Sarcomas of the breast: a clinicopathologic analysis of ten cases

Myxofibrosarcoma of the Breast: A Case Report

Development of a myxofibrosarcoma in the breast tissue is extremely rare. Reported here is a case of myxofibrosarcoma found in the left breast tissue of a male in his late fifties. The patient first underwent tumor resection, followed by a left mastectomy with the reconstruction of the vastus lateralis valve. The tumor comprised atypical spindle-shaped cells in a myxoid matrix with elongated blood vessels. Myxofibrosarcoma was diagnosed based on histology and immunohistochemical examination results performed for differential diagnosis. At two years and two months after the mastectomy, no local occurrence or metastasis had occurred.

Fibrossarcoma de mama - Relato de caso

Os autores relatam um caso de fibrossarcoma de mama em uma mulher de 19 anos, abordando a conduta e a terapêutica utilizadas. Revisam a literatura, quanto à incidência, diagnóstico e tratamento realizado. A abordagem diagnostica, além da propedêutica clínica, pode ser confirmada com segurança por biópsia Trucut e por biópsia aspirativa por agulha fina. No caso relatado, procedeu-se à biópsia excisional. O diagnóstico diferencial se fez com o fibrohistiocitoma angiomatoso maligno. Para estabelecer o diagnóstico histopatológico de certeza e elaborar o plano terapêutico foi utilizado estudo de imunohistoquímica, que confirmou tratar-se a peça de um fibrossarcoma. As terapêuticas utilizadas por vários autores foram comparadas, e optou-se por se fazer uma mastectomia simples. Apesar de este tumor ser pouco freqüente, observa-se que a estratégia terapêutica deve ser baseada no seu comportamento biológico e na sua origem histogenética, inclusive quanto ao modo de disseminação. Logo, é de se enfatizar a importância de publicações de relatos de casos.

Sarcoma of the Breast: Clinical Characteristics and Outcomes of 991 Patients from the National Cancer Database

Background

Sarcoma of the breast is a rare malignancy with heterogeneous histology. Angiosarcoma, including secondary angiosarcoma from previous radiation, is the most common type of sarcoma of the breast. Other types of sarcomas of the breast have limited clinical and survival information.

Methods

We obtained clinicopathological data and survival outcomes from the patients with sarcoma of the breast, excluding angiosarcoma, that were registered in the National Cancer Database (NCDB) from 2004 to 2016. The treatment patterns and prognostic factors were analyzed.

Results

A total of 991 patients had sarcoma of the breast other than angiosarcoma. The most common histology was spindle cell sarcoma (13.4%), followed by leiomyosarcoma (11.7%) and giant cell sarcoma (10.1%). Surgical resection was performed in 894 out of 991 patients (90.2%), including R0 resection achieved in 781 (87.4%). The patients who received surgery showed better survival than the patients without surgery regardless of radiation therapy. When radiation was added to the surgical management, the OS (overall survival) benefit was marginally significant (hazard ratio 1.30 (CI 1.01–1.67), p=0.044). Adding chemotherapy did not improve OS.

Conclusions

Surgical resection seems to be the most important treatment modality in sarcoma of the breast from the analysis of a large database. Radiation therapy added a minor survival benefit to the patients who received surgical resection. Systemic chemotherapy did not play a clear role in sarcoma of the breast.

Report on a Case of Breast Sarcoma Metastatic to the Axillary Lymph Nodes

Breast sarcoma is a rare entity that accounts for less than 1% of all breast malignancies; it may spread by direct invasion and/or through the blood. Axillary lymph node involvement is extremely rare and usually associated with advanced-stage disease. In the surgical treatment of this neoplasm, complete axillary lymphadenectomy is important for the local clearance of the clinically involved lymph nodes. We report a case of a 65-year-old woman affected by follicular dendritic cell sarcoma of the left breast. Six months after breast surgery she developed an axillary metastasis from the same disease.

Breast Leiomyosarcoma: A Systematic Review and Recommendations for Management

Background

Leiomyosarcomas of breast are very rare tumors, with only 54 cases reported in the literature to date.

Methods

We report a case of leiomyosarcoma in a 52-year-old woman who presented with a painless left breast mass in the upper outer quadrant of her left breast. It measured about 6 cm in diameter and was located within the breast parenchyma with no skin involvement. Mammogram was suggestive of BI-RADS IV lesion, and core biopsy of the lesion was inconclusive.

