GIANT BREAST TUMORS
Mohammed B. Hawary, FRCSC; Eufemiano Cardoso, MD;
Sultan Mahmud, MD; Jamal Hassanain, MD
For a variety of reasons, giant breast tumors continue to
pose a challenge in diagnosis and management. These
tumors are poorly understood because of their rarity and
unpredictable behavior. Their rapid growth, associated with
skin congestion and ulceration, and tendency to recur, gives
rise to a suspicion of malignancy.1,2 In addition, owing to
the varied histological features seen in these tumors, there
have been widely varying interpretations and diagnoses by
pathologists.3 This has led to inappropriate, and at times
unnecessarily radical, surgical therapy. In the 1950s, breasts
were amputated for this relatively non-threatening
condition.4 However, the present trend is towards more
conservative management. In order to ensure proper
surgical management, an understanding of the natural
history of the disease and its biologic behavior is essential.
We present six cases of giant breast tumors treated at
King Khalid University Hospital over a 15-year period. Our
aim is to increase awareness of the existence of this rare
condition in the Middle East. The literature is reviewed to
elucidate principles of management of these tumors.
All six cases studied presented with unilateral, rapidly
growing breast mass over a period of six to eighteen
months. The patients were in good health, and their
menstrual cycles were regular. There was no family history
of breast disease in any of them. The clinical features,
relevant investigations and the surgical management of
representative cases are summarized below.
Case 1
A 14-year-old Saudi girl complained of an excessive
increase of her right breast over a period of 12 months.
Examination revealed a diffusely enlarged right breast,
about three times the size of the left. The mass was firm,
non-tender, and did not have any discrete masses in it.
Dilated veins were present on the surface. An incisional
biopsy showed hyperplasia of stroma and the epithelial
From the Department of Surgery, Division of Plastic Surgery, King Khalid
University Hospital, Riyadh, Saudi Arabia.
Address reprint requests and correspondence to Dr. Hawary:
Department of Surgery, King Khalid University Hospital, P.O. Box 7805,
Riyadh 11472, Saudi Arabia.
Accepted for publication 21 November 1998. Received 19 August
1998.
lining the ducts. The histological report was inconclusive,
and a diagnosis of unilateral virginal hypertrophy was
made. A reduction mammoplasty using an inferior pedicle
174
Annals of Saudi Medicine, Vol 19, No 2, 1999
technique was carried out, and 780 g of breast tissue was
excised. Histology of the excised tissue showed a giant
fibroadenoma.
Follow-up at six months showed right breast
engagement due to a recurrence. She was readmitted a year
later and complete excision of the tumor was done.
Excision margins were confirmed to be negative
microscopically. No recurrence was noted at the eight-year
follow-up.
Case 2
An 11-year-old Saudi girl presented with swelling of the
right breast. It started soon after her menarche and grew
rapidly over a nine-month period. The right breast was 2½
times larger than the left. The swelling was diffuse but not
tender. There were no discrete lumps. The overlying skin
was stretched and showed engorged veins. Mammography
showed a homogenous mass occupying the whole breast
and the normal breast tissue compressed into a thin rim at
the periphery.
After open biopsy confirmed the tumor to be a giant
fibroadenoma, the tumor (15x12x12 cm) was enucleated
through an inframammary incision. Follow-up showed no
recurrence over a 10-year period.
Case 3
An 18-year-old Saudi female had normal breasts until
the age of 16, when the left breast began to grow rapidly
over a 16-month period. The left breast was about three
times the size of the right one. The swelling was diffuse,
non-tender and firm with no discrete masses. The veins over
the surface were distended. Mammography findings were
identical to those of Case 2.
The mass was confirmed to be a giant fibroadenoma by
aspiration biopsy. At operation, the tumor (18x16x12 cm)
was enucleated through a submammary incision. The
thinned-out, wrinkled excess skin was excised. There was
no recurrence over a six-year follow-up period.
Case 4
A 17-year-old Saudi female complained of a painless
large swelling in her right breast that had been growing for
16 months. Local examination showed a solitary, nontender, firm lump about 9 cm in diameter in the right upper
quadrant. It was freely mobile. The left breast was normal.
