2014, Volume 30, Number 3, Page(s) 237-240
Cytopathologic Diagnosis of Spontaneous Infarction of Fibroadenoma of the Breast
Neelam WADHWA1, Richa JOSHI1, Nidhi MANGAL1, Nirupma Panikar KHAN2, Mohit JOSHI1
1Department of Pathology, University College of Medical Sciences, University of DELHI, INDIA
2Guru Teg Bahadur Hospital, Shahdra, DELHI, INDIA
Keywords: Fibroadenoma, Breast, Infarction, Fine needle biopsy, Cytology
Infarction is an uncommon event in a fibroadenoma, which is
the commonest benign tumor of the breast. Most often it occurs
in pregnancy, lactation or is secondary to fine needle aspiration.
Spontaneous infarction of a fibroadenoma in the absence of a
predisposing condition is very rare. The cytopathologic features of
infarction are necrosis and worrisome nuclear features, which are
often misinterpreted as either inflammation or malignancy. We
detail a report of accurate cytopathologic diagnosis of spontaneous
infarction of fibroadenoma in a 17-year-old adolescent non pregnant
girl. Careful attention to the cytopathologic clues like uniform
thickness of the necrotic epithelial fragments, branching pattern
reminiscent of the staghorn pattern despite atypical nuclear features
and clinical details like young age of the patient and recent onset
pain in a pre-existing lump helped arrive at the correct diagnosis and
spared the patient of a radical excision. To the best of our knowledge,
there are no earlier reports of correct cytopathologic diagnosis.
Infarction rarely occurs in a fibroadenoma, the most
common tumor of the female breast. Most cases of infarction
are secondary to fine needle aspiration1
infarction is extremely uncommon, and typically seen in
pregnant or lactating women2,3
. Most cases of infarction
of fibroadenoma are misdiagnosed clinically, radiologically
and cytopathologically as malignant masses, thus prompting
a radical surgical intervention3-6
Spontaneous infarction of fibroadenoma of the breast in
non-pregnant women is rarely described in the medical
literature, and correct cytopathologic diagnosis has not
been previously reported4,5. Herein, we report a case
of spontaneous infarction of fibroadenoma of the breast
in a non pregnant adolescent girl diagnosed on fine needle
aspiration cytopathology. The cytopathologic diagnosis was
confirmed by histologic evaluation of the conservatively excised surgical specimen. We also highlight the diagnostic
cytopathologic features of infarction, the recognition of
which spared the patient a radical surgery.
A 17-year-old adolescent non pregnant girl presented with
a lump in the upper inner quadrant of her right breast
for the last 3 months which had recently become painful.
There was no history of trauma, fever, hormone intake or
family history of breast carcinoma. A well-circumscribed,
mildly tender, mobile mass, 4 x 4 x 3 cm was palpable in
the right breast. Bilateral axillae and the contra-lateral
breast did not reveal any lump. Fine needle aspiration was
performed percutaneously using a 10 mL syringe and a 23
G needle under sterile conditions. May-Grünwald-Giemsa
and Papanicolaou staining were done on air-dried and wetfixed
Air-dried May-Grünwald-Giemsa stained smears showed
sheets and clusters of epithelial cells, some with
typical branching staghorn shapes. Although the overall
impression on low magnification was suggestive of a
fibroadenoma; the clusters appeared ghostly and necrotic
(Figure 1). The cells were discohesive and the edges of the
epithelial clusters were frayed, unlike the well-defined edges
usually seen in fibroadenoma. The stromal fragments were
magenta but dull, lacking the usual refractile quality seen
in fibroadenoma (Figure 2). Most nuclei were found to be missing both in the epithelial and stromal fragments. The
occasional nuclei were visualized better on Papanicolaustained
smears: these were enlarged, smudgy, and focally
irregular (Figure 3). In isolation, these cells could have been
misinterpreted as malignant cells in a necrotic background.
Considering the cellular cohesion and largely preserved
shape of the epithelial cell clusters and the history of recent
onset pain, despite the presence of occasional worrisome
nuclei, a diagnosis of spontaneous infarction of FA of the
breast was rendered.
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|Figure 1: Necrotic epithelial fragments showing well defined
contours reminiscent of fibroadenoma. Note the uniform
thickness of the fragment (May Grünwald-Giemsa; x400).
Click Here to Zoom
|Figure 2: Dull looking necrotic stromal fragments with irregular
shapes and variable thickness. Contrast these with the necrotic
epithelial fragments on their right for regular outlines and
uniformity of thickness (May Grünwald-Giemsa; x40).
Click Here to Zoom
|Figure 3: Individually scattered cells devoid of nuclei in the
background. Only occasional cells show hyperchromatic nuclei
(Papanicolaou stain; x400).
