1. AbstractFibroadenomas (FA), are common benign tumor of the breast, can be treated with simple excision. Breast cancer arising within FA is a rare phenomenon. We report a 47-years old female, admitted to Istanbul Faculty of Medicine Department of Surgery and presented with multiple breast lumps and axillary suspected lymph node of three months duration. Patient underwent a lumpectomy, sentinel lymph node biopsy. 4 FAs were identified. In FAs ductal carcinoma in-situ (DCIS) were detected. In the sentinel lymph node there was a subcapsular circumscribed DCIS-like foci measuring detected. No further disease was observed in 5 year follow-up. 4 FAs were identified. In a FA 2 mm ductal carcinoma in-situ (DCIS), in another 1,5 mm DCIS, microcalcifications and atypic lobular hyperplasia were detected. In the sentinel lymph node there was a subcapsular circumscribed DCIS-like foci measuring 1,25 mm, within a 3 mm glandular inclusion. The morphology of DCIS-like lesion in the lymph node was similar to DCIS within FAs. This report aimed to attract attention to the the need for extensive tissue sampling in multiple FAs as the clinicoradiological features of malignant transformation may be quite suitable to be easily missed on routine examination.
2. IntroductionBenign breast disease has a high prevalence rate with fibroadenoma(FA) occurring in one of every five women and one of every two women is affected by fibrocystic disease FAs, a biphasic tumor with stromal and epithelial component, are benign tumors of not much concern. Malignant transformation in a FA is an uncommon feature [1]. Ductal carcinoma in-situ (DCIS) of the breast the tumour is confined within the ducts without invading the periductal stroma. Tumour spread has not yet occurred, as reflected by the favourable long-term breast cancer-specific mortality rate of 1-2 percent [2]. DCIS can be diagnosed reliably only after careful histological investigation requiring extensive tumour sampling to exclude invasion. A drawback of core biopsy is the limited sampling of a lesion, and therefore we report this case without adequate core biopsy diagnosis, but DCIS diagnosis after definitive pathologic examination.
3. Clinical SummaryA 47-years old woman presented with history of lump in the left breast of three month duration. Patient admitted from another clinic with diagnoses of malignant phyllodes tumor and multiple fibroadenoma (FA) of the left breast according to core biopsies. There was no family history of breast or ovarian lesions in the past. pathology department. Pathology department reported that there was no suspicious of malignancy findings in the available materials except FA features. On examination, a freely mobile firm mass was felt in left upper outer quadrant measuring 3 × 2 cm in size. Multiple smaller mobile lumps ranging in size from 0.5 cm to 1 cm were also palpable in upper quadrant near the axillary tail. There was no palpable lymph node in the left axilla. Mammography (MG) was not clerarly diagnostic because of high density of breast tissue, however MG revealed multiple small round nodular lesions with smooth margins and a larger lesion in the left breast on upper inner quadrant (Figure 1). Ultrasonography(USG) of left breast showed well-defined round to oval shaped hypoechoic lesions with smooth to macrolobulated margins. Magnetic resonance imaging(MRI) revealed similar findings, also MRI detected one suspected malignant lymph node in the left axilla. With surgeon’s opinion and patient’s request patient underwent a lumpectomy to the left upper outer quadrant and sentinel lymph node biopsy(SLNB).
4. Pathological FindingsIn definitive pathologic examination 4 FAs were identified. In a FA 2 mm ductal carcinoma in-situ(DCIS) (Figure 2), in another 1,5 mm DCIS, microcalcifications and atypic lobular hyperplasia were detected. In the sentinel lymph node there was a subcapsular circumscribed DCIS-like foci measuring 1,25 mm, within a 3 mm glandular inclusion. The morphology of DCIS-like lesion in the lymph node was similar to DCIS within FAs. The DCIS in FAs and lymph node were estrogen and progesterone receptor positive, cerb-2 negative. A circumfarential cavity shaving as reexcision, which involved an intercanalicular FA and postoperative breast tissue, was performed. Prophylaxis was continued with hormone therapy. No further disease was observed in 5 year follow-up period.
5. DiscussionEpithelial hyperplasia within fibroadenomas(FAs) is a common finding and infrequently atypical hyperplasia of ductal or lobular type may also be noted. Carter et al. found atypical hyperplasia in 0.8 - 1% of FAs [4]. Review of literature reveals few case studies with in situ/ invasive ductal and lobular carcinoma in a FA These findings draw our attention to rather rare events that occurs in a FA ranging from epithelial hyperplasias to in-situ or invasive carcinomas. Progression of epithelial component into in situ and invasive carcinomas is quite rare that occurs usually in women over 40 years [5]. Ductal carcinoma in-situ (DCIS) is a lesion which has a theoretical risk of 0% for metastases, axillary metastases have been found in 1-2% of the patients treated with axillary dissection. In a metaanalysis of 3166 patients, the incidence of sentinel lymph node(SLN) metastases was 7.4% in patients with a preoperative diagnosis of DCIS compared with 3.7% in patients with a definitive postoperative diagnosis of DCIS alone. Furthermore, SLN positivity in DCIS is higher than reported axillary positivity ranging between 1% and 13% in published reports [6-8]. In this present study a SLNB was performed according to suspicious of axillary lymph node by imaging and in this lymph node a small DCIS foci in an ephitelial inclusion was detected. To conclude, this case report highlights the need for extensive tissue sampling in multiple FAs as the clinicoradiological features of malignant transformation may be quite suitable to be easily missed on routine examination.
6. AcknowledgmentWe are grateful to Istanbul University Pathology Department fort the exellent breast histopathological section.
7. Ethical ApprovalAll procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
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Ilhan B .A Review for Diagnostic Inaccuracy of Pure Ductal Carcinoma Insitu in Multiple Fibroadenomas and Axillary Nodal Involvement . Annals of Clinical and Medical Case Reports 2021