Case 25

2018-04-18T00:11:03Z

Carvalho: /* IHC */Changed CD34 from NEGATIVE to POSITIVE.

===Provided clinical history===
42 year old woman, breast mass

===Site===
Left breast mass

===Primary image===
[[Image: Pseudoangiomatous stromal hyperplasia -a- low mag.jpg |500px|link=|center|]]
<center>Low magnification. [[H&E stain]].</center>

{{hidden|Intermediate magnification|[[Image: Pseudoangiomatous stromal hyperplasia -a- intermed mag.jpg |500px|link=|center|]]
<center>Intermediate magnification. [[H&E stain]].</center>}}

{{hidden|High magnification|[[Image: Pseudoangiomatous_stromal_hyperplasia_-_high_mag.jpg |500px|link=|center|]]
<center>High magnification. [[H&E stain]].</center>}}

===Differential diagnosis===
{{hidden|Differential diagnosis|<center>[[fibroadenoma]], low-grade [[angiosarcoma]]</center>}}

===Additional tests===
====More history====
{{hidden|More history|<center>BI-RADS 4 (requires biopsy).</center>}}

====Ask a colleague====
{{hidden|Ask a colleague|<center>Looks benign.</center>}}

====Stains====
{{Case Stains
| blank=Dr Torres would ask why!
| alcpas=
| alc1=
| alc25=
| aur=
| biel=
| bili=
| iron=
| congored=
| cresylv=
| diffquik=
| fontana=
| gallyas=
| giemsa=
| gms=
| gomori=
| gram=
| gremelius=
| jms=
| jones=
| kinyoun=
| luxol=
| masson=
| mmas=
| mucicar=
| oilredo=
| orecein=
| pas=
| pasd=
| pasf=
| ptah=
| prussian=
| reticulin=
| sudanblackb=
| toluidine=
| verhoeff=
| vonkossa=
| warthinstarry=
}}
====IHC====
{{Case IHC
| blank=Dr Torres would ask why!
| ae1ae3=
| a1at=
| acth=
| afp=
| alk1=
| amacr=
| b2microgl=
| b723=
| bcatenin=
| bcl2= '''POSITIVE'''
| bcl6=
| bclxl=
| c3=
| calcit=
| calponin=
| calretinin=
| cd10=
| cd117=
| cd15=
| cd1a=
| cd20=
| cd21=
| cd23=
| cd3=
| cd30=
| cd31= '''NEGATIVE'''
| cd34= '''POSITIVE'''
| cd35=
| cd4=
| cd43=
| cd45=
| cd5=
| cd56=
| cd68=
| cd7=
| cd79a=
| cd8=
| cd99=
| cea=
| chromo=
| ck19=
| ck20=
| ck34be12=
| ck7=
| cmv=
| cmyc=
| cyclind1=
| desmin=
| ebv=
| ema=
| erpr=
| fascin=
| fsh=
| fviii= '''NEGATIVE'''
| fxiiia=
| gastrin=
| gcdfp=
| gh=
| glucag=
| hbme1=
| hbvc=
| hbvs=
| hcg=
| hepatocyte=
| her2=
| hmb45=
| hpv=
| hsv1=
| hsv2=
| inhibin=
| insulin=
| kappa=
| ki67=
| lambda=
| lca=
| leu7=
| lga=
| lgg=
| lgm=
| lh=
| lysozyme=
| melanina=
| mitf=
| myleoperox=
| myod1=
| myog=
| myog=
| nse=
| p16=
| p53=
| p63=
| panker=
| pcna=
| plap=
| pnl2c=
| prolac=
| psa=
| s100=
| sma=
| somatsat=
| synapto=
| tdt=
| tfe3=
| thyrogl=
| toxopl=
| tsh=
| ttf1=
| ubiquitin=
| uchl1=
| ulexeurope=
| vim= '''POSITIVE'''
| vip=
| vzv=
| wt1=
}}

====Chromosomal translocations====
{{Case Translocations
| blank=Dr Torres would ask why!
| t1_13=
| t11_14=
| t11_22dsrct=
| t11_22ews=
| t12_15=
| t12_16afh=
| t12_16liposar=
| t12_22=
| t14_18=
| t15_17=
| t16_21=
| t17_22=
| t2_13=
| t21_22=
| t8_14=
| t9_22=
| t9_22=
| tx_17=
| tx_18=
}}
===Diagnosis===
{{hidden|Diagnosis|<center>[[Pseudoangiomatous stromal hyperplasia]]</center>}}
<br>
===Other cases===
{{Cases navigation}}

__NOTOC__

[[Category:Cases]]

[[Category:Cases in breast pathology]]
[[Category:Cases difficulty 3]]
[[Category:Cases in breast pathology - junior]]

Pseudoangiomatous stromal hyperplasia

2018-04-18T00:09:40Z

Carvalho: Fixed CD34 staining pattern (is positive).

