Findings
Mammogram - MLO view of right breast showing both calcification and well defined oval mass with enlarged axillary lympnodes. Slice 62 of MLO tomosynthesis showing well defined oval mass surrounded by thin capsule containing fat and soft tissue component. Slice 32 of tomosynthesis of showing calcification in the inner breast. Ultrasound: Multiple heterogenous masses noted, largest is seen in supero-medial quadrant and it shows multiple echogenic foci , suggestive of calcification and is hard on elastography. Usg image 2 : heterogenously hyperechoic mass with hypoechoic capsule in central quadrant , extending to lower quadrant .Another heterogenous mass with calcification is noted superior and separate to above mentioned mass. CECT images of PET SCAN shows Orange arrow - Large well circumscribed fat containing lesion is seen in central quadrant of the right breast with glandular tissue within and shows well-defined capsule and measures ~9 cm in size. Blue arrow - ill-defined heterogeneously enhancing mass is seen in the superomedial quadrant of the right breast measuring ~6 x 4 cm. PET IMAGES: Orange arrow - ill-defined heterogeneously enhancing mass in the superomedial quadrant and multiple other foci of the right breast seen in CECT are FDG avid. And the other fat containing lesion is not taking up FDG
Answer
A rare case of coexisting hamartoma and malignancy in the breast .
Discussion
Breast hamartomas are benign breast lesions composed of fatty, fibrous, and glandular elements in varying amounts. So it is also called as “lipofibroadenoma,” “fibroadenolipoma,” and “adenolipoma”, reflecting the predominant component of the lesion. The reported incidence of breast hamartomas is 0.7% of benign breast tumors in females. Cowden syndrome can be associated with multiple hamartomas. Mammography : Well circumscribed oval mass with thin capsule and contains fat and soft tissue. "breast within a breast“ or a "slice of sausage" appearance. Ultrasound : Usually mixed in echotexture , resembles normal breast tissue. No hyper-vascularisation on doppler imaging. Capsule may or may not be seen. On elastography - Color pattern contains mainly blue and light blue indicating it is less elastic than the surrounding tissue as it highly contains fibrous tissue Few papers have reported malignancy arising from pre-existing hamartoma where mammography showed micro calcifications within the fatty mass. An irregular hypoechoic tumor within the hamartoma is the most common finding in ultrasonography. Microscopically , neoplasms arising from the this fibroadenolipoma show large tumor cells which are arranged in solid clusters with pleomorphic nuclei In our case , the two lesions are seen separate from each other . The malignant mass is not seen within the hamartoma , so it is not arising from the hamartoma. History taking , physical examination and imaging should be done in detail when a patient with known hamartoma comes with new onset of symptoms like palpable hard lump , discharge from nipple, retraction of nipple etc. We should be aware of the suspicious features within a hamartoma during the performance and interpretation of imaging studies.
Reference
Li, Mengxin MM; Lin, Gu MM; You, Wu MM; Zhen, Wang MM; Xu, Chengzhao MM; Hong, Jinghui MM; Ye, Du MD; Dong, Song PhD∗ Hamartoma of the breast in a man, Medicine: December 2019 - Volume 98 - Issue 50 - p e1837 doi: 10.1097/MD.0000000000018372 Breast hamartoma: a case report Giovanna Gatti, Giovanni Mazzarol, European Institute of Oncology, Postgraduate School of General Surgery, University of Perugia; 4 Division of Pathology, European Institute of Oncology, Milan; 5 University of Milan, Italy