Results

Histopathology and immunohistochemistry of the excision biopsy of the mass confirmed the diagnosis of leiomyosarcoma approaching the specimen margins. The patient underwent simple mastectomy, which did not reveal any residual tumor or additional lesions. Follow-up for a year after her mastectomy did not show any local or systemic recurrence.

Conclusions

We reviewed the literature and summarize our findings as recommendations for management of leiomyosarcoma of breast.

Primary Breast Atypical Lipomatous Tumor/ Well-Differentiated Liposarcoma and Dedifferentiated Liposarcoma

Atypical lipomatous tumor/well-differentiated liposarcoma (ALT/WDL) and its higher-grade counterpart, dedifferentiated liposarcoma (DDL), are extraordinarily rare tumors in the breast. The main differential diagnostic consideration of primary breast ALT/WDL is malignant phyllodes tumor with liposarcomatous differentiation, and the main differential diagnostic consideration of DDL in the breast is metaplastic breast carcinoma, particularly the spindle cell type, with heterologous sarcomatous differentiation. These differential diagnoses may be particularly challenging when evaluating limited core needle biopsy sampling. MDM2 and/or CDK4 protein overexpression and gene amplification are beneficial ancillary studies that can help establish the diagnosis of primary breast ALT/WDL and DDL, and effectively rule out the diagnoses of malignant phyllodes tumor and metaplastic breast carcinoma.

Primary Osteosarcoma of the Breast: Pathophysiology and Imaging Review

Extraskeletal osteosarcoma are rare malignant mesenchymal neoplasms of soft tissues representing around 1% of all soft tissue. The exact mechanism of tumorigenesis of primary breast osteosarcoma is still unclear. However, most of the cases develop without a recognized etiologic factor. Primary osteosarcoma of the breast is often initially misdiagnosed as breast fibroadenoma. Different imaging modalities and pathology play important role in differentiating breast osteosarcoma from other benign and malignant lesions of the breast resulting in dramatic change in the management.

A case of primary extraskeletal osteosarcoma of the breast

Background

Primary sarcomas of the breast are rare and account for less than 1% of all primary breast malignancies. We experienced a case of extraskeletal osteosarcoma of the breast that had a unique clinical course and remarkable findings of mammography and magnetic resonance imaging (MRI). A review of the case reports published in the past few decades showed no reports of a case in which a calcified lesion was followed up three different times on mammography, making this a valuable case report.

Case presentation

A 52-year-old woman noticed a right breast mass and underwent a breast examination. Mammography showed a 1.5-cm coarse calcified lesion in the upper outer portion of the right breast. Because fine-needle aspiration (FNA) revealed no suspicion of malignancy, she was followed up. Sixteen months later, the tumor grew progressively to 4.5 cm in size with new calcifications that were fine and irregular in shape and density surrounding an enlarged, coarse calcified lesion. Contrast-enhanced magnetic resonance imaging (MRI) showed a high signal intensity in the periphery of the tumor. Extirpation of the tumor was indicated. The pathological findings were extraskeletal osteosarcoma. She underwent additional resection and latissimus dorsi flap reconstruction at the Department of Orthopedic Surgery.

Conclusion

The present case suggests that mammography findings of a tumor with coarse calcifications that are not typical of benign lesions may be extraskeletal osteosarcoma. A diagnosis must be made as early as possible in order to improve the prognosis of this disease.

Smooth Muscle Tumors of the Breast: Clinicopathologic Features of Two Cases

Two cases of smooth muscle tumor of the breast with high tendency to local relapses are reported. The common cytohistologic feature of these infrequent neoplasms is interfacing bundles with spindle-shaped cells showing eosinophilic cytoplasm and blunt-ended nuclei. In estimating the prognosis of these lesions, the mitotic index must be evaluated together with evidence of necrosis and hypercellularity. The present cases suggest that, in the absence of the ancillary features, a mitotic rate of 1-3 × 10 HPF might define a “grey zone” in the spectrum of lesions between leiomyomas and leiomyosarcomas: the smooth muscle tumors of indeterminate prognosis (low risk lesions).

Surgery for Malignant Mesenchymal Tumors of the Breast: A Series of 31 Cases

Thirty-one cases of malignant mesenchymal tumors of the breast were analyzed with the purpose of identifying the most suitable type of surgery to be recommended. All the cases considered underwent pathologic review. Even young women were affected, and menopausal status did not seem to influence the development of mesenchymal tumors. Mammography was of little use for diagnosis. All cases underwent surgery and 26 had an adequate follow-up. In 8 cases a relapse occurred with a mean free interval of 6 months. Total mastectomy was sufficient to provide local control, whereas axillary dissection turned out to be not worthwhile. Postoperative radiotherapy did not improve distant results. Relapses mainly consisted of lung metastases. Fifteen patients were alive, free of disease, at a time ranging from 9 months to 13 years after surgery.