The breast mass was conservatively excised. The surgical
specimen measured 5 x 4.5 x 3 cm, and contained a wellcircumscribed
2.2 cm tumor. Grossly, the tumor was yellow
with tiny foci of hemorrhage (Figure 4). The specimen was
fixed in 10% neutral buffered formalin, paraffin embedded
and 4 mm thick hematoxylin and eosin stained sections
prepared. The sections showed coagulative necrosis with only
ghostly outlines of epithelial fronds with intra-canalicular
and peri-canalicular stromal proliferation (Figure 5). As
in the cytopathologic smears, nuclei were conspicuously
absent in both epithelial and stromal components. The
tumor margin showed mild acute inflammatory infiltrates;
no thrombotic or occlusive vascular lesions were identified.
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|Figure 4: Well circumscribed yellow colored tumor with areas
of hemorrhage is seen distinct from the surrounding breast
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|Figure 5: Fibroadenoma showing coagulative necrosis with
partially preserved intra-canalicular architecture and loss of
nuclei. Adjacent breast parenchyma is identifiable on the right
Fibroadenoma accounts for up to 50% of all palpable breast
lumps in young females3
. Development of infarction
in a fibroadenoma of the breast is an uncommon event,
seen in 0.5% to 1.5% of all cases including those seen in
. A painful breast lump is the most
common complaint; other presentations include lump
with irregular margins, fixity to underlying structures, skin
tethering, nipple discharge and axillary lymphadenopathy.
In such patients, a clinical diagnosis of an inflammatory or
neoplastic process is not inappropriate2-5
features like heterogeneous echotexture and acoustic
shadows may reinforce the suspicion of a malignancy6
The history of recent onset pain in a previously painless
lump, as in our case, may be the only clue to its clinical
Infarction of tumors is a known albeit an uncommon
complication of fine needle aspiration cytopathology.
Besides tumors of the breast, it has been occasionally
reported in thyroid, lymph nodes and salivary gland1. The
vascular trauma during the needling procedure may incite
thrombosis and hence infarction of the tumor. Spontaneous
infarction of fibroadenoma, per se a rare event, as been
mostly described in the third trimester of pregnancy and
lactation2,3,6. The relative ischemia for the hyperplastic
tumor tissue in these physiological conditions is the most
widely accepted hypothesis. Spontaneous infarction in a
fibroadenoma of the breast in the absence of pregnancy
or lactation is a rare enigmatic entity4,5,7. In such cases,
the increased demand hypothesis is not applicable. Also,
vascular lesions like thrombosis have been demonstrated
only rarely. Given the rarity of spontaneous infarction,
possibility of a probable torsion due to increased mobility
of a fibroadenoma also remains speculative at best.
The cytopathological features of infarction in a fibroadenoma
are inflammation, necrosis and worrisome nuclear features
of the surviving cells. Till date, all cases of spontaneous
infarction of fibroadenoma have been misdiagnosed either
as a high-grade malignancy or as mastitis4,5. The necrosis
in a case of high-grade carcinoma is characteristically
punctate and shows streaking due to smearing. Although,
large chunks of necrosis may be seen, they tend to have
irregular margins and non-specific shapes. The necrosis in
a fibroadenoma is similar to that seen in a malignancy only
in the loss of nuclei. The most striking feature is the necrotic
epithelial cell clusters that maintain their typical branching
staghorn shape. Although their margins may appear
frayed, they are still regular and preserved. The thickness
of the necrotic fragments is another important clue. The
necrotic epithelial fragments appear homogenously opaque
reproducing the mono-layered sheets. In contrast, the
necrotic fragments in a malignancy are thick and opaque
in the center and become thinner and translucent towards
the edges due to the smearing effect. The necrotic stromal
fragments are more difficult to distinguish from necrosis of
a carcinoma and may be misinterpreted as a component of
malignancy. A careful scrutiny of the necrotic fragments
will invariably reveal the diagnostic necrotic epithelial
clusters. A meticulous search is also likely to reveal a few
preserved epithelial cell clusters, although they may scant.
A diagnosis of malignancy should not be rendered in the
absence of viable / unequivocal tumor cells. In cases of
suspicion, a guarded report is prudent and re-aspiration or
needle biopsy should be done.
In view of necrosis and the acute inflammatory response,
it is also advisable to exclude the possibility of mastitis. In pyogenic mastitis, abundance of neutrophils is the most
striking feature8. Intra-cellular cocci are often found
on diligent search. In tuberculosis, the characteristic
epithelioid cells, often accompanied by multinucleate giant
cells are found. The demonstration of tubercle bacilli by
Ziehl Neelsen stain clinches the correct diagnosis8,9. The
inspissated secretions of duct ectasia may be confused as
necrosis. The typical presentation as a sub-areolar cord like
mass in older women is most helpful10.
Infarction in a fibroadenoma poses diagnostic challenge.
We have presented a case of spontaneous infarction of
fibroadenoma in a non pregnant adolescent girl highlighting
the cytopathologic approach its correct diagnosis. This
unusual complication of a common tumor should be kept
in mind if necrosis is identified in the breast lump aspirate
from a young female.
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