elements of the breast. radiological examinations and FNA in juvenile patients. Moreover. It is used either as a diagnostic modality that seeks to answer speciﬁc questions about the health of the breast or as a screening test to identify any abnormality within the breast. we performed surgery to resect the tumor. The child underwent appropriate surgery as planned. Moreover. The tumor was formed during fetal development and expanded progressively under the control of hormonal stimuli. blood nipple discharge. the tumor was a solid. Mammography is clearly the most sensitive and speciﬁc test that can routinely be used to complement the physical examination of the breast. However. Twenty-two ﬁbroadenomas were identiﬁed and 19 cases were surgically resected because the mass had a diameter . The pathological examination conﬁrmed the ﬁbroadenoma diagnosis. We could not exclude the possibility of breast malignancy.41(2) 263 of alveoli. MRI provides better detail of the breast over mammography and ultrasound imaging and can be a valuable adjunct to other imaging techniques. However. including maternal estrogen delivered through breastfeeding. The diagnosis of breast mass in adults can be made through physical examination. the right breast had been larger since birth compared with the left one and a mass could be palpated at the age of 1 year. the nipple and the areolar region in order to increase the chance that the mammary bud will develop normally during adolescence. Incidences in pediatric and adult patients are similar and prognosis is favorable in both groups. intraductal papilloma. mastitis and breast abscesses. Palpable breast masses in pediatric patients are uncommon. In the current case. Cystosarcoma comprises epithelia and stroma that has been invaded by stromal cells. Therefore. This type of epithelial hyperplasia is usually benign.11). The excision was preformed without any complications. But in this case the patient is a female infant and it was not sure whether ultrasound and mammography results were trustworthy in terms of malignancy. Moreover. By using a small incision near the areola. a typical ﬁbroadenoma is frequently left untreated when the tumor is encountered in the breast of young women (6). There is a lack of case reports referring to the diagnosis and treatment of infant breast tumor in the current literature. In Europe. Fibroadenoma that occurs in the infant is more cellular in nature than cases of adult ﬁbroadenoma (6). 5 cm and were painful (13). Heteromorphism occurs in the stromal cells (12). mammography and MRI. and the ducts then drain into the nipple. According to the patient’s history. cytology and core needle biopsy. Valuable information can be supplied by a detailed history of the disease. the FNA revealed the presence of clustering abnormal cells. Breast development proceeds over 3 – 5 years and involves increased fat deposition. since the MRI showed that the mass is separated and does not develop from the nipple bud.
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