Myofibroblastic, fibroblastic and myoid lesions of the breast

Myofibroblastic, fibroblastic and/or myoid lesions are rare in the breast but comprise the majority of mammary mesenchymal spindle cell lesions. Whereas most have similar features to their counterparts at extramammary sites, pseudoangiomatous stromal hyperplasia is considered a breast-specific myofibroblastic proliferation on the same spectrum as myofibroblastoma. Other lesions with myofibroblastic/fibroblastic differentiation include fibromatosis and nodular fasciitis, as well as more aggressive tumors such as the rarely reported myofibrosarcoma, inflammatory myofibroblastic tumor and fibrosarcoma. Lesions with myoid differentiation include benign leiomyoma, myoid hamartoma and leiomyomatous myofibroblastoma, but primary leiomyosarcoma and rhabdomyosarcoma may also rarely arise in the breast. Furthermore, fibroepithelial lesions and metaplastic carcinomas can demonstrate myoid metaplasia. Diagnosis can be challenging, particularly on core biopsy, but benign lesions with or without recurrence potential must be distinguished from more aggressive tumors, especially metaplastic carcinoma and phyllodes tumors. This article will review lesions with myofibroblastic, fibroblastic and myoid differentiation in the breast, with special emphasis on differential diagnosis.

Sarcoma of the breast: an update on a rare entity

Breast sarcoma is a rare condition. It consists of a heterogeneous group of non-epithelial tumours arising from the mesenchymal tissue of the breast. It has a distinctly different natural history, treatment response and prognosis as compared with carcinoma of the breast. A different diagnostic approach and treatment strategy have to be defined for this group of tumours. Due to its rarity, the current understanding on breast sarcoma is limited and is mostly based on small retrospective case series or case reports. Hence, the management generally follows the algorithms derived from randomised control trials of soft tissue sarcomas in the extremities and chest wall. Through this review, we discuss the results of major retrospective studies on breast sarcomas including data on epidemiology, aetiology, diagnostic approach, treatment strategies and outcomes of this challenging and potentially aggressive condition.

Primary osteosarcoma of breast, a rare case

Mammary sarcomas are very uncommon and make up less than 1% of all primary breast malignancies.Primary osteosarcoma of the breast is extremely rare and represents 12.5% of mammary sarcomas. A secondary lesion from a primary osteosarcoma of the bone should be considered in the differential diagnosis. In addition, the absence of a direct connection between the tumour and the underlying skeleton is mandatory for the diagnosis.We report a case of primary osteosarcoma of the breast occurring in young patient with fatal evolution.

Rare breast tumors: Review of the literature

Breast cancer tumors have different morphological phenotypes and specific histopathological types with particular prognostic and clinical characteristics. The treatment of rare malignant lesions is frequently controversial due to the absence of trials to determine the optimal managements. This review describes the spectrum of rare breast tumors indicating the clinical, epidemiological and treatment characteristics.

Primary well differentiated breast liposarcoma with divergent cartilagenous differentiation: a case report

Primary liposarcomas of the female and male breasts are very rare. Heterologous differentiation in adipocytic tumors is also an exceedingly rare phenomenon, which is occasionally reported in the literature. We describe the case of a 22 year-old female who presented with a relatively large left breast mass which was clinically diagnosed as a case of giant fibroadenoma, but histologically showed a well differentiated liposarcoma with evidence of extensive chondroid differentiation. The mammographic and radiological features are presented and correlated with the histopathological appearances together with literature review and comparison with similar reported cases.

Do primary mammary osteosarcoma and chondrosarcoma exist? A review of a large multi-institutional series of malignant matrix-producing breast tumours

The existing literature describing the clinicopathological features and behaviour of matrix-producing (MP) malignant breast tumours presents conflicting results. As a consequence it remains uncertain whether these tumours should be treated as sarcoma and managed by a specialist sarcoma team or treated using the same principles as conventional ductal carcinoma, a dilemma that prompted this study. Improved understanding of the clinicopathological characteristics of primary mammary MP-sarcomas, namely osteosarcoma and chondrosarcoma, is required.

