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Pathology Research International
Volume 2011, Article ID 482046, 4 pages
D. B.Nikumbh, S.R.Desai, P.S.Madan, N.J.Patil,andJ.V.Wader
Department of Pathology, Krishna Institute of Medical Sciences, Karad, District Satara, Maharashtra 415110, India
Correspondence should be addressed to D. B. Nikumbh, firstname.lastname@example.org
Received 9 October 2010; Revised 4 April 2011; Accepted 7 April 2011
Academic Editor: Elizabeth Wiley
Copyright © 2011 D. B. Nikumbh et al.ThisisanopenaccessarticledistributedundertheCreative CommonsAttributionLicense,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Juvenile fibroadenoma constitutes only 4% of the total fibroadenomas. The incidence of giant juvenile fibroadenomas is found to
be only 0.5% of all the fibroadenomas. Bilateral giant juvenile fibroadenomas are extremely rare, and only four cases have been
reported intheliterature. Tothebestofourknowledge,wearepresentingthefifthcaseofbilateralgiantjuvenilefibroadenomasina
12-year-old prepubertal girl. The diagnosis was made on fine-needle aspiration cytology which was confirmed on histopathology.
In this paper, we present this rare case to illustrate the diagnosis and management of this tumour and to emphasize that these
tumours are almost always benign and should be treated with breast-conserving surgery to provide a healthy physical and social
life to the patient.
Breast masses are uncommon in childhood. The majority of
them are related to inflammation (infection or abscess) 
or benign tumors as fibroadenomas . Juvenile fibroade-
noma is a rare clinical entity and forms 4% of the total
fibroadenomas, and giant juvenile fibroadenoma constitutes
only 0.5% of all fibroadenomas [3, 4]. Bilateralgiant juvenile
fibroadenomas are extremely rare in prepubertal girls. To
the best of our knowledge, only four case reports are
available in the English literature [3, 5–7]. Stanford School
of Medicine clearly defined both the entities of juvenile
and giant fibroadenoma . Our case satisfied both these
definitions; therefore, it is a rare case of bilateral giant juve-
nile fibroadenomas in a twelve-year-old prepubertal female
child. The provisional diagnosis of the patient was made
on fine-needle aspiration cytology which was subsequently
confirmed on histopathology.
A 12-year-old premenarche girl presented with bilateral,
rapidly enlarging breast lumps for three months (Figure 1).
There was history of dull ache in the breasts. There was no
family history. History of trauma, nipple discharge, fever,
anorexia, or weight loss was absent. On local examination
bilateral slightly tender, huge, well-circumscribed masses in
both the breasts were seen, which were firm in consistency.
The overlying skin was tense and shiny with prominent
superficial veins. The right breast lump measured 15 ×
12cms and left breast lump measured 17 × 15cms. On
both the sides, the lumps were not fixed to underlying
structures. There was no discharge from the nipple, and axil-
lary lymphadenopathy was absent. Routine hematological
and biochemical examinations were within normal limits.
Chest-X ray was normal. Ultrasonography was carried out
which showed heterogenous parenchymal pattern suggestive
of bilateral fibroadenoma. The patient was subjected to
fine-needle aspiration cytology (FNAC) of bilateral breast
lumps which revealed cellular smears comprising of many
branching monolayer sheets along with myoepithelial cells
Background showed bare nuclei and myxoid stromal
fragments. Based on the cytological findings, diagnosis
of benign proliferative lesion without atypia suggestive of
bilateral fibroadenomas was given. The patient underwent
breast tissue, nipple, and areola by the plastic surgeon. The
two resected specimens were sent for histopathological study
in the department of pathology. The right-sided excised
lump measured 15×12×6.5cms and weighed 800gms. The
950gms. Overlying skin was unremarkable. External surface
was bosselated, and both the lumps were well circumscribed
2 Pathology Research International
Figure 1: Gross appearance of bilateral breasts tumors.
Figure 2: FNAC from breast lumps showed many branching sheets
of epithelial cells with many bare nuclei and myxoid stromal
fragments in background. (H &E stain X100).
and encapsulated (Figure 3). Cut sections from both the
lumps showed multiple gray white nodules showing myxoid,
gray white appearance along with occasional slit-like spaces
and tiny cysts (Figure 4).
Hematoxylin- and eosin-stained sections revealed well-
encapsulated tumors with hyperplasia of both epithelial and
stromal components. Epithelial component showed tubular
or tufted pattern of epithelial hyperplasia with characteristic
tufts of cells protruding into the lumina (Figure 5). The
glands were lined by bilayered epithelium at places showing
stratification. Most of the areas in both the tumors showed a
pericanalicular patternof fibroadenoma. Stroma was cellular
and showed myxoid change (Figure 6). Though stromal
cellularity was increased, there was no leaf-like growth
pattern and focal periductal concentrate of cells which was
the characteristic of phyllodes tumor. There was occasional
mitosis (0-1/hpf) and absence of cytological atypia. The
final histopathological diagnosis of Bilateral Giant Juvenile
followup and doing well at six-month followup.