{{ Infobox diagnosis
| Name = {{PAGENAME}}
| Image = Pseudoangiomatous_stromal_hyperplasia_-_high_mag.jpg
| Width =
| Caption = Pseudoangiomatous stromal hyperplasia. [[H&E stain]].
| Synonyms =
| Micro = abundant breast stroma, small complex inter-anastomosing (blood vessel/capillary-like) channels
| Subtypes =
| LMDDx = [[fibroadenoma]], low-grade [[angiosarcoma]]
| Stains = Bcl-2 +ve, vimentin +ve, CD34 +ve, SMMHC +ve, CD31 -ve, factor VIII -ve
| IHC =
| EM =
| Molecular =
| IF =
| Gross =
| Grossing =
| Site = [[breast]]
| Assdx =
| Syndromes =
| Clinicalhx =
| Signs = +/-breast mass
| Symptoms =
| Prevalence = uncommon
| Bloodwork =
| Rads =
| Endoscopy =
| Prognosis = benign
| Other =
| ClinDDx = [[fibroadenoma]]
| Tx = followup or excision
}}
'''Pseudoangiomatous stromal hyperplasia''', abbreviated ''PASH'', is benign lesion is [[breast pathology]].

It is also known as '''nodular myofibroblastic stromal hyperplasia of the mammary gland'''.<ref name=pmid12199757>{{Cite journal | last1 = Leon | first1 = ME. | last2 = Leon | first2 = MA. | last3 = Ahuja | first3 = J. | last4 = Garcia | first4 = FU. | title = Nodular myofibroblastic stromal hyperplasia of the mammary gland as an accurate name for pseudoangiomatous stromal hyperplasia of the mammary gland. | journal = Breast J | volume = 8 | issue = 5 | pages = 290-3 | month = | year = | doi = | PMID = 12199757 }}</ref>

==General==
*Benign lesion.
*Thought to arise due to myofibroblast abnormality - though not well understood.<ref name=pmid7872425>{{cite journal |author=Powell CM, Cranor ML, Rosen PP |title=Pseudoangiomatous stromal hyperplasia (PASH). A mammary stromal tumor with myofibroblastic differentiation |journal=Am. J. Surg. Pathol. |volume=19 |issue=3 |pages=270–7 |year=1995 |month=March |pmid=7872425 |doi= |url=}}</ref>
*An incidental finding ''or'' occasionally a mass.<ref name=pmid21862488>{{Cite journal | last1 = Drinka | first1 = EK. | last2 = Bargaje | first2 = A. | last3 = Erşahin | first3 = ÇH. | last4 = Patel | first4 = P. | last5 = Salhadar | first5 = A. | last6 = Sinacore | first6 = J. | last7 = Rajan | first7 = P. | title = Pseudoangiomatous stromal hyperplasia (PASH) of the breast: a clinicopathological study of 79 cases. | journal = Int J Surg Pathol | volume = 20 | issue = 1 | pages = 54-8 | month = Feb | year = 2012 | doi = 10.1177/1066896911418643 | PMID = 21862488 }}</ref>
*May be suspicious on imaging ([[BI-RADS]] 4 or 5).<ref name=pmid19097540>{{Cite journal | last1 = Wieman | first1 = SM. | last2 = Landercasper | first2 = J. | last3 = Johnson | first3 = JM. | last4 = Ellis | first4 = RL. | last5 = Wester | first5 = SM. | last6 = Lambert | first6 = PJ. | last7 = Ross | first7 = LA. | title = Tumoral pseudoangiomatous stromal hyperplasia of the breast. | journal = Am Surg | volume = 74 | issue = 12 | pages = 1211-4 | month = Dec | year = 2008 | doi = | PMID = 19097540 }}</ref>
*May be followed (expectant management) or (surgically) excised.<ref name=pmid20887819>{{Cite journal | last1 = Jaunoo | first1 = SS. | last2 = Thrush | first2 = S. | last3 = Dunn | first3 = P. | title = Pseudoangiomatous stromal hyperplasia (PASH): a brief review. | journal = Int J Surg | volume = 9 | issue = 1 | pages = 20-2 | month = | year = 2011 | doi = 10.1016/j.ijsu.2010.09.005 | PMID = 20887819 }}</ref>

==Gross==
Features:<ref name=pmid7872425>{{cite journal |author=Powell CM, Cranor ML, Rosen PP |title=Pseudoangiomatous stromal hyperplasia (PASH). A mammary stromal tumor with myofibroblastic differentiation |journal=Am. J. Surg. Pathol. |volume=19 |issue=3 |pages=270–7 |year=1995 |month=March |pmid=7872425 |doi= |url=}}</ref>
*May form mass.
**Grey-white & firm.
**Well-circumscribed borders.