METHODS

In this large international multicenter series of malignant MP-tumours of the breast (no = 101) with follow-up information has been assessed and their outcome is compared to other subtypes of metaplastic breast carcinoma (MBC) (no = 253) and to grade, lymph node and hormone receptor-matched ductal breast carcinomas (no = 258).

RESULTS

The majority of MP-cancers were associated with epithelial features, which supports the concept that the majority of, if not almost all, primary MP breast sarcomas are of epithelial in origin (MBC). 21% showed nodal metastasis and the distribution of distant metastases resembled conventional mammary carcinoma. The prognosis of MP-MBC is comparable to matched ductal breast carcinoma and slightly better than other subtypes of MBC. Advanced stage (T3&T4) and development of recurrences were predictors of shorter survival in MP-MBC while grade and vascular invasion were not.

CONCLUSION

Most malignant MP breast tumours are variants of MBC. MP-MBC with predominant mesenchymal components behaves similar to ductal carcinomas and although data on their response to systemic therapy is limited, there is no evidence that they should be managed differently from other forms of triple negative breast cancer.

Primary leiomyosarcoma of breast in an adolescent girl: a case report and review of the literature

Leiomyosarcoma of the breast is a rare neoplasm, primarily reported in older women. Only 44 cases have been reported in world literature and to the best of our knowledge, no case has been reported from India till date. We report a case of primary breast leiomyosarcoma in an adolescent girl who underwent a lumpectomy for rapidly increasing lump in the left breast. Here we report the histological findings and immunohistochemical profile of this entity, along with a review of existing literature.

Primary osteosarcoma of breast

Primary osteosarcoma of breast is rare. The authors present a case of a 51-year-old female who was admitted with a large necrotising tumour involving the right breast. CT scan confirmed chest wall invasion along with a solitary lung metastasis. She underwent a primary mastectomy with chest wall reconstruction. Unfortunately 3 months later she developed local recurrence.

Stromal sarcoma of the breast with lung metastases showing a clinical complete response to doxorubicin plus ifosfamide treatment: report of a case

A 29-year-old woman presented with a painful right breast tumor, measuring 15 cm in diameter, which had progressed rapidly over 3 months. Core needle biopsy of the tumor revealed a malignant mesenchymal tumor. A mastectomy was performed, and pathological examination of the tumor showed stromal sarcoma. Solitary pleural dissemination in the right lung was suspected, based on the computed tomography image taken before the operation. Two months after surgery, bilateral multiple lung nodules were demonstrated. Systemic chemotherapy with doxorubicin plus ifosfamide was performed, and 3 months later the lung metastases had disappeared. Moreover, there is still no sign of recurrence at 5 months after the initiation of the chemotherapy. Breast stromal sarcoma is very rare, accounting for less than 1% of mammary neoplasms, and the treatment strategy is not well established, especially regarding chemotherapy. This case demonstrates the effectiveness of chemotherapy with doxorubicin plus ifosfamide for lung metastases from breast stromal sarcoma.

Primary fibrosarcoma of the breast: a case report

A primary fibrosarcoma of the breast is a rare tumor. Here we report on a case of a primary fibrosarcoma of the breast that presented as a palpable left breast mass in a 47-year-old woman. The physical examination revealed a 3 cm sized, round mass in the left upper outer breast. The mammograms revealed a 3 cm sized, partially circumscribed and partially obscured, high density mass in the upper outer quadrant of the left breast. An ultrasonogram demonstrated a 3 cm sized, ovoid, circumscribed and hypoechoic mass with peripheral increased vascularity on Doppler imaging. Surgical excision was performed and the pathology revealed a low grade fibrosarcoma.

Primary leiomyosarcoma of the breast treated by partial resection of the breast including nipple and areola: report of a case

A 46-year-old female patient presented with a tumor measuring 0.5 cm in diameter under the areola of the breast. Because no definite malignancy was found with inspection and palpation, imaging analysis, or with a fine-needle aspiration cytology examination, follow-up observation was recommended. When the patient visited the hospital 6 months later, the mass was 0.9 cm in diameter. The tumor was excised and histopathologically diagnosed as a leiomyosarcoma. Subsequently, the patient underwent a partial resection of the breast, including the nipple and areola. A follow-up examination revealed no evidence of distant metastasis or local recurrences 8 years 4 months after the surgery. Primary leiomyosarcoma of the breast is extremely rare. Only 33 cases, which are reviewed in the present study, have been previously reported in the literature.

