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  Table of Contents    
LETTER TO EDITOR  
Year : 2020  |  Volume : 63  |  Issue : 4  |  Page : 667-669
Painful left breast hamartoma: Underdiagnosed and under-reported entity


1 Department of Pathology, National Institute of Unani Medicine, Bengaluru, Karnataka, India
2 Department of Obstetrics and Gynecology, National Institute of Unani Medicine, Bengaluru, Karnataka, India

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Date of Submission23-Nov-2019
Date of Decision15-Feb-2020
Date of Acceptance24-Feb-2020
Date of Web Publication28-Oct-2020
 

How to cite this article:
Nagaraj RB, Sultana A. Painful left breast hamartoma: Underdiagnosed and under-reported entity. Indian J Pathol Microbiol 2020;63:667-9

How to cite this URL:
Nagaraj RB, Sultana A. Painful left breast hamartoma: Underdiagnosed and under-reported entity. Indian J Pathol Microbiol [serial online] 2020 [cited 2020 Nov 30];63:667-9. Available from: https://www.ijpmonline.org/text.asp?2020/63/4/667/299336




Dear Editor,

Hamartomas are considered poorly recognized, benign, non-neoplastic lesions that are endogenous to a particular site and may recur.[1] Depending on the predominant component of the breast tissue, it is also described as a fibroadenolipoma, adenolipoma, or lipofibroadenoma.[2] The incidence of breast hamartoma in females is 0.1%–0.7% of all benign tumors in the breast.[2],[3]

Breast hamartoma pathogenesis remains indistinct, and clinicians and pathologists frequently underestimate its diagnosis[3] because of its categorization as fibroadenomas. It is differentiated by a focal mixture of mature cells and tissues normally present in the affected area, which lack a distinguishing appearance.[1] Sometimes, the clinical findings may be similar to fibroadenoma and the patients may receive an instant diagnosis if there is a palpable mass.[2] It is important to note that the lesion can be easily missed if not appreciated by clinical examination or radiologically.[1],[4] Hence, we present a case report of the breast hamartoma.

A 42-year-old perimenopausal woman who visited our hospital with a painful lump in the left breast, which was noticed one week back on self-examination. The patient had no family history for breast cancer, no history of trauma, or any other history related to the lesion.

The local examination revealed the presence of the lesion in the left outer quadrant of the breast 5 cm away from the nipple about 3 cm in diameter, mobile, firm with elastic consistency and margins were well defined. There was no axillary lymphadenopathy. The ultrasonography report revealed a hyperechogenic lesion measuring 2.5 × 3.5 cm with irregular border suspicious of malignancy, however, axillary lymph nodes were not enlarged. Routine investigations were normal. The FNAC was done and it was inconclusive. [Figure 1]. The patient was referred for mammography since there was a suspicion for malignancy. However, the mammograph reported it as fibroadenoma [Figure 2]. The patient was referred for excision and the lesion was excised by simple excision and sent for histopathological evaluation. Histopathological examination revealed a mass that measured 5.4 × 3.5 cm with smooth consistency and had a grey-white cut surface with areas of congestion. Microscopic examination showed normal breast parenchyma with marked stromal fibrosis and cystic dilatation of ducts, with hyalinized stroma and entrapped lobules of mature adipose tissue. The focal sclerosing adenosis areas were noted. The histological findings were suggestive of the benign lesion with features of hamartoma [Figure 3]. Eight months after surgery the patient follow-up showed negative for recurrence.
Figure 1: (a) Showing few ductal epithelial cells with inflammatory cells (HPE-10X) in FNAC; (b) Showing only hemorrhagic background with inflammatory cells (HPE-10X)

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Figure 2: Mammography showing an ovoid well circumscribed mass of mixed density with fat and smooth capsule

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Figure 3: (a) Showing dilated glandular tissue and admixed with adipose tissue showing benign mammary tissue in mature adipose tissue (HPE-10X); (b) Showing mammillary glandular tissue in fibrous stroma (HPE-40X); (c) Showing mature mammary tissue with fibrous stroma and mature adipocytes (HPE-40X); (d) Showing glandular tissue, fibrous stroma and adipose tissue (HPE-4X)

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In this case report, the age of the patient was 42 years. The previous studies reported the mean age was 41.8 years and the range was 19–56 years. There was only one patient under 20 years of age and 7 patients were over 50 years of age.[5] The specific etiopathogenesis for breast hamartoma development remains obscure. Nevertheless, it is thought to be a consequence of a developmental aberration rather than a true neoplastic process.[3.5] It was reported that epithelial and stromal component of the breast hematoma expresses estrogen (ER) and progesterone (PR) receptors.[1],[5] Furthermore, there are unclear data on the source of smooth muscle for myoid hamartomas. Another theorized the existence of CD34 on smooth muscles is a significant sign of the metaplasia of stromal cells into smooth muscle cells.[5]

