Primary pulmonary rhabdomyosarcoma

Primary fibrosarcoma of the breast: a case report

Jin-Young Lee, Dae-Bong Kim, Beom Seok Kwak,* **Department of Radiology, Dongguk University Il-San Hospital, Dongguk University*Departement of Surgery, Dongguk University Il-San Hospital, Dongguk University**Department of Pathology, Dongguk University Il-San Hospital, Dongguk UniversityAddress for reprints: Dae-Bong Kim Department of Radiology, Dongguk University International Hospital, Dongguk University, 814 Siksa-dong, Ilsandong-gu, Goyang-si, 410-773, Korea

E-mail: dbkim@duih.orgPhone: 031-961-7837, 031-961-7825Fax: 031-961-8281Primary fibrosarcoma of the breast: a case report

AbstractA primary fibrosarcoma of the breast is extremely rare. We report a case of primary fibrosarcoma of the breast that presented as a palpable left breast mass an a 47-year-old woman. A physical examination revealed a about 3 cm sized, round mass in the left upper outer breast. Mammograms revealed a 3cm sized, partially circumscribed and partially obscured, and high density mass in the upper outer quadrant of the left breast. A sonogram demonstrated a 3cm sized, ovoid, circumscribed, and hypoechoic mass with increased vascularity in the periphery at Doppler imaging. A surgical excision was performed , and The pathology revealed a fibrosarcoma. Keywords: Breast

Mammography

UltrasonographyPrimary fibrosarcoma

Introduction

Primary sarcomas of the breast are malignant tumors arising from the mesenchymal tissue of the breast[1]. Although primary carcinoma arising from breast tissue is relatively common, but primary sarcomas of the breast are extremely rare and constitute less than 0.1% of malignant breast neoplasm[2]. Fibrosarcoma of the breast is the subtype of the breast sarcoma, and is also quite rare[3]. A few cases about fibrosarcomas arising in the irradiated breast or post-operative scar have been reported[4]. But primary fibrosarcoma of the breast in female is exceedingly rare[1]. We report the mammographic and sonographic findings of a pathologically proven primary fibrosarcoma of the breast in a 47-year-old woman with no history of previous breast lesion. Case report

A 47-year-old woman presented with a chief complaint of a painless palpable mass in the left breast. The patient noticed the breast mass incidentally 10 days prior to hospital visit. She had no history of breast abnormalities, previous breast surgery or radiation therapy. A physical examination revealed a about 3 cm sized, round mass in the left upper outer breast. There was no overlying skin abnormality. No axillary or supraclavicular lymph nodes were palpable. Mammography showed a 3 cm, ovoid, partially obscured, partially circumscribed high-density mass in ther upper outer portion of the left breast. Calcifications were not observed within the mass (Fig. 1A, B). Breast sonography demonstrated a 2.5cm sized, ovoid, circumscribed, homogeneous hypoechoic solid mass with posterior acoustic enhancement at the 2 oclock direction of the left breast (Fig. 1C). Color Doppler study showed vascularity in the peripheral portion of the mass (Fig. 1D). We classified the mass as Breast Imaging Reporting and Data System(BI-RADS) category 4b. Next, we performed US-guided core needle biopsy and histological examination of the biopsy specimen revealed the presence of cellular spindle cell proliferative neoplasm with intermittent mitosis. These findings was not efficacious in the differentiation between spindle cell mesenchymal neoplasm from fibroepithelial neoplasm, and could not provide a diagnosis. Therefore, surgical excision was performed, and the gross specimen showed a well defined round mass without necrosis. Histological examination showed a high celluar, spindle cell tumor, displaying mild to moderate celluar atypia, and mitoses(up to 9~10 per high-power field) (Fig. 1E). The results of immunohistochemical staining were SMA (-) and S-100 (-), indicating a fibrous tumor (Fig. 1F). The final diagnosis was a low-grade fibrosarcoma. Discussion