Figure 3: Gross appearance of bilateral lumpectomy specimens.
Figure 4: Cut surface of both the specimens showed multiple
gray white nodules with myxoid appearance and occasional slit-like
Accordingto Stanford School of Medicine, juvenilefibroade-
noma of the breast is defined as circumscribed, often large,
breast mass usually occurring in adolescent females with
stromal and epithelial hypercellularity but lacking the leaf-
like growth pattern of phyllodes tumors . Diagnostic
criteria for juvenile fibroadenoma are (1) circumscribed and
rarely multiple; (2) biphasic stromal and epithelial process
in which pericanalicular pattern is most common and lacks
leaf-like growth pattern in uniformly hypercellular stroma.
Fibrotic areas may be present; (3) lack of atypical features
in stroma-like periductal increase in cellularity, stromal
overgrowth, cytologic atypia, and mitotic rate >3/hpf; (4)
frequent epithelial and myoepithelial hyperplasia; (5) most
patients’ age is 10–20 years with a mean age of 15 years.
Juvenile fibroadenomas may be multiple .
Giant fibroadenoma is defined as a tumor >500gms or
disproportionally large compared to the rest of the breast.
It is more frequently seen in young and black patients.
Pathology Research International3
Figure 5: Light microscopy showed well-encapsulated tumor with
hyperplasia of both epithelial and stromal components. (H&E stain
epithelium at places showed stratification and cellular stoma with
myxoid change (H&E Stain X400).
Giant fibroadenoma may be either adult type or juvenile
fibroadenoma [8, 9].
Giant juvenile fibroadenoma simultaneously occurring
in both the breasts is very rare. Four case reports are
available in the English literature [3, 5–7]. Giant juvenile
fibroadenoma is an uncommon tumor presenting in ado-
lescent females and the exact etiology is not known. Hor-
monal influences are thought to be contributing factors .
Excessive estrogen stimulation and/or receptor sensitivity or
reduced levels of estrogen antagonist during puberty have
been implicated in pathogenesis [9, 10].
It is necessary to excludethe closedifferentials ofjuvenile
fibroadenoma which are benign low-grade phyllodes tumor,
virginal hypertrophy, and other rare differentials such as
lipoma, hamartoma, breast abscess, macrocyst, adenocar-
cinoma, and pseudoangiomatous stomal hyperplasia, as
the treatment modalities and the prognosis differ quite
significantly in these various conditions. Some of the lesions
were treated by mastectomy, but some lesions may require
only local excision, aspiration, or conservative management
Giant juvenile fibroadenoma is a benign tumor, and total
excision of the lump with conservation of nipple and areola
is the optimal treatment [10–12].
Benign low-grade phyllodes tumor occurs in the older
(>40 years) age group and has no racial predisposition.
Generally, they present as a solitary mass confined to
unilateral breast, and bilateral involvement is rarely seen
. In low-grade phyllodes tumor, prominent leaf-like
architecture is seen due to stromal cellularity and, there is a
characteristic stromal condensation around the ducts, and it
infiltrates the surrounding breast tissue with mitotic figures
<4/hpf. In high-grade phyllodes tumor, stromal overgrowth
with atypia and atypical mitotic figures (<10/hpf) are seen.
It is treated by wide excision with a margin of normal tissue
or mastectomy [10, 11, 13, 14].
In juvenile breast hypertrophy, rapid and distressing
enlargement of one or both breasts occurs, which is often
asymmetrical and occasionally in an adolescent female.
Histological examination shows abundant connective tissue
and duct proliferation, frequently with epithelial hyperplasia
but little or no lobule formation. It is treated by reduction
mammoplasty [10, 12, 14].
Giant lipoma can cause unilateral breast hypertrophy.
encapsulated nodules of mature adipose tissue on histology
[10, 12, 14].
Breastabscesses developingduring puberty causesudden
and rapid growth in the breast. Pain, fluctuation, and
erythema are present. Histological examination reveals focal
collection of polymorphs with necrotic material in the
lobules. Hamartomas can be easily suspected on imaging
with their multilobular structures. Microscopically, these
lesions are composed of an admixture of ducts, lobules,
fibrous stroma, and adipose tissue in varying proportions
[13, 14]. Pseudoangiomatous stromal hyperplasia reveals
complex interanastomosing spaces, some of which have
spindle-shaped stromal cells at their margins simulating
endothelial cells [10, 12, 14]. FNAC and biopsy easily rule
out these conditions.