Primary Osteosarcoma of the Breast: Report of 2 Cases

Two distinct histologic variants of primary breast osteosarcoma in 2 elderly women are described. The first patient was an 88-year-old woman with a long-standing, slow-growing, 18-cm mass in her right breast. The second patient was a 96-year-old woman with a recently self-detected, painless, 7.5-cm lump in her left breast. Clinically, there was no evidence of metastasis, and both women underwent simple mastectomy. Histologic features of both specimens were those of high-grade primary breast osteosarcoma. The first patient's tumor was classified as a chondroblastic variant, and the second as an osteoblastic variant of osteosarcoma. The patients were alive without evidence of local recurrence or hematogenous spread at a 16- and 4-month follow-up, respectively. Primary mammary osteosarcoma should be distinguished from metaplastic/ sarcomatoid carcinoma with heterologous osseous/cartilaginous differentiation or malignant phyllodes tumor because it has a different biological behavior and requires a different treatment approach.

Primary osteosarcoma of the breast

We report a case of primary osteosarcoma of the breast, which is a rare histological type of all breast tumors. A 58-year-old woman had noticed a right breast mass long before presenting to our hospital because it had gradually increased in size. The mass was bony-hard, 90 x 70 mm in size, and was located mainly in the upper outer quadrant of the left breast. Mammography demonstrated a round radiopaque mass with a shaggy outline. There were small bone metastases to the pelvis and scapula on bone radionuclide scan, but no other metastasis was observed with subsequent investigations. Modified radical mastectomy including axillary lymph node dissection was performed. Histologically, the excised tumor was consistent with extraskeletal osteosarcoma of the breast accompanied by lymph node metastses. In spite of adjuvant chemotherapy, the patient suffered a local recurrence four months later and died of aggressive multiple metastases 7 months after surgery.

[Primary breast sarcoma. A retrospective study of 42 patients treated at the Bergonié Institute during a 32-year period]

OBJECTIVE

To evaluate the experience of a single cancer center with unusual tumors. To analyze Primary breast sarcomas (PBS). To investigate treatment and prognostic factors influencing overall survival (OS) and disease-free survival (DFS).

PATIENTS AND METHODS

Retrospective study of a series of 42 patients. We reviewed the clinical records and pathology slides of 42 women with PBS treated in our institution between 1970 and 2002. Log-rank tests were used to determine OS and DFS.

RESULTS

The median age at diagnosis was 56.9 years (24-81 years). Surgery was part of the therapeutic strategy in all the patients. Patients with angiosarcoma and those with malignant cystosarcoma constituted distinct populations. The 10-year OS and DFS rates were 53% and 55% for angiosarcoma patients and 89% and 100% for cystosarcoma patients (p=0.009 and 0.01 respectively).

CONCLUSION

Careful preoperative multidisciplinary assessment is required before making the decision to treat. Mastectomy is generally indicated. Axillary lymph node dissection is not indicated.

Stromal Sarcoma of the Breast: A Case Report

We report a case of a 36-year-old lady who presented with a huge fungating tumour that involved the entire right breast. The tumour was diagnosed histologically as undifferentiated primary stromal tumour of the breast with axillary lymph node metastasis. We review the literature of this rare malignant tumour. Stromal sarcomas of the breast lack epithelial participation, and diagnosis of these tumours can be difficult. Genome-wide expression profiling is currently used to determine the cell of origin of most sarcomas. Surgery offers the best therapeutic option. Adjuvant radiotherapy is not very beneficial, while chemotherapy has, to date, no established role in the management of this disease. The prognosis is dismal for patients with lymph node involvement. The size of the tumour has a lesser bearing on outcome.

Primary breast sarcoma: clinicopathologic series from the Mayo Clinic and review of the literature

Primary sarcomas of the breast are extremely rare, with less than 0.1% of all malignant tumours of the breast. Mayo Clinic Surgical Pathology database was searched for all breast sarcoma from 1910 to 2000. Pathology reports and slides were reviewed and tumour types were determined. Metaplastic carcinomas and phyllodes tumours were excluded. There were 25 women ranging in age 24-81 years (mean 45 years). All but one patient presented with a palpable lump. Mastectomy was performed in 19 patients and lumpectomy in five patients. Histopathological diagnoses were fibrosarcoma (six), angiosarcoma (six), pleomorphic sarcoma (six), leiomyosarcoma (two), myxofibrosarcoma (three), hemangiopericytoma (one) and osteosarcoma (one). Tumour size ranged from 0.3 to 12 cm (mean 5.7). Low-grade lesions were observed in 10 cases and high-grade in 15. Overall, mean follow-up was 10.5 years. Local recurrence was observed in 11 patients and ranged from 2 to 36 months (mean 15 m), while distant metastasis was observed in 10 patients (40%) affecting lungs, bones, liver, spleen, and skin. Of the 25 patients, 12 have died of disease and six of other causes. Five-year overall (OS) and cause-specific survival (CSS) were 66 and 70%, respectively. OS and DFS at 5 years were 91% for tumours < or =5 cm and 50% for tumours >5 cm. Tumour size was significantly associated with OS (risk ratio=1.3 per 1 cm increase; 95% CI, 1.02-1.7; P=0.036). There was no significant difference in OS or CSS between low- and high-grade lesions. In this series, tumour size was a more valuable prognostic factor than tumour grade.

