Case Report

DCIS Breast Arising in a Fibroadenoma- Case Report of a Rare Condition

Gollapalli V*, Bibi A K Shah S and Gilchrist B
Department of Surgery, Bronx-Lebanon Hospital, USA


*Corresponding author: Gollapalli V, Department of Surgery, Bronx-Lebanon Hospital, 1650 Selwyn Avenue, Suite 4A, Bronx, New York 10457, USA


Published: 15 Feb, 2017
Cite this article as: Gollapalli V, Bibi A K Shah S, Gilchrist B. DCIS Breast Arising in a Fibroadenoma- Case Report of a Rare Condition. Clin Surg. 2017; 2: 1312.

Abstract

Fibroadenoma (FA) is a type of benign tumor that occurs in young women below the age of 35 years old. The incidence of carcinoma arising with FA is rare with range of 0.002 to 0.125%. Most cases are detected at an early stage, cases of locally advanced carcinoma with distant metastasis have been published. We report a case of DCIS with microinvasion arising within Fibroadenoma which was being followed for 9 years.
Keywords: Breast cancer; Fibroadenoma; Carcinoma in situ

Case Presentation

This is a 43 year female who was being followed for an image detected lesion (fibroadenoma) in the right breast upper outer quadrant, since age 34 (9 years ago). She had no family history of breast cancer. Imaging with mammogram and ultrasound which showed a vague lesion in a dense breast tissue on right side. Her serial mammogram was inconclusive BI RADS 0 due to density of breast (Figure 1). Serial ultrasound showed a hypoechoic lesion of less than 2 cm lesion between 8 to 9 '0'clock position with a calcification focus (Figure 2-5). Each time it was categorized as BIRADS 3 and required closed follow up. After 9 years of follow up, mammogram showed focus of polymorphic micro calcifications warranting biopsy (Figure 6-9). Ultrasound guided biopsy showed ductal carcinoma in situ, with areas of micro invasion. She underwent needle localized partial mastectomy and Sentinel lymph node biopsy. Final pathology showed in-situ ductal carcinoma arising from hylanized FA with micro invasion. The size was 0.5 cm (pT1mic) and lymph node negative (pN0). Tumor was estrogen and progesterone receptor positive and Her2 neu receptor negative. All margins were negative. She is currently undergoing radiation therapy followed by hormonal therapy. The patient was followed up every 3 months, and at the last follow-up examination in June 2016, the patient exhibited no signs of recurrence.

Figure 1

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Figure 1
Density of Breast.

Figure 2

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Figure 2
Hypoechoic lesion.

Figure 3

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Figure 3
Hypoechoic lesion.

Figure 4

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Figure 4
Hypoechoic lesion.

Figure 5

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Figure 5
Hypoechoic lesion.

Figure 6

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Figure 6
Polymorphic micro calcifications.

Figure 7

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Figure 7
Polymorphic micro calcifications.

Figure 8

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Figure 8
Polymorphic micro calcifications.

Figure 9

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Figure 9
Polymorphic micro calcifications.

