Pseudoangiomatous Stromal Hyperplasia (PASH)

  • Introduction:
    • PASH may be mistaken for mammary angiosarcoma:
      • But is not associated with an increased risk of developing:
        • Angiosarcoma
        • Invasive ductal carcinoma, or 
        • Other breast malignancies
    • There is no indication for genetic counseling or testing:
      • Based on a diagnosis of PASH
    • Excisional biopsy is not required:
      • With concordant and benign findings on mammography and core biopsy
  • Pseudoangiomatous stromal hyperplasia (PASH):
    • Is a benign proliferative breast disease that was first described by Vuitch et al.
    • This lesion is characterized by:
      • dense, collagenous proliferation of mammary stroma:
        • Forming inter-anastomosing capillary-like spaces
    • It is thought that hormonal factors play an important role in PASH:
      • According to Anderson et al:
        • This lesion represents an important hyper-response to progesterone and estrogen
    • PASH is a common histological finding in breast biopsy specimens and can also be found in a normal breast:
      • That is in association with proliferative or non-proliferative fibrocystic changes:
        • But it is rarely a symptomatic lesion
    • Clinically, PASH can presents as:
      • solitary firm, mobile, palpable lump 
      • As multifocal nodules:
        • In 60% of cases 
      • Can be discovered incidentally on imaging
    • PASH can be found in:
      • Teenage girls as well as in postmenopausal women with or without hormonal therapy replacement
    • It is important to recognize this entity because it can be easily confused with:
      • Other benign tumors, such as:
        • Fibroadenoma
        • Phyllode tumor
      • With malignant tumors, such as:
        • Angiosarcoma
    • Unfortunately, imaging features of PASH are non-specific:
      • On mammography:
        • The most common appearance described is:
          • well-defined, uncalcified mass, with regular borders
        • Spiculated borders, suspicious borders, and architectural distortion can also be seen:
          • But are uncommon
      • On ultrasound:
        • PASH tends to be:
          • An oval, round hypoechoic mass or 
          • Can presents as a heterogeneous mass with cystic areas 
      • According to Cohen et al:
        • When a focal lesion with well-defined borders, containing no calcifications on mammography or a well-defined hypoechoic mass on ultrasound is seen:
          • PASH can be considered and included in the differential diagnosis
    • Clinically and on imaging, the differential diagnosis include:
      • Fibroadenoma:
        • Especially in young patient
      • Phyllode tumor:
        • In older women
    • Histologically:
      • PASH can be very similar to low-grade angiosarcoma
      • Definitive diagnosis is based on histology:
        • But unlike low-grade angiosarcoma:
          • PASH has no invasive features and contains no necrosis, mitoses, and no destruction of mammary epithelial structures
    • Management of PASH depends on presentation:
      • When PASH is incidentally discovered or when it is asymptomatic:
        • It can be followed up yearly by ultrasound or mammography:
          • For a period of 36 months
      • Surgical procedures are indicated for:
        • Symptomatic lesion with mechanical complaints
        • Pain
        • Apprehension for an alternative malignant lesion 

Imaging: bilateral MLO and CC views of the breasts. There is an ovoid mass in the right lower, outer quadrant.

Mammogram at the time of presentation here demonstrated a new, lobulated, oval mass in the right lower outer quadrant measuring 5 cm x 4 cm. 
Mammogram at the time of presentation here demonstrated a new, lobulated, oval mass in the right lower outer quadrant measuring 5 cm x 4 cm. 
A heterogeneous, lobulated 4.6 cm mass was seen at the 8:00 position of the right breast.
  • References:
    • Celliers L, Wong DD, Bourke A. Pseudoangiomatous stromal hyperplasia: a study of the mammographic and sonographic features. Clin Radiol. 2010;65(2):145-149.
    • Guray M, Sahin AA. Benign breast diseases: classification, diagnosis, and management. Oncologist. 2006;11(5):435-439.
    • Hargaden GC, Yeh ED, Georgian-Smith D, Moore RH, Rafferty EA, et al. Analysis of the mammographic and sonographic features of pseudoangiomatous stromal hyperplasia. AJR Am J Roentgenol. 2008;191(2):359-363.
    • Salvador R, Lirola JL, Domínguez R, López M, Risueño N. Pseudo-angiomatous stromal hyperplasia presenting as a breast mass: imaging findings in three patients. Breast. 2004;13(5):431-435.

#Arrangoiz #BreastSurgeon #BreastCancer #CancerSurgeon #Teacher #SurgicalOncologist #Mexico #Miami #PASH #PseudoangiomatousStromalHyperplasia

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