Primitive leiomyosarcoma of the breast: case report and review of the literature

Sarcomas of the breast account for under 1% of breast tumours. Leiomyosarcomas are less common, being a subgroup of sarcomas of the breast. Only 23 cases with immunohistochemical or electron microscopy confirmation are reported in the literature. The case of a 58-year-old woman with a leiomyosarcoma 4 cm in diameter in the upper external quadrant of the right breast is presented. Mammography and sonography were compatible with a fibroadenoma or phylloides tumour, and fine-needle aspiration (FNA) suggested medullary carcinoma. The patient underwent a Madden-type modified radical mastectomy and axillary lymphadenectomy. Adjuvant chemotherapy was implemented with Adriamycin (four cycles of 21 days). One year after surgery the patient is tumour free.

Primary leiomyosarcoma of the breast: diagnosis, management and outcome. A report of a new case and review of literature

Primary leiomyosarcoma of the breast is very rare and represents a diagnostic challenge. Only 16 cases have been reported in the English language literature. We report another new case and have analysed reports of the previous cases aiming to present a simple evidence-based approach to the clinical, radiological and pathological diagnosis of this rare tumour. The average age of presentation is 56 years. All neoplasms have been limited to the breast at the time of diagnosis. The usual presentation is a slowly growing mass, but in the current case report the patient present with mastalgia. There is always a possibility of local recurrence or distant spread, which can occur many years after primary surgery. Leiomyosarcoma must be histologically distinguished from leiomyoma and the presence of >3 mitoses per 10 high-power fields is usually indicative of malignancy. Immunohistochemistry is helpful to confirm diagnosis. As this is a slow-growing malignant tumour with a propensity for local recurrence, total mastectomy is the treatment of choice. The tumour is not hormone-dependent and hormone manipulation is not a treatment option.

Primary osteosarcoma of the breast

Primary osteosarcoma of the breast is a rare malignant tumour. We report such a case in a 77-year-old lady who presented with a hard lump which was clinically and mammographically indistinguishable from a calcified fibroadenoma. Wide local excision of the lesion was carried out. Detailed histological and immunohistochemical features of the tumour are described. Because there was no evidence of metastasis and adequate local excision, no further treatment was considered necessary and she remains disease free at 39 months.

Primary Leiomyosarcoma of the Breast: A Case Report with Review of the Literature

Breast sarcomas account for about 1% of all malignant breast cancers. Leiomyosarcoma (LMS), one of the rarest, was first described 20 years ago, and yet few published reports exist. A case of primary LMS in a 25-year-old woman is presented and is only the 18th well-documented case in the literature. The clinical presentation, diagnosis, therapy, and pathologic features are reviewed.

Leiomyosarcoma of the breast: a difficult diagnosis on fine-needle aspiration biopsy

Leiomyosarcoma of the breast is rarely encountered in fine-needle aspiration (FNA) cytologic material. We report a case of primary leiomyosarcoma of the breast in a 52-yr-old female. Aspiration cytology showed large, dissociated round to spindle cells with abundant vacuolated cytoplasm, pleomorphic nuclei, prominent nucleoli, and occasional intranuclear cytoplasmic invaginations. Mitotic figures, osteoclast-like giant cells, and stromal fragments were identified. A diagnosis of malignant neoplasm representing either a sarcoma, a poorly differentiated carcinoma, or a metaplastic carcinoma was made. The patient underwent a wide excision of the lesion after negative work-up. Histologic examination and immunohistochemical studies established the diagnosis of leiomyosarcoma. This case is presented here because we feel that, although FNA cytology with eventual ancillary studies is a valuable diagnostic tool to evaluate any breast mass, malignant spindle cell neoplasms of the breast still represent a diagnostic challenge for the cytopathologist. Recognition of all cytologic features of leiomyosarcoma may help to formulate a correct diagnosis.