Mammography was not done. Open biopsy revealed that the
BRIEF REPORT: GIANT BREAST TUMORS
mass was a giant fibroadenoma. At operation, the tumor
(10x8x8 cm) was enucleated through a lateral
inframammary incision. There was no evidence of
recurrence for 12 years.
Case 5
A 28-year-old Saudi female, married with four children,
presented with swelling of the right breast of 18 months’
duration. The swelling was painless and had increased in
size rapidly. On examination, a firm non-tender, mobile
mass measuring about 15 cm in diameter was noted in the
inferior half of the breast. The superficial veins were
distended. Mammography and ultrasound showed a
homogenous well-defined mass, which was confirmed by an
open biopsy to be a benign cystosarcoma phylloides. Using
a submammary incision, the tumor (15x14x15 cm) was
excised with a margin of normal breast tissue.
Magnification (3x) was used, and redundant skin was
excised. The patient was followed up for 2½ years without
evidence of recurrence.
Case 6
A 32-year-old Palestinian female, married with three
children, was referred to the Plastic Surgery Clinic with an
enormous swelling of the left breast which had grown
rapidly for 12 months, and an ulcer with a serosanguinous
discharge for two months. A solitary mass about 18 cm in
diameter, non-tender and firm was found occupying the
lateral half of the breast. An ulcer 1.5 cm in diameter and
0.6 cm deep was found over the center of the mass. The
mass was fixed to the skin at the site of the ulcer, but it was
freely mobile over the underlying muscles. Dilated veins
were present over the surface. Axillary lymph nodes were
not palpable. Mammogram confirmed a homogenous mass
infiltrating the skin at the site of the ulcer. Aspiration
biopsy of the mass revealed benign cystosarcoma
phylloides. Using the submammary approach and
magnification (3x), the tumor was excised with a margin of
normal breast tissue. A large ellipse of skin centered over
the ulcer was excised together with the tumor. The breast
was reconstructed after excision of the excess skin. There
was no evidence of recurrence after one year. The patient
failed to attend follow-up after this period.
Discussion
Giant breast tumors are rapidly growing breast masses
with diameters exceeding 5 cm and/or weights of more than
500 g.1,5 They can grow to immense proportions, resulting
in congestion and ulceration of skin by centrifugal
pressure.1 Such an enlargement of the breast can be due to
giant fibroadenoma, cystosarcoma phylloides or virginal
hypertrophy, occurring in that order of frequency. 5-7 These
tumors are believed to be closely related variants of a
similar pathologic process.7 They are characterized by
proliferation of epithelial and connective tissue elements in
varying proportions. The exact etiology is not known.
Hormonal influences are thought to be contributory factors.
Excessive estrogen stimulation and/or receptor sensitivity,
or lack of estrogen antagonists have been implicated in the
pathogenesis.7-10 Nevertheless, the fact that these tumors are
unilateral and have an apparent geographical distribution
suggests that other factors, possibly genetic and
environmental, could be involved.
Benign virginal hypertrophy is usually bilateral, but on
rare occasions may occur unilaterally. Typically, there is a
diffuse enlargement of breast without any associated dilated
cutaneous veins. Histological differentiation between
virginal hypertrophy and giant fibroadenoma is often
difficult.5 We experienced similar difficulty in Case 1.
Reduction mammoplasty is the treatment of choice,
although in rare cases the disease may recur from the
residual breast tissue.
Giant fibroadenoma occurs predominantly in adolescent
Blacks and in the Oriental race.1-3 The disease is often
confined to one breast as a solitary mass occupying part or
the whole breast. In rare cases, it may be multifocal and
involve both breasts. The tumor is well-encapsulated and
has histologic features of a fibroadenoma, with a variable
growth pattern of epithelial and connective tissue elements.
The condition is normally benign, and the potential to grow
decreases with age. Simple enucleation of the tumor is all
that is required to control the disease. Tailoring of skin
envelope may be indicated in a massive breast enlargement.
