ARRS 2022 Abstracts


E1935. Pseudoangiomatous Stromal Hyperplasia: A Multimodality Imaging Presentation and Case Base Management Review
  1. Sara Zamanian; University of Kentucky
  2. Fara Shikoh; University of Kentucky
  3. Aurela Clark; University of Kentucky
Pseudoangiomatous stromal hyperplasia (PASH) is an uncommon benign breast condition first described in 1986. It is not a premalignant or a high risk lesion. A similar number of cases are picked up incidentally at screening and as palpable abnormality. It is considered to respond to hormonal influence and as such is predominantly encountered in premenopausal women and postmenopausal women on hormone replacement therapy (HRT). PASH has a broad spectrum of imaging presentation. Although it is a benign entity, PASH may coexist with malignancy and should not be accepted as a final diagnosis on bases of pathology alone. For this educational exhibit, we retrospectively reviewed biopsy-proven cases of PASH during the last 5 years at our Breast Imaging Comprehensive Cancer Center. Ten representative cases are illustrated to depict the spectrum of imaging findings in each modality, encompassing patient presentation, pertinent history, and the management rationale. The most important learning points will be highlighted.

Educational Goals / Teaching Points
The learning objectives in this study are to illustrate the spectrum of imaging features of PASH predominant lesions through a case-base pictographic presentation, review the literature on management recommendations, discuss our management recommendation for each case including the more challenging cases discussed at multidisciplinary breast tumor conference, and emphasize the importance of imaging-pathological correlation. Suspicious imaging features merit immediate surgical attention. PASH is not infrequent in biopsy specimens, thus it is important to be familiar with the imaging findings so that unnecessary surgery can be avoided. Currently the treatment of PASH remains controversial. Many papers cite return to screening following a biopsy concordant with imaging findings, whereas others suggest imaging follow up, likely secondary to lack of long-term outcome studies. Surgical excision is recommended for larger lesions and in women at an increased risk for developing breast cancer. In our practice, cases of biopsy-proven PASH with interval growth are recommended for surgical excision; stable cases enter screening.

Key Anatomic/Physiologic Issues and Imaging Findings/Techniques
The most common mammographic presentation is an oval circumscribed mass without calcifications, resembling a fibroadenoma; the second most common is asymmetry. On ultrasound, PASH often appears as a hypoechoic or mixed echogenicity oval or irregular mass. On MRI, PASH usually presents as foci of clumped non-mass enhancement with progressive (type 1) enhancement, less frequently plateau (type 2). Pathologically, PASH may mimic a low-grade angiosarcoma, so excisional biopsy is usually performed if a mass diagnosed as PASH shows interval growth.

Through this image-rich exhibit, the audience will review the imaging features of PASH predominant lesions, appreciate changes under hormonal influence, understand management rationale on a case basis, and most importantly be alerted to coexisting discordant malignant imaging features.