|Year : 2015 | Volume
| Issue : 4 | Page : 1032
Pseudoangio-matous stromal hyperplasia: A rare tumor of the breast
Kedar Singh Shahi1, Geeta Bhandari2, Rakesh Kumar Gupta1, Malvika Sawai1
1 Department of Surgery, Government Medical College, Haldwani, Nainital, Uttarakhand, India
2 Department of Anaesthesia, Government Medical College, Haldwani, Nainital, Uttarakhand, India
|Date of Web Publication||15-Feb-2016|
Kedar Singh Shahi
Department of Surgery, Government Medical College, Haldwani, Nainital, Uttarakhand
Source of Support: None, Conflict of Interest: None
Pseudoangiomatous stromal hyperplasia (PASH) is a benign breast entity described first by Vuitch et al., in 1986. PASH is a benign stromal lesion containing complex anastomosing channels lined by slender spindle cells. It can be mistaken with fibroadenoma on ultrasound examination and histologically with low-grade angiosarcoma and phyllodes tumor. Here, presented is a case report of a 30-year-old female who presented with huge palpable lump in left breast. Ultrasonography revealed the lesion as giant fibroadenoma and fine needle aspiration cytology report was suggestive of cystosarcoma phyllodes. Excision and reduction mammoplasty was done and histopathology report was suggestive of PASH.
Keywords: Breast lump, cystosarcoma phyllodes, fibroadenoma, pseudoangiomatous stromal hyperplasia
|How to cite this article:|
Shahi KS, Bhandari G, Gupta RK, Sawai M. Pseudoangio-matous stromal hyperplasia: A rare tumor of the breast. J Can Res Ther 2015;11:1032
| > Introduction|| |
Pseudoangiomatous stromal hyperplasia (PASH) of the breast is a localized mesenchymal stromal cell overgrowth that occurs almost mostly in premenopausal women as a painless, palpable breast mass. ,, The lesion is pale, fibrous, has a homogeneous cut surface and is typically well-circumscribed. Its ramifying slits lined by flattened myofibroblastic cells are mistaken histopathologically with diagnosis of angiosarcoma.  PASH of the breast is a lesion characterized on histology by the presence of anastomosing slit-like spaces embedded in a hyalinized fibrous stroma.  The exact etiology and pathogenesis of PASH is still not known, but a proliferative response of myofibroblasts to hormonal stimuli has been postulated.  A case of a 30-year-old lady with gross enlargement of left breast causing asymmetry is discussed here with the review of literature.
| > Case report|| |
A 30-year-old woman, otherwise healthy, presented with the progressive enlargement of her left breast for one year and noticed a palpable mass for three months. She had normal menstrual cycle. There were no other significant past or current medical problems. Physical examination of the patient suggested a mass in her left breast. The lymph nodes were not palpable. The skin overlying the mass showed dilated and visible veins, nipple and areola were normal and intact. Her right breast was normal. [Figure 1] She was subjected to a routine examination of the mass using ultrasonomammography. Bilateral mammography was suggestive of benign giant fibroadenoma of 20 cm × 18 cm in left breast. Fine needle aspiration cytology (FNAC) was performed, which suggested the lesion to be cystosarcoma phyllodes. Reduction mammoplasty was done. [Figure 2] The gross appearance and histopathology report were consistent with the diagnosis of PASH [Figure 3] and [Figure 4].
|Figure 3: Gross appearence of tumour on cut surface showing solid grayish white with areas of myxoid changes|
Click here to view
|Figure 4: Histopathology showing duct ectasia with stasis of eosinophilic secretion, cystically dilated glands and columnar cell layer hyperplasia with mild atypia|
Click here to view
| > Discussion|| |
Vuitch et al. in 1986 first described PASH as benign proliferation of myofibroblasts.  The term pseudoangiomatous emphasize the fact that histological pattern mimics but not actually constitute a vasoformative proliferation. Most common manifestation of PASH is a single, circumscribed palpable mass in a premenopausal female. ,, It can present as a microscopic focus; as a solitary clinically palpable mass; as multifocal nodules; or as a diffuse massive process with asymmetry of the breast. ,,, The mass is usually large (5-6 cm in diameter), with reported diameters ranging from 1 to 12 cm. ,, The reported age range of patients with PASH is 14-67 years, although most patients are in their forties or late thirties. ,,,,, On clinical examination, PASH is usually misdiagnosed as a fibroadenoma. , Lesions due to PASH are usually noncalcified and appear well-circumscribed or partially circumscribed on mammography. The masses are seen at ultrasonography as hypoechoic solid masses.  PASH increase in size over time and may recur after surgery, but they are neither associated with malignancy nor considered to be premalignant lesions.  Histologically, PASH has a "characteristic pattern of proliferating myofibroblasts that creates slit-like spaces". ,,,, The myofibroblasts are assumed to react aberrantly to progesterone and start as a focal accentuation of mammary physiologic changes during the menstrual cycle. ,, Foci that eventually create discrete masses probably escape normal physiological control mechanisms, cease cycling with the remaining breast, and acquire the capacity for independent myofibroblastic proliferation.  True masses are generally asymmetrical in relation to the other breast, distinct from the surrounding tissues and three-dimensional.  Benign lesions of breast have discrete, well-defined margins and are mobile. Cysts cannot reliably be distinguished from solid breast masses by palpation. The use of triple testing in the diagnosis of palpable masses has been utilized to increase the true positive rate. Highly suspicious physical examination should prompt biopsy regardless of the imaging findings. Family history should be used to determine appropriate diagnosis and patient care. This case had some unique features like huge enlargement of breast and ill-defined mass on clinical examination. FNAC and sonographic findings suggested fibroadenoma/cystosarcoma phyllodes. Operative findings were features of a benign lesion with characteristics of PASH, which was proven on histopathology. Therefore, this lesion should be considered in differential diagnosis of benign breast lesions.
