HAMARTOMA OF THE FEMALE BREAST

HAMARTOMA OF THE FEMALE BREAST
Rajeev M Joshi*, Ashutosh Darbari**, Prasad K Wagle***
*Associate Professor; **Resident; ***Lecturer, Department of Surgery, BYL Nair Charitable Hospital.
A 22 year old female presented with tender, mobile, irregular lump in upper outer quadrant of the left breast which she had noticed 15 days back. Thee was history of inadequate lactation for both her children. FNAC report was suggestive of a benign breast disease requiring close follow up / excision. Histopathology confirmed this swelling to have been a hamartoma of the breast
INTRODUCTION

Arrigoni in 1972 termed hamartoma of the breast as all those swellings which are grossly circumscribed, encapsulated masses composed of mammary ducts and prominent lobules admixed with varying amounts of fibrous and adipose tissue.

Often misdiagnosed as fibroadenomas or mammary dysplasias, a protocol needs to be established as regards mammographic and pathological details to confirm the existence of these lesions as a distinct entity.

Pathognomonic radiological findings help identify these lesions, confirmed later on tissue diagnosis.

CASE REPORT

We present a 22 year old female G2P2AO, who was symptomatic for a tender irregular breast lump in the left breast, 15 days before consultation with us. Though there was local warmth, there was no history of trauma, nipple discharge, skin changes or lactation in the recent past.

On further examination, we confirmed the irregular 2.5 cm x 2.5 cm rubbery lump in the upper outer quadrant of the left breast which had ill-defined margins but was not fixed to the skin or underlying fascia. There was no nipple discharge expressible on pressure and the axilla and opposite breast were normal.

The only significant positive history was that of inadequate lactation from the left breast twice. This was not further investigated and grossly there seemed no evidence of any hormonal imbalance or tuberculosis in the past.

After an FNAC, excision was advised in view of a ? benign breast disease. The patient was taken up for wide excision of the lump under general anaesthesia. The histopathological diagnosis of the lump was reported to be a hamartoma.

On gross, the specimen seemed capsulated, well defined, with lobulated surface and having rubbery consistency.

Histology revealed a lobular architecture with few intact lobules. The rest showed fibrous tissue encroaching the lobules and presence of mature adipose tissue admixed with normal breast tissue. There was no evidence of hyperplasia, dysplasia or metaplasia.

Histologically an entire spectrum of altered ductal and lobular architecture is seen. However there is no evidence of atypical hyperplasias, dysplasias or metaplasias thus differentiating it from other benign lesions such as fibroadenoma.

DISCUSSION

When there is a rather soft, irregular lumps palpable in the female breast not very different from normal breast tissue and is often reported as atypical fibroadenoma or mammary dysplasia on FNAC, a diagnosis of hamartoma should come to ones mind.

Seen only in 16 cases of 10,000 consecutively mammographied breast over a span of 20 years, distinct criteria emerged to help diagnose this rare disorder.

Arrigoni et al[2] coined this term in 1972 and it appears the most appropriate for these group of lesions, also known in literature as adenolipomas, fibroadenolipomas or post lacta tional breast tumours. There appears to be no relation of lactation to these lesions.[4]

It is seen over a wide span of age viz. 13-65 years and seems to affect the left breast more than the right.[4]

Ranging from 1-13.5 cms, it averages 6 cms and usually has a soft, rubbery consistency with a lobulated yellow-gray cut surface.[4]

It is strikingly different from normal breast tissue which it compresses. Often the breast tissue expands back after removal of this mass.

Diagnosis on mammography is considered to be conclusive. The lesion is completely separate from the breast having a circular configuration resembling a capsule with a radioluscent zone separating it from the normal breast tissue which it compresses.

Distribution of glandular structures is irregular and contrasts sharply with normal tissue which even when dysplastic maintains a triangular, nipple oriented structure. Being completely devoid of this architecture and separated from it by a radiolucent zone, the hamartoma is therefore quite evident even on first glance.

FNAC is more often than not inconclusive and diagnosis is usually confirmed on histopathology.

Jones et al classified these lesions into 4 variants based on their microscopic features

1.circumscribed fibrocystic change with fat collagen and/or smooth muscle (apocrine metaplasia, duct ectasia, terminal duct metaplasia, sclerosing adenosis).

2.Fibroadenoma with mature adipose tissue or cartilage.

3.Fibro adenoma with lobules within.

4.Adenolipoma.

Certain additional features as suggested by Davies et al clinch the diagnosis viz.

1.Encasement of adiposites by hyaline collagen.

2.Presence of pseudo-angiomatous hyperplasia.

3.Presence of ducts and shell like (HERATI) areas.

4.Distortion of parenchyma, seed like fibrocystic cells, presence of lobules and fibrosis.

SUMMARY

Hamartoma form a rare and distinct group of benign breast lesions which are characterised by distinctive mammographic and pathological features added to a high degree of clinical suspicion.

REFERENCES

Hessler Christian, Schnyder Pierre, Dizello Luciano. Hamartoma of Breast. Diagnostic observation of 16 cases. Radiology. Jan. 1978; 26 : 95-8.

Arrigoni, Malcolm B, Dockerty, Judd AS. The identification and treatment of mammary Hamartoma. Surgery, Gynecology and Obstetrics. October, 1971; 133; 577-82.

Haagensen CD. Disease of the breast. Saunders, Philadelphia 2nd edition. 1971; 307-8.

Jones MW, Norris HJ, Wargotz ES. Surgery, Gynecology and Obstetrics. July, 1991; 173 : 54-6.

Davies JD, Kulka J, Mumford AD, et al. Histo Pathology. 1994; 24 : 161-8.

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