Stromal sarcoma of the breast with leiomyosarcomatous pattern

We report an unusual case of stromal sarcoma of the breast with leiomyosarcomatous pattern, which recurred locally and was finally treated by radical mastectomy. The tumor was composed of pleomorphic and hyperchromatic spindle-shaped cells arranged in an interdigitating fascicle. The nuclei were of moderate to severe atypia. An average of 10 mitoses per 10 high-power fields was seen. Immunohistochemically, the stromal cells were positive for vimentin and alpha-smooth muscle actin, but negative for S-100 protein, cytokeratin and desmin. The average Ki-67 (MIB1) labeling index in the stromal cells was 34%. Electron microscopic evaluation revealed further evidence of smooth muscle differentiation; stromal cells had frequently indented nuclei, well-developed rough endoplasmic reticulum, thin basal lamina and dense patch-like structures within the cytoplasm. Analysis of previous literature on 17 cases reveals mitotic activity of the tumor seemingly of little prognostic value. This case indicated difficulty in diagnosing leiomyosarcoma. The risk of local recurrence remains even if the surgical margin is free of tumor cells.

P53 expression is a factor for prognostic assessment in breast sarcoma

The present study was undertaken with the aim of evaluating the clinical and anatomopathological findings, emphasizing expression of the protein p53 as possible prognostic markers, in patients with breast sarcoma. p53 immunohistochemical expression was determined in archival paraffin embedded tissue blocks of 30 breast sarcoma patients, (19 fibrosarcomas, nine malignant fibrohistiocytomas and two liposarcomas) treated at the Hospital do Cancer AC Camargo, São Paulo, Brazil from 1955 to 1990. Immunopositivity was present in 50% of the cases. The survival of the patients was compared with the above parameters. Median follow up time was 113 months. The 5 years specific survival rates were 55.1% for patients with a positive expression of p53 contrariwise to 92.3% of specific survival found in p53 negative patients (p = 0.04). Positive expression of p53 was found in 3/4 (75%) of the patients with local recurrence and in 7/9 (77%) of patients with metastatic disease. No significant correlation between survival and clinicopathologic features (age, menopausal status, tumor size, stage and histological type), was found. A slight positive correlation between high grade and poor outcome was observed, 89% of the metastatic cases being classified as high grade (p = 0.02, by one sided Fisher's exact test). When we have compared, independently, survival probability curves between p53 positive/negative expression and each category of clinicopathologic features a worse prognosis was observed when p53 was positive in patients older than 50 years (p = 0.01), in tumors larger than 5 cm (p = 0.02), within the malignant fibrous histiocytoma subtype (p = 0.01) and in tumors classified as high grade (p = 0.07). In conclusion p53 expression seems to be a useful prognostic marker for this type of tumor.

Primary soft tissue sarcoma of the breast

Primary soft tissue sarcoma (STS) of the breast is a rare and heterogeneous disease. The rarity of this tumor limits most studies to small retrospective case reviews and case reports. The optimal treatment of primary STS of the breast can best be determined through multidisciplinary discussions prior to the initiation of therapy. Whether chemotherapy is indicated is primarily determined by tumor size. There is evidence that tumors larger than 5 cm are associated with an elevated risk of systemic failure and a poor prognosis. Negative surgical margins are more important for local recurrence and overall survival than is the extent of surgical resection. Thus, neoadjuvant chemotherapy should be considered in order to shrink the tumor and help obtain negative surgical margins. After surgical resection, patients with chemosensitive tumors should undergo additional adjuvant chemotherapy to treat micrometastatic disease. Patients with tumors less than 5 cm that are easily resectable should undergo complete resection to the extent required to provide negative surgical margins. Radiation therapy should be used to improve local control in cases in which the tumor is larger than 5 cm and in cases with positive surgical margins. The appropriate treatment of primary STS of the breast requires a multidisciplinary approach necessitating experienced surgeons, pathologists, radiotherapists, and medical oncologists.

Nonmammary malignancies of the breast: ultrasound, CT, and MRI

The three major categories of nonmammary malignancies of the breast include primary and secondary lymphoreticular malignancy, primary and secondary sarcoma, and hematogenous metastasis. This article describes the imaging features of 35 nonmammary malignancies of the breast and axilla with histopathologic confirmation. These include primary and secondary breast lymphoma, primary axillary nodal lymphoma, metastatic acute lymphatic leukemia, metastatic plasmacytoma, granulocytic sarcoma, primary angiosarcoma, metastatic rhabdomyosarcoma, hematogenous metastasis from primary lung, ovarian, cervical, thyroid, and colonic carcinoma, malignant melanoma, carcinoma of the nasal cavity, and adenocarcinoma of unknown primary. Wherever possible, correlation between mammography and ultrasound, computed tomography (CT), and/or magnetic resonance (MR) imaging is made.