Cystosarcoma phylloides occur in the older age group,
with a mean age of 40 years.5,11 They are rare in adolescents
and appear to have no racial predisposition.11,12 Generally,
they present as a solitary mass confined to one breast. It is
rare to find bilateral breast involvement.3,12 In older
patients, 5%-10% of these tumors may be malignant,5,12 but
those that occur in adolescence are rarely malignant.1,2,13
Malignant degeneration has not been reported to occur in a
benign cystosarcoma.3 The diagnosis of benign or
malignant cystosarcoma is based on a combination of
histologic features, such as stromal cellularity,
pleomorphism, mitotic rate per 10 high-power field, stromal
overgrowth and infiltrating, as opposed to pushing,
borders.3 A high mitotic rate (>4 per 10 high-power field),
stromal overgrowth and infiltrating margins are indicators
of malignancy.3,13 Malignant cystosarcoma phylloides,
however, are low-grade locally invasive tumors which
rarely metastasize to regional lymph nodes. Since these
tumors do not have a true capsule,2,12 they must be excised
with a margin of normal tissue. Excision with a wider
margin of normal tissue is indicated in malignant
cystosarcoma phylloides.3 In adolescent females, however,
cystosarcoma phylloides may be locally excised without
sacrificing the normal breast tissue. Mastectomy may be
indicated as a last resort in the unusual instance of repeated
recurrences or a biologically virulent tumor.3
The nature of surgical therapy demands considerable
familiarity with the pathological process of a disease. Huge
masses growing rapidly inside the breast cause pressure
atrophy of the surrounding normal breast tissue. This
Annals of Saudi Medicine, Vol 19, No 2, 1999
175
HAWARY
ET AL
phenomenon was evident in five of our patients who had
tumors of 15 cm diameter or greater. But in all of them, the
affected breast regained volume spontaneously and matched
the opposite normal breast in six to nine months. Giant
breast tumors, including the malignant cystosarcoma
phylloides, usually behave in a non-virulent manner.
Surgical removal of these large tumors is accomplished in
most instances through a submammary incision. Complex
reconstructive procedures are unnecessary and also
inappropriate. It is worth emphasizing that sacrifice of
breast in such young patients should be avoided unless the
tumor is unusually aggressive.
All patients with giant breast tumors, and those with
cystosarcoma in particular, should be followed up for
recurrence. This could occur in the first two years after the
primary excision.3 In most instances, this results from
incomplete excision of tumor, as was the case with one of
our patients. Complete excision should be confirmed
histologically by looking for tumor-free margins.
Because of the rarity of this disease, our experience of
six cases over a period of 15 years is too limited to draw
any definite conclusions. However, by treating these cases
along the guidelines suggested, we were able to control the
disease without mutilation of the breast.
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
176
Raganoonan C, Fairbain JK, Williams S, Hughes LE. Giant breast
tumours of adolescence. Aust NZ J Surg 1987;57:243-7.
Carl D, Patel V. Surgical problems in the management of the breast.
Am J Obstet Gynecol 1985;152:1010-5.
Hart J, Layfield LJ, Trembull WE, et al. Practical aspects in the
diagnosis and management of cystosarcoma phylloides. Arch Surg
1988;123:1079-83.
McDonald JR, Harrington SW. Giant fibroadenoma of the breast
(cystosarcoma phylloides). Ann Surg 1950;131-234.
Musio F, Mozingo D, Otchy DP. Multiple giant fibroadenoma. Am
Surg 1991;57:438-41.
Amiel C, Tramier D, Marck MF, et al. Le fibro-adenome mamaire
geant. J Gynaecol Obstet Biol Reprod 1993;22:764-5.
Kier LC, Hickey RC, Keetal WC, et al. Endocrine relationships in
benign lesions of the breast. Ann Surg 1952;135:782-7.
Nambier R, Kutty MK. Giant fibroadenoma in adolescent females: a
clinicopathologic study. Br J Surg 1974;61:113-7.
Wulsin J. Large breast tumours in adolescent female. Ann Surg
1960;152:151-9.
Oberman HA. Breast tumours in the adolescent female. Pathol Ann
1979;14:175-201.
Pike A, Oberman H. Juvenile adenofibromas: a clinicopathologic
study. Am J Surg Pathol 1985;9:730-6.
Briggs RM, Walters M, Rosenthal D. Cystosarcoma phylloides in
adolescent female patients. Am J Surg 1983;146:172-14.
Hart WR, Bauer RC, Oberman HA. A clinico-pathologic study of 25
hypercellular periductal stromal tumours of the breast. Am J Clin
Pathol 1978;70:211-6.
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