| > Conclusion|| |
PASH is a relatively uncommon benign stromal lesion of the breast and has good prognosis. PASH should always be included by surgeon in the differential diagnosis of a circumscribed mass in the premenopausal female population. The masses grow slowly over time and can recur after excision. Diagnosis of PASH is usually done by MRI and ultrasonography imaging followed by core cut or excisional biopsy for histopathological examination. Pathologist must be aware of the presence of a mass lesion and appreciate the stromal changes characteristic of such a lesion. It can be confused with vascular tumors such as low grade angiosarcoma and cystosarcoma phyllodes, and can be differentiated by immunohistochemistry. Surgical excision of the tumor mass is recommended treatment, and mastectomy must be avoided.
| > References|| |
Gow KW, Mayfield JK, Lloyd D, Shehata BM. Pseudoangiomatous stromal hyperplasia of the breast in two adolescent females. Am Surg 2004;70:605-8.
Castro CY, Whitman GJ, Sahin AA. Pseudoangiomatous stromal hyperplasia of the breast. Am J Clin Oncol 2002;25:213-6.
Vicandi B, Jimenez-Heffernan JA, Lopez-Ferrer P, Ortega L, Viguer JM. Nodular pseudoangiomatous stromal hyperplasia of the breast. Cytologic features. Acta Cytol 1998;42:335-41.
Prasad S, Houserkova D, Svach I, Zlamalova N, Kucerova L, Cwiertka K. Pseudoangiomatous stromal hyperplasia of breast: A case report. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2008;152:117-20.
Vuitch MF, Rosen PP, Erlandson RA. Pseudoangiomatous hyperplasia of mammary stroma. Hum Pathol 1986;17:185-91.
Taira N, Ohsumi S, Aogi K, Maeba T, Kawamura S, Nishimura R, et al
. Nodular pseudoangiomatous stromal hyperplasia of mammary stroma in a case showing rapid tumor growth. Breast Cancer 2005;12:331-6.
Abdull Gaffar B. Pseudoangiomatous stromal hyperplasia of the breast. Arch Pathol Lab Med 2009;133:1335-8.
Sng KK, Tan SM, Mancer JF, Tay KH. The contrasting presentation and management of pseudoangiomatous stromal hyperplasia of the breast. Singapore Med J 2008;49:e82-5.
Ibrahim RE, Sciotto CG, Weidner N. Pseudoangiomatous hyperplasia of mammary stroma: Some observations regarding its clinicopathological spectrum. Cancer 1989;63:1154-60.
Okoshi K, Ogawa H, Suwa H, Saiga T, Kobayashi H. A case of nodular pseudoangiomatous stromal hyperplasia (PASH). Breast Cancer 2006;13:349-53.
Iancu D, Nochomovitz LE. Pseudoangiomatous stromal hyperplasia: Presentation as a mass in the female nipple. Breast J 2001;7:263-5.
Cho N, Oh KK, Park KY, Noh TW. Sclerosing lobular hyperplasia: Sonographic pathologic correlation. Eur Radiol 2003;13:1645-50.
Powell CM, Cranor ML, Rosen PP. Pseudoangiomatous stromal hyperplasia (PASH). A mammary stromal tumor with myofi broblastic diff erentiation. Am J Surg Pathol 1995;19:270-7.
Cohen MA, Morris EA, Rosen PP, Dershaw DD, Liberman L, Abramson AF. Pseudoangiomatous stromal hyperplasia: Mammographic, sonographic, and clinical patterns. Radiology 1996;198:117-20.
Gunhan-Bilgen I, Memiº A, Ustun EE, Ozdemir N, Erhan Y. Sclerosing adenosis: Mammographic and ultrasonographic findings with clinical and histopathological correlation. Eur J Radiol 2002;44:232-8.
Mercado CL, Naidrich SA, Hamele-Bena D, Fineberg SA, Buchbinder SS. Pseudoangiomatous stromal hyperplasia of the breast: Sonographic features with histopathologic correlation. Breast J 2004;10:427-32.
Polger MR, Denison CM, Lester S, Meyer JE. Pseudoangiomatous stromal hyperplasia: Mammographic and sonographic appearances. AJR Am J Roentgenol 1996;166:349-52.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]