Discussion

Fibroadenoma (FA) is a common type of benign tumor that occurs in younger women below the age of 35 years old, with a reported incidence rate of 7–13% in female individuals. It may occur at any age; however, the peak age of incidence is in the second and third decade of life. They occur asymptomatically in 25% of all patients. The FA can be stimulated by estrogen, progesterone, pregnancy and lactation, and may undergo atrophy during menopause [1,2]. Furthermore, FA is a biphasic tumor composed of stromal and epithelial components, and can be effectively treated by local excision [3].
The majority FAs is clinically identifiable; however, 25% of cases are non-palpable and, thus, require mammography and/or ultrasonography (US) for diagnosis [4-6]. Currently, the therapeutic methods used for breast cancer include surgery, chemotherapy, radiotherapy, endocrine therapy and targeted therapy [3]. The incidence of carcinoma arising with FA is rare with range of 0.002 to 0.125%. Previous studies have reported that fibroadenoma can evolve into different types of malignancy, such as lobular intraepithelial neoplasia, lobular carcinoma in situ, malignant phyllodes tumors and microinvasive lobular carcinoma [4,6-9].
According to its clinicopathological presentation, FA can be divided into simple and complex FA. Complex FA is characterized by cysts, sclerosing adenosis, epithelial calcification or papillary apocrine change [10-12]. Carcinoma arising within a fibroadenoma is a rare with an incidence rate of 0.1–0.3% in a screened population (10) and unique subtype of mammary cancer, which was reported by Buzanowski-Konakry et al. [7] in 1975. To date, < 130 cases have been reported in the worldwide literature.
Therefore, histological diagnosis is typically unexpected [1,8,9,13,14]. The mean age of patients with carcinoma in FA has been reported as 42–44 years, ~20 years subsequent to the peak age of occurrence of FA [15,16]. Our patient was in this 40's age group. Two-thirds of carcinomas within FA are lobular, and one-third are ductal or mixed ductal and lobular, with the frequency of LCIS and ductal carcinoma in situ almost equal [2,15]. Carcinoma is diagnosed as arising within FA if: 1) The carcinoma is entirely encased within the FA; or 2) if the carcinoma is only focally involved with the adjacent breast tissue [16]. The case presented in the present study met the first criterion.
FA is typically considered to be a type of benign lesion and requires careful observation. However, data regarding whether FA is a risk factor for carcinoma is inconsistent [17]. A number of studies have provided evidence of the association between the excised FA and carcinoma. The relative risk of developing breast cancer following surgically excised FA appears to depend on the histological characteristics of FA and the state of the breast parenchyma [18-24].
The present case showed that FAs containing foci of carcinoma in situ can be indistinguishable from benign lesions following imaging, therefore, despite the incidence of carcinoma within FA is estimated at 0.1–0.3%, it should be considered a long-term risk factor for invasive breast cancer. The present describes a case of DCIS arising within an FA and conducts a review of the relevant literature [25-30].
FA is considered to be an aberration of normal breast development [19] and the majority that occur in younger females may resolve or reduce in size without intervention [6,20]. Although malignancy in FA is rare it may be difficult to predict malignant transformation in an FA, as the clinical and radiological signs may be masked [2,21]. There is a general consensus that the management of FA depends on the age of the patient, the nature of the lesion, the family history of breast or ovary carcinoma, or any data of proliferative changes in the breasts from previous biopsies [6,20]. For example, previous studies have proposed a conservative therapeutic strategy for FA in patients younger than a certain age. However, the threshold ages proposed or conservative treatments are inconsistent, and have been reported as 25, 35 and 45 years [22-25].
If the lesion increases in size, excision is immediately performed. However, if the lesion is regressive, follow up should be continued until the regression is complete. If the lesion does not completely regress, or stabilizes by the age of 35 years, a lumpectomy is suggested. For females aged >35 years, surgery is recommended when the lesion is stable or increases in size after a 6- to 12-month follow-up period. Additionally, excision is recommended for any complex FA. For patients with a family history of breast and/or ovarian cancer, surgery is more actively advised. The treatment for DCIS arising within fibroadenoma is not clearly defined. DCIS is treated by surgical excision, followed by radiotherapy as part of breast conserving treatment, and/or endocrine therapy.
The aggressiveness, morbidity and mortality are not clear. Presence of carcinoma could also be a sign of the deficiency related to the screening system. As most of these patients are young and have dense breast that might preclude detection of these lesions. Ultrasound is operator dependent close follow up may not be as accurate as possible. Hence suggest early MRI of breast as an option.


Conclusion

In conclusion, the present case was reported to increase awareness that FA in the middle and older age group can harbor cancer, early intervention in this age group is suggested. Complex FA has a higher risk. High degree of suspicion is needed, as there are limitations in screening, which adds to the problem of delayed diagnosis.


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