An analysis of 78 breast sarcoma patients without distant metastases at presentation

PURPOSE

A retrospective review of a single cancer center experience was undertaken to identify clinical or treatment prognostic factors for these unusual tumors, to allow for a recommendation regarding management.

METHODS AND MATERIALS

The charts of 76 women and 2 men with breast sarcoma and without distant metastases at presentation registered from 1958 to 1990 were reviewed. Pathology was centrally reviewed in 54 cases. Histology, tumor size, grade, nodal status, age, menopausal status, history of benign breast disease, extent of surgery, resection margins, and radiation dose were each examined as potential prognostic factors by univariate analysis. To allow an analysis of radiation dose, total dose was normalized to a daily fraction size of 2 Gy.

RESULTS

The median age at diagnosis was 50.5 years (13-82 years). The pathologic diagnosis was found to be malignant cystosarcoma phyllodes in 32 patients, with the remainder being stromal sarcoma (14), angiosarcoma (8), fibrosarcoma (7), carcinosarcoma (5), liposarcoma (4), other (8). Eighteen patients had grade I or II tumors, 43 had grade III or IV, and 18 were not evaluable. The 5- and 10-year actuarial rates for all 78 patients were 57% and 48% for cause-specific survival (CSS), and 47% and 42% for the relapse-free rates (RFR), respectively. The local relapse-free rate (LRFR) was 75% at both 5 and 10 years. The 5-year CSS for grade I or II tumors was 84% versus 55% for grade III or IV tumors (p = 0.01). Conservative surgery versus mastectomy did not lead to statistically significant different outcomes for CSS, RFR, or LRFR. The comparison of positive versus negative margins showed a 5-year LRFR of 33% versus 80% (p = 0.009). Pairwise comparisons of the 5-year CSS of 91% for > 48 Gy versus either 50% for < or = 48 Gy or 50% for no radiation showed p-values of 0.03 and 0.06, respectively.

CONCLUSION

The authors propose that if negative surgical margins can be achieved, breast sarcoma should be managed by conservative surgery with postoperative irradiation to a microscopic tumoricidal dose (50 Gy) to the whole beast, and at least 60 Gy to the tumor bed. The decision to treat should be preceded by a preoperative multidisciplinary assessment. It is also recommended that an axillary lymph node dissection is not indicated, with the possible exception of patients with carcinosarcoma.

Primary osteogenic sarcoma of the breast: a clinicopathologic analysis of 50 cases

Extraskeletal osteosarcomas are rare. Few primary mammary osteosarcomas have been reported; many of these have been described in association with a biphasic tumor. Fifty pure osteosarcomas of the breast, diagnosed between 1957 and 1995, were reviewed after excluding those of biphasic origin. The absence of epithelial differentiation was confirmed using a panel of immunohistochemical markers in 32 cases and using ultrastructural evaluation in an additional four cases. Tumors occurred in 49 women and one man; age ranged from 27 to 89 years (median, 64.5 years). One patient received radiotherapy for ipsilateral breast carcinoma 9 years before presentation. Patients were treated by excisional biopsy (n = 13), tylectomy (n = 5) or mastectomy (n = 32). All axillary nodes, dissected in 20 patients, were free of tumor. One patient had extramammary spread at diagnosis. The neoplasms were 1.4 cm to 13.0 cm (mean, 4.6 cm), and 60% were grossly circumscribed. Tumors were classified as fibroblastic (n = 28), osteoclastic (n = 14), or osteoblastic (n = 8). Of 39 patients with available follow-up information, locally recurrent (n = 11) and metastatic (n = 15) disease developed in 23 (59%) at a mean of 10.5 and 14.5 months from diagnosis. Eight (73%) patients in whom local recurrence developed were treated with excisional biopsy or tylectomy; of these, seven had a positive margin. Sixteen (41%) patients died of disease at a mean of 17.1 months, within 20 months of onset of metastases, most commonly to the lung. Mammary osteosarcomas are aggressive tumors with a propensity for blood-borne rather than lymphatic spread. Total excision without axillary dissection is advised.