It is essential to know that giant juvenile fibroadenoma
may recur after complete excision, and the chance of
recurrence becomes less after the third decade . In
view of bilateral giant juvenile fibroadenomas, possibility of
Carneys complex should be considered, which constitutes
multiple myxoid fibroadenomas, endocrine hyperactivity,
cardiac myxoma, cutaneous hyperpigmentation, and other
In our case, other components of Carneys complex were
absent with the lack of family history except for multiple
Isolated case reports of unilateral juvenile fibroade-
noma and multiple giant fibroadenoma in single breast
were available [9, 12, 15, 16]. In the literature, only four
case reports of bilateral giant juvenile fibroadenomas were
reported [3, 5–7]. The last case was reported in 2009 . To
conclude, we present an extremely rare case of bilateral giant
FNAC and subsequently confirmed on histopathology. The
patient is treated by the removal of both the fibroadenomas
4 Pathology Research International Download full-text
conserving the breast tissue. The patient is doing well with
The Authors sincerely acknowledge the support of Dr.
Vanjari and Dr. S. J. Bhosale professors in the Department
of Surgery, KIMS, Karad and late Dr. M. R. Naniwadeker, a
professor in the Department of Pathology, KIMS.
 A. Boothroyd and H. Carty, “Breast masses in childhood and
adolescence. A presentation of 17 cases and a review of the
literature,” Pediatric Radiology, vol. 24, no. 2, pp. 81–84, 1994.
 G. Pettinato, J. C. Manivel, D. R. Kelly, L. E. Wold, and L. P.
Dehner, “Lesions of the breast in children exclusive of typical
fibroadenoma and gynecomastia. A clinicopathologicstudy of
113 cases,” Pathology Annual, vol. 24, pp. 296–328, 1989.
 R. L. Moore, A. Mungara, K. Shayan, and A. M. Wallace,
“Bilaterally symmetric juvenile fibroadenomas and tubular
breast deformity in a prepubescent girl,” Journal of Pediatric
Surgery, vol. 42, no. 6, pp. 1133–1136, 2007.
 C. A. Park, L. R. David, and L. C. Argenta, “Breastasymmetry:
presentation of a giant fibroadenoma,” Breast Journal, vol. 12,
no. 5, pp. 451–461, 2006.
 M. Baxi, A. Agarwal, A. Mishra, G. Agarwal, and S. K. Mishra,
“Multiple bilateral giant juvenile fibroadenomas of breast,”
European Journal of Surgery, vol. 166, no. 10, pp. 828–830,
 C. J.Lee, Y. J.Kim, Y. T. Seo, S. J.Pak, andS. I. Lee, “Treatment
by central pedicle breast reduction, with vertical and short
horizontal scar: case report,” Aesthetic Plastic Surgery, vol. 28,
no. 4, pp. 228–230, 2004.
 M. Mukhopadhyay, R. Patra, S. Mondal, A. Ghosh, and A.
K. Ray, “Bilateral giant juvenile fibroadenoma of breasts: case
report,” Journal of Indian Association of Pediatric Surgeons, vol.
14, no. 2, pp. 68–69, 2009.
 R. L. Kempson and R. V. Rouse, “Juvenile fibroade-
noma of the breast,” Stanford school of medicine, http://
 F. Musio, D. Mozingo, and D. P. Otchy, “Multiple, giant
fibroadenoma,” American Surgeon, vol. 57, no. 7, pp. 438–441,
 M. Issam, “Giant fibroadenoma. Case report and review of
literature,” Basrah Journal of Surgery, vol. 12, pp. 1–4, 2006.
 D. S. Chang and M. H. McGrath, “Management of benign
tumors of the adolescent breast,” Plastic and Reconstructive
Surgery, vol. 120, no. 1, pp. 13–16, 2007.
 F. Uygur and C. Yigitler, “Rare juvenile giant fibroadenoma,”
The Journal of Breast Health, vol. 5, pp. 164–166, 2009.
 S. J. Schnitt, R. R. Millis, A. M. Hanby, and H. A. Oberman,
“The breast,” in Sternbergs’s Diagnostic Surgical Pathology, S.
E. Mills, D. Carter, J. K. Greenson, H. A. Oberman, U. Reuter,
and M. Scoler, Eds., vol. 1, pp. 371–372, Lippincott Williams
Wilkins Indian, 4th edition, 2004.
 R. Juan, “Breast,” in Rosai and Ackermans Surgical Pathology,
R. Juan, Ed., vol. 2, pp. 1769–1771, Elsevier, Mosby, Mo, USA,
9th edition, 2009.
 D. Gobbi, P. Dall’Igna, R. Alaggio, D. Nitti, and G. Cecchetto,
“Giant fibroadenoma of the breast in adolescents: report of 2
cases,” Journal of Pediatric Surgery, vol. 44, pp. 39–41, 2009.
 A. Ahuja and A. Seth, “Juvenile fibroadenoma of breast,”
Indian Pediatrics, vol. 42, p. 72, 2005.