In our case, ultrasonography and FNAC were not able to diagnose it as hamartoma. It is reported that hamartomas cannot be differentiated from fibroadenomas that generally have a glandular homogeneous density within a thin halo of compressed fat.[4] Further, hamartomas do not possess specific diagnostic histological features. The role of FNAC and needle core biopsy in making the diagnosis is limited and requires clinical and radiological correlation to avoid underdiagnosis.[3] The previous study had mentioned the presence of adipose tissue and dense fibrous tissue on FNAC, which was observed with occasional epithelial cells attached was an important feature that was diagnostic, however, both these findings were not seen in our case, underdiagnosing it on FNAC.[3],[6]

Hence, the patient was advised for mammography. However, in our case, even the mammography findings failed to favor the diagnosis of hamartoma and showed fibroadenoma.[3] The mammographic appearance of breast hamartoma is unpredictable and the characteristic mammographic appearance of this lesion is infrequent.[4]

A retrospective study in 25 cases of only with breast hamartoma diagnosed on histopathology showed that most of the ultrasound, mammography, and magnetic resonance imaging (MRI) have done on these patients, diagnosis of lipofibroadenoma or hamartoma were given. However, mammograms showed mixed fibrous and adipose tissue without suspicion for malignancy were reported.[3] The mammogram shows a well-capsulated nodule without calcifications with features similar to those of fibroadenoma.

The definitive diagnosis is only by resection of the hamartoma followed by histopathological study.[7] Thus, the patient was referred to the surgical department for excision biopsy, and the sample was sent for histopathological study. In our study, histopathological features revealed the lesion as hamartoma. The findings of histopathological examination (HPE) showed normal breast parenchyma with marked stromal fibrosis and cystic dilatation of ducts, with hyalinized stroma and entrapped lobules of mature adipose tissue. The focal sclerosing adenosis areas were noted.

One of the studies reported the importance of correct identification of hamartoma as there are chances for recurrence if there isco-incidental epithelial malignancy in the lesion. Further, they emphasized on histological examination to rule out malignancy or any epithelial changes to diagnose breast lesion.[3] Surgical removal is the curative method for breast hamartomas.[1],[3] If there is a co-incidental epithelial malignancy in the lesion, there is a potential for recurrence.[3]

Hamartoma is a rare benign lesion, imaging features may be similar to a fibroadenoma. It is easily under-diagnosed and under-reported if not appreciated clinically or radiologically. Its definite diagnosis is only through histological examination.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Amir RA, Sheikh SS. Breast hamartoma: A report of 14 cases of an under-recognized and under-reported entity. Int J Surg Case Rep 2016;22:1-4.  Back to cited text no. 1
    
2.
Sonmez FC, Gucin Z, Yildiz P, Tosuner Z. Hamartoma of the breast in two patients: A case report. Oncol Lett 2013;6:442-4.  Back to cited text no. 2
    
3.
Tse GM, Law BK, Ma TK, Chan AB, Pang LM, Chu WC, et al. Hamartoma of the breast: A clinicopathological review. J Clin Pathol 2002;55:951-4.  Back to cited text no. 3
    
4.
Farrokh D, Hashemi J, Ansaripour E. Breast hamartoma: Mammographic findings. Iran J Radiol 2011;8:258-60.  Back to cited text no. 4
    
5.
Sevim Y, Kocaay AF, Eker T, Celasin H, Karabork A, Erden E, et al. Breast hamartoma: A clinicopathologic analysis of 27 cases and a literature review. Clinics (SaoPaulo) 2014;69:515-23.  Back to cited text no. 5
    
6.
Gómez-Aracil V, Mayayo E, Azua J, Mayayo R, Azua-Romeo J, Arraiza A. Fine needle aspiration cytology of mammary hamartoma: A review of nine cases with histological correlation. Cytopathology 2003;14:195-200.  Back to cited text no. 6
    
7.
Vergine M, Scipioni P, Santucci E, Colangelo M, Livadoti G, De Meo D, et al. Hamartoma of the breast in a young woman. Case report. G Chir 2013;34:161-3.  Back to cited text no. 7
    

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Correspondence Address:
Renuka B Nagaraj
Department of Pathology, National Institute of Unani Medicine, Bengaluru, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJPM.IJPM_915_19

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  [Figure 1], [Figure 2], [Figure 3]



 

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