==Microscopic==
Features:<ref name=pmid3949338>{{cite journal |author=Vuitch MF, Rosen PP, Erlandson RA |title=Pseudoangiomatous hyperplasia of mammary stroma |journal=Hum. Pathol. |volume=17 |issue=2 |pages=185–91 |year=1986 |month=February |pmid=3949338 |doi= |url=}}</ref><ref name=pmid18084246>{{Cite journal | last1 = Ferreira | first1 = M. | last2 = Albarracin | first2 = CT. | last3 = Resetkova | first3 = E. | title = Pseudoangiomatous stromal hyperplasia tumor: a clinical, radiologic and pathologic study of 26 cases. | journal = Mod Pathol | volume = 21 | issue = 2 | pages = 201-7 | month = Feb | year = 2008 | doi = 10.1038/modpathol.3801003 | PMID = 18084246 }}</ref>
*Abundant breast stromal.
*Small, complex, inter-anastomosing (blood vessel/capillary-like) channels - '''key feature'''.
**''Pseudoangiomatous'' = blood vessel-like.

Notes:
*May mimic angiosarcoma at low power; PASH may have the same architecture but lack nuclear atypia.
*Occasionally has mitotic activity - ''proliferative PASH''.

DDx:
*[[Angiosarcoma]].
*[[Fibroadenoma]].

===Images===
<gallery>
Image:Pseudoangiomatous stromal hyperplasia -a- low mag.jpg | PASH - low mag. (WC/Nephron)
Image:Pseudoangiomatous stromal hyperplasia -a- intermed mag.jpg | PASH - intermed. mag. (WC/Nephron)
Image:Pseudoangiomatous stromal hyperplasia -a2- intermed mag.jpg | PASH - intermed. mag. (WC/Nephron)
Image:Pseudoangiomatous stromal hyperplasia -a- high mag.jpg | PASH - high mag. (WC/Nephron)
</gallery>
<gallery>
Image:Pseudoangiomatous stromal hyperplasia - intermed mag.jpg | PASH - intermed. mag. (WC/Nephron)
Image:Pseudoangiomatous stromal hyperplasia - high mag.jpg | PASH - high mag. (WC/Nephron)
Image:Pseudoangiomatous stromal hyperplasia - very high mag.jpg | PASH - very high mag. (WC/Nephron)
</gallery>
www:
*[http://www.nature.com/modpathol/journal/v21/n2/fig_tab/3801003f1.html#figure-title PASH (nature.com)].<ref name=pmid18084246>{{Cite journal | last1 = Ferreira | first1 = M. | last2 = Albarracin | first2 = CT. | last3 = Resetkova | first3 = E. | title = Pseudoangiomatous stromal hyperplasia tumor: a clinical, radiologic and pathologic study of 26 cases. | journal = Mod Pathol | volume = 21 | issue = 2 | pages = 201-7 | month = Feb | year = 2008 | doi = 10.1038/modpathol.3801003 | PMID = 18084246 }}</ref>

==IHC==
Findings:<ref name=pmid7872425/>
*CD34 +ve.
*Vimentin +ve.
*Bcl-2 +ve.<ref name=pmid21843705/><ref>URL: [http://surgpathcriteria.stanford.edu/breast/pash/printable.html http://surgpathcriteria.stanford.edu/breast/pash/printable.html]. Accessed on: 28 April 2012.</ref>
*Factor VIII -ve.
*CD31 -ve.<ref name=pmid21843705>{{Cite journal | last1 = Baker | first1 = M. | last2 = Chen | first2 = H. | last3 = Latchaw | first3 = L. | last4 = Memoli | first4 = V. | last5 = Ornvold | first5 = K. | title = Pseudoangiomatous stromal hyperplasia of the breast in a 10-year-old girl. | journal = J Pediatr Surg | volume = 46 | issue = 8 | pages = e27-31 | month = Aug | year = 2011 | doi = 10.1016/j.jpedsurg.2011.04.063 | PMID = 21843705 }}</ref>

==See also==
*[[Breast pathology]].
*[[Fibroadenoma]].

==References==
{{Reflist|2}}

[[Category:Breast pathology]]
[[Category:Diagnosis]]

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Case 25

Pseudoangiomatous stromal hyperplasia