Breast sarcoma is rare, accounting for less than 0.1% of malignant neoplasm of the breast[2]. Primary fibrosarcomas of the breast are type of malignant stromal sarcoma. Fibrosarcoma is composed of immature mesenchymal elements surrounded by collageneous substances [3]. Because of the rarity of this tumor, the overall incidence of primary fibrosarcoma of the breast has not been established. Pollard et al. reviewed 25 cases of primary breast sarcoma that diagnosed pathologically at London hospital during the 80-year period of the study. Among the 25 cases, 4 cases were fibrosarcoma [5]. Fibrosarcomas may occur at any age, but they occur commonly in woman between 40 and 50 years old. There are no clinical features that distinguish fibrosarcomas from other breast neoplasms. They grow rapidly and local tumor recurrence after local excision is common [6]. Metastasis of the tumor is primarily hematogenous, particularly to lung and bone. Lymphatic metastasis is rare [3]. Imaging features of fibrosarcoma of the breast have not been well established yet. Elson et al. reviewed mammographic findings of 5 cases with fibrosarcoma of the breast. In this study, the tumors were dense masses with largely indistinct margin, ranging from 1.5 cm to 7.0 cm on mammography, and one of them contained calcified structure. These findings were nonspecific and cannot differentiate the mass from other breast tumors [3]. In our case, the mass appeared an ovoid, partially obscured, partially circumscribed high-density mass on mammography. On ultrasonography, it appeared an ovoid, circumscribed, homogeneous hypoechoic solid mass with posterior acoustic enhancement. The main treatment of primary breast sarcoma, including fibrosarcoma, is surgical excision[7]. The aim of surgery is for excellent local control, and the surgery include simple mastectomy and local excision with negative surgical margin[8]. Our patient was treated by surgical excision, and since then neither distant metastases nor local recurrence have developed.

We have presented a rare case of primary fibrosarcoma of the breast with mammography and ultrasonography finding. Due to its rarity, more data and research is required.

References

1. Adem C, Reynolds C, Ingle JN, Nascimento AG. Primary breast sarcoma: clinicopathologic series from the Mayo Clinic and review of the literature. Br J Cancer. 2004 Jul 19;91(2):237-41.

2. O'Donnell ME, McCavert M, Carson J, Mullan FJ, Whiteside MW, Garstin WI. Non-epithelial malignancies and metastatic tumours of the breast. Ulster Med J. 2009 May;78(2):105-12.

3. Elson BC, Ikeda DM, Andersson I, Wattsgrd C. Fibrosarcoma of the breast: mammographic findings in five cases. AJR Am J Roentgenol. 1992 May;158(5):993-5.

4. Iwasaki K, Nagamitsu S, Tsuneyoshi M. Postirradiation fibrosarcoma following radical mastectomy. Jpn J Surg. 1978 Mar;8(1):73-7.

5. Pollard SG, Marks PV, Temple LN, Thompson HH. Breast sarcoma. A clinicopathologic review of 25 cases. Cancer. 1990 Sep 1;66(5):941-4.

6. Deodhar SD, Khope S, Kinare SG. Fibrosarcoma of the breast (a case report). J Postgrad Med. 1983 Apr;29(2):122B, 123-4.

7. Trent JC, Benjamin RS, Valero V. Primary soft tissue sarcoma of the breast. Curr Treat Options Oncol. 2001 Apr;2(2):169-76.

8. Teo T, Wee SB. Clinically 'benign' breast lumps: sarcoma in hiding?--Case reports and literature review. Ann Acad Med Singapore. 2004 Mar;33(2):270-4.

Figure Legends

Fig.1.A&B Mammography showed a 3 cm, ovoid, partially obscured, partially circumscribed high-density mass in ther upper outer portion of the left breast. Calcifications were not observed within the mass.

C. Breast sonography demonstrated a 2.5cm sized, ovoid, circumscribed, homogeneous hypoechoic solid mass with posterior acoustic enhancement at the 2 oclock direction of the left breast.

D. Doppler study showed vascularity in the peripheral portion of the mass.Fig.1.E. The tumor consists of cellular spindle cells with elongated nuclei arranged in interwoven bundles. The mitotic activity is increased. (Hematoxylin & Eosin stain. original magnification X400).

F. The tumor is negative for smooth muscle actin. (Immunohistochemistry. Original magnification X400).

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