18 October 2006 – Case of the Week #62
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Case of the Week #62
A 22 year old Caucasian woman had a two-month history of an enlarging right breast mass. There was no nipple discharge and she denied use of hormones or other drugs. The mass was tender to palpation without any external signs of inflammation. The resected specimen was 540 grams, 14 x 11 x 4 cm, solid, ovoid and well-circumscribed. The cut surface was white, firm and homogenous with a few scattered slit-like spaces (Figures 1, 2). Low and medium power showed large hyperplastic lobules with a proliferation of ductules and acini. Few ducts were dilated (Figure 3, 4, 5). The enlarged lobules were strongly immunoreactive for cytokeratin 8 (Figure 6).
The sclerosis seemed to start at the center of the lobule and radiate towards the periphery, incarcerating the acini with severe fibrosis and atrophy (Figure 7, 8). The Trichrome stain highlighted dense interlobular fibrosis and a peculiar periacinar sclerosis with a glomeruloid pattern (Figure 9, 10). The myoepithelial cells were prominent in these areas, as demonstrated by Calponin immunoreactivity (Figure 11)
What is your diagnosis?
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Sclerosing lobular hyperplasia of the breast
Sclerosing lobular hyperplasia is an uncommon lesion of the female breast characterized by prominent hyperplasia of the lobules with severe and extensive fibrosis of the intralobular stroma, and to a lesser degree, the interlobular parenchyma. It occurs almost exclusively in young women. Patients generally complain of a palpable, painless or slightly tender and well-defined lump in the breast of short duration. This lesion was first reported by Kovi et al (1) who described it in a group of 18 patients, mainly young women. It is possible that Cheatle (2) in 1922 was referring to the same lesion. The mean age of patients is 28 to 32 years, with a range of 12 to 46 years (3).
Its relation to fibroadenoma or fibroadenomatoid changes around the hyperplastic lobules was noted in the original article, and some authors have redefined this lesion as fibroadenomatosis, fibroadenoid mastopathy, or fibroadenomatoid hyperplasia (1, 4). In our case, this feature is not present.
The clinical differential diagnosis includes giant juvenile fibroadenoma and juvenile hypertrophy in younger patients, and phyllodes tumor in older patients. None of these lesions have been associated with lobular sclerosis.
Pathologically, the resected specimens vary from small ovoid and white solid tumors of 1 cm up to large solid tumors. Fine needle aspiration findings are nonspecific and overlap with fibroadenoma, including flat sheets of oval ductal epithelial cells in an acinar arrangement, a few bare nuclei in a clean background and variable stromal fragments (5, 6).
The natural course of sclerosing lobular hyperplasia is not known. However, no association with malignancy or recurrence has been documented.
1. Kovi J, Chu HB and Leffall LD: Sclerosing lobular hyperplasia manifesting as a palpable mass of the breast in young black women. Hum Path 1984;15:336
2. Cheatle GL.: Hyperplasia of epithelial and connective tissues in the breast: its relation to fibroadenoma and other pathological conditions. Br J Surg;1922;10: 436
3. Poulton TB, de Paredes ES and Baldwin M: Sclerosing lobular hyperplasia of the breast: imaging features in 15 cases. AJR Am Roentgenol 1995;165:291
4. Rosen PP.: Fibroepithelial neoplasms. In Rosen's Breast Pathology (2nd Edition). Lippincott Williams and Wilkins 2001; pages 163-170
5. Kapur P, Rakheja D, Cavuoti DC and Johnson-Welch SF: Sclerosing lobular hyperplasia of breast: cytomorphologic and histomorphologic features: a case report. CytoJournal 2006;3:8
6. Panikar N and Agarwal S: Sclerosing lobular hyperplasia of the breast: fine needle aspiration cytology findings--a case report. Diagn Cytopathol 2004;31:340
Nat Pernick, M.D., President
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