Giant Breast Hamartoma : A Case Report in Togo

We report the case of a 50-year-old patient, who was explored in mammography, ultrasound and CT for a large painful mass of the right breast that had been evolving for 30 years and gradually increasing in size. There was a typical “sausage slice” appearance with clear center macrocalcifications on the mammogram; an aspect of “breast in the breast” on ultrasound. The scanner had made it possible to specify the dimensions of the mass, which measured 21.4 cm in height; 18.6 cm wide and 9.5 cm thick. Histology after exeresis noted the adenolipofibromatous nature of the mass.


Background
Mammary hamartomas are a set of rare benign breast tumors, representing approximately 4.8% of all benign tumors of the breast [1].These are lesions consisting of glandular, adipose and fibrous tissues in often abnormal proportions [1] [2].These are rare lesions whose pathological appearance is not distinctive although they may have some radiological features [3].Most reported cases are small to moderate with a size often between 1.2 and 14 cm and an average of 3.8 cm [4].Giant hamartomas with chronic evolution are rare.We present a clinical radio file of giant hamartoma of the breast evolving for 30 years in a patient of

Case Report
A 50-year-old Mrs. L. O, housewife, married, living in precarious conditions, fifth parapopal gesture, menopausal for 16 years, with no history of surgery or chronic pathology, presented a painful mass of the hypertrophied right breast, evolving for about 30 years.The pain was moderate (3/10 on the numerical scale), intermittent and had been treated with analgesics.This mass appeared at the age of 20 at the end of the first trimester of her second pregnancy.It gradually increased in size especially during the following pregnancies and at the time of breastfeeding.After several medical consultations, surgical treatment was proposed but refused by the patient.The persistence of the pains and the discomfort of this hypertrophy of the right breast had motivated a new consultation.There is no concept of hormone replacement therapy or a history of breast cancer in the family.
The physical examination noted a large right breast hanging with the lower limit at the height of the ipsilateral iliac crest (Figure 1).No changes in the skin and nipple were observed outside of a wart in the super-outer quadrant.The mass measured 20 centimeters long axis and 10 Centimeters small axis around.(Figure 2).There were also macrocalcifications within this mass.The dimensions of this mass were difficult to specify on the clichés.There were no intra-mammary microcalcifications or adenomegalies in the axillary extensions.

Discussion
Described for the first time in 1971 by Arrigoni et al. [5], hamartoma of the breast is a rare benign breast tumor [6] [7] [8].Its frequency is between 0.04% -1.15% and it represents 4.8% of all benign breast tumors [6] [9].It can be diagnosed at any age from puberty.In the majority of cases, it is seen in women aged over 35, with extremes ranging from 16 to 76 years [4] [10].The lesion occurred in our patient at a relatively young age (20 years).Whether hamartoma is found in an elderly patient or younger, a common trait is that this benign tumor develops before menopause [11].Clinically, hamartoma can evolve in an occult or asymptomatic manner [1] [8] [12], which is then often the object of fortuitous discovery [12].It can be associated with a mastodynia.The hamartoma is revealed most of the time during a palpation as a firm nodule, mobile benign characters such as adenofibroma [4] [10] [13] and this was the case of our patient.In addition, the absence of axillary adenomegaly, a criterion of benignity noted in our patient has also been reported [1] [12].Some bilateral forms have been described [7].The onset of signs can range from two months to two years [7] before diagnosis or even more as in our patient with a chronic course in thirty years marked by painful episodes during pregnancy.This is a particular character emphasized by this radio-clinical case; late use of appropriate care is an African trait.Another peculiarity of our observation and the most important is the large size of the hamartome which measured 216 mm × 186 mm × 94 mm.
Work has described variable sizes ranging up to a maximum of 14 cm [10] or 17 cm [14].A hamartoma similar in size to our case had never been described before.
In terms of imaging, the radiological aspects depend on the contents of the hamartoma.Several aspects have been described in mammography including the pathognomonic found in mixed or adipose hamartomas, which is sufficient to carry the diagnosis without further exploration [1] [5] [12].It is an opacity of variable size, well limited, surrounded by a hyperdense border corresponding to a pseudo capsule with partially greasy content sometimes with calcifications giving an aspect of "breast in the breast" or "slice of sausage".It is this aspect that has been observed in our case.In some types of hamartoma, the mammography appearance is that of a lipoma [1] Ultrasonography is useful in some cases to guide the biopsy and shows a benign type mass: round or oval, poorly contrasted, well encapsulated with an echogenicity close to the surrounding normal tissue that is repressed [10] [12] [15].The well encapsulated character giving the appearance of "breast in the breast" was clearly visible in our patient.We performed a breast computed tomodensitometry in our patient in order to have the precise dimensions of the mass; our mammograph is not equipped with a Potter adapted for the large breast size.The use of Magnetic Resonance Imaging mammography can be useful in some forms indeterminate mammography and ultrasound [8] [11].It shows a well-defined lesion of homogeneous hyposignal T1 that enhances homogeneously after injection of contrast medium with a non-enhanced peripheral border [16].Biopsy or excision with histological examination is not necessary for the diagnosis [8], but allows to affirm the benignity because rare cases of carcinomatous degeneration have been reported [3] [8].
Surgical removal is the curative method of hamartomas of the breast [1] [2].It is not systematic.However it can be discussed in case of desire of the patient, aesthetic discomfort or monitoring difficulties [6].In our observation it was done for aesthetic reasons but mainly because of the pain that became recurrent and increasingly important.

Conclusion
The diagnosis of breast hamartoma remains based on mammography coupled with ultrasound.Certainty of benignity remains the prerogative of histology

Figure 1 .
Figure 1.Photograph showing a right gigantomastia, normal volume left breast.

Figure 2 .
Figure 2. Facial incidence of the lower extremity mammogram showing upper limits of mass with thin capsule (red arrows).

Figure 3 .
Figure 3. Ultrasound section of the right breast showing part of the breast mass well encapsulated (red arrows head).

Figure 4 .
Figure 4. Non-injected thoracic CT, Sagittal reconstruction by the right breast showing the large, well-encapsulated heterogeneous mass (red arrows).