Fibromatosis of the breast: age-correlated morphofunctional features of 33 cases

Diagnosis and Management of Desmoid Fibromatosis of the Breast

Desmoid fibromatosis of the breast (also known as desmoid tumor of the breast) is a rare entity infrequently encountered by oncologists and surgeons caring for patients with breast disease. The current body of literature is highly reliant on case series and extrapolations from other sites of desmoid tumor-related disease. Much remains unclear regarding the pathological origins, natural history, and response to treatment of this condition. Traditional treatment strategies have centered on surgical resection, which may result in significantly disfiguring cosmetic and functional outcomes, frequent need for re-operation, and associated morbidity. There are limited data to support the superiority of upfront surgical resection when compared to medical therapy or watchful waiting strategies. Current treatment guidelines for desmoid tumors do not focus on the breast as a site of disease and are purposefully ambiguous due to the paucity of evidence available. We aim to review the literature concerning desmoid fibromatosis of the breast and propose an algorithm for current evidence-based management of this rare disease in the context of our experience with this pathology at a high-volume quaternary referral center.

Mammary fibromatosis in a female dog: case report

Fibromatosis, or desmoid tumour, is characterized by excessive and infiltrative proliferation of connective tissue originating from aponeurotic muscle structures. Mammary fibromatosis is rare in humans and animals and its precise aetiology is unknown. A 10-year-old mixed-breed female dog developed a mass in the right cranial thoracic mammary gland (M1) and underwent lumpectomy. The mass was firm, with an irregular surface and distinct limits. Microscopically, it was a neoplastic proliferation of fusiform cells with low atypia, interspersed with abundant dense collagenous tissue, confirmed by histochemical staining with Gomori's trichrome and Masson's trichrome and immunopositivity for vimentin and smooth muscle actin, confirming mammary fibromatosis. Mammary fibromatosis in dogs needs further studies to elucidate its clinical, epidemiological and aetiopathogenic aspects.

Lower Rate of CTNNB1 Mutations and Higher Rate of APC Mutations in Desmoid Fibromatosis of the Breast: A Series of 134 Tumors

Desmoid fibromatosis (DF) is a rare, locally aggressive, nonmetastasizing fibroblastic/myofibroblastic tumor with a tendency to recur and an unpredictable clinical course. A "wait-and-see" policy is the new standard of care. DF are characterized by activating alterations of the wnt/β-catenin pathway: CTNNB1 or adenomatous polyposis coli gene (APC) mutations (these mutations being mutually exclusive). Desmoid-type fibromatosis of the breast (DFB) is rare with an incidence of 0.2% of breast tumors. The diagnosis of DFB is difficult, as it must be distinguished from metaplastic carcinoma and other spindle cell lesions. Sequencing of 128 DFB identified a lower rate of CTNNB1 mutations using Sanger (65.6%) or Sanger+next-generation sequencing (77.7%) and a higher rate of APC mutations (11.8%) than in all-site DF. By excluding patients with familial adenomatous polyposis (n=2), the rate of APC mutations in DFB was high (10.7%). The distribution of CTNNB1 mutations in DFB was different from all-site DF, with a higher rate of T41A (68.9%), a lower rate of S45F (5.7%), and a similar rate of S45T (12.6%). By combining the 2 molecular techniques in a 2-step manner (Sanger, then next-generation sequencing), we increased the detection rate of CTNNB1 mutations and lowered the rate of wild-type tumors from 34.4% to 9.8%, therefore improving the diagnosis of DFB. The identification of the exon 3 CTNNB1 mutation in breast spindle cell lesions is a highly specific tool for the diagnosis of DFB, in addition to extensive immunohistochemical analysis. Our study also underlines the importance of APC in DFB tumorigenesis. These findings have significant implications for patient care and management.

Clinicopathological and radiological characterization of myofibroblastoma of breast: A single institutional case review

Myofibroblastoma is a rare type of benign myofibroblastic neoplasm in the breast. It is clinically presented as a well-circumscribed mass, usually small in size (usually less than 4.0 cm), and can mostly be cured by local excision. Rare cases of giant myofibroblastoma greater than 10 cm have been reported, but also follow a benign clinical course. Histologically, breast myofibroblastoma is featured by bland fascicles of spindle cells intermixed with thick hyalinized collagen bundles. Mast cells are frequently found within the stroma. However, a wide spectrum of morphological variants can occur in myofibroblatoma, making its diagnosis challenging sometimes. Differential diagnosis of myofibroblastoma with other spindle cell lesions in the breast, either benign or malignant, is also important in practice. In this study, we collected 15 cases of breast myofibroblastoma diagnosed in our institution during a 20 year period. The sizes of these cases range from 0.4 cm to 35.2 cm (mean is 3.7 cm). To our knowledge, the case of giant breast myofibroblastoma we presented here is the largest one reported to date. The histological examination of the cases show great morphological variations. Besides the classical type, features of cellular, collagenized, palisading, epithelioid, myxoid, myoid, solitary fibrous tumor-like are also identified in the case series. Immunohistochemical staining patterns as well as clinical features of the cases are also summarized and compared. All cases in this study show no recurrence on follow-up. In addition, cases that are important differential diagnosis for breast myofibroblastoma are also studied. Their key histological characteristics are compared with myofibroblastoma, and their immunohistochemical and molecular features are discussed.

Fibromatosis of the breast: a 10-year multi-institutional experience and review of the literature

BACKGROUND

Breast fibromatosis is a rare clinical entity, but poses significant diagnostic and therapeutic challenges. In light of recent changes in management practices, the aim was to review our institutional experience of breast fibromatosis and provide a review of current available literature on such management.

METHODS

A search of pathological databases within two tertiary institutions for all patients diagnosed with fibromatosis of the breast over a 10-year period (2007-2016) was performed. Clinicopathological characteristics and modes of treatment were recorded for each patient. Concurrently a comprehensive literature search was performed and studies relating to breast fibromatosis and its management were identified and reviewed.

RESULTS

Sixteen patients were identified. Median age at diagnosis was 42 (range 21-70) and all patients were diagnosed with core biopsy. The most useful imaging modality in diagnosis was ultrasonography and magnetic resonance imaging. 13/16 were treated surgically whilst 3/16 were treated using a watch-and-wait approach. 6/13 (46%) required re-excision of margins and 2/13 (15%) had recurrence after surgery. On review of the literature, there is no dedicated guideline in place for the management of breast fibromatosis. Currently a 'watch and wait' approach is favoured over surgical intervention due to high levels of recurrence and associated surgical morbidity. All cases should be discussed at a sarcoma multidisciplinary team meeting and tyrosine kinase inhibitors should be considered in advanced cases.

CONCLUSIONS

Breast fibromatosis is rare but affects young patients. Active surveillance is now favoured over surgical resection due to high recurrence rates and extensive morbidity. Dedicated guidelines are required to ensure best outcomes.

Practical approach to diagnosis of bland-looking spindle cell lesions of the breast

The diagnosis of bland-looking spindle cell lesions of the breast is often challenging because there is a close morphological and immunohistochemical overlap among the different entities. The present review will discuss reactive spindle cell nodule/exuberant scar, nodular fasciitis, inflammatory pseudotumor, myofibroblastoma (classic type), lipomatous myofibroblastoma, palisaded myofibroblastoma, benign fibroblastic spindle cell tumor, spindle cell lipoma, fibroma, leiomyoma, solitary fibrous tumor, myxoma, schwannoma/neurofibroma, desmoid-type fibromatosis, dermatofibrosarcoma protuberans, low-grade fibromatosis-like spindle cell carcinoma, inflammatory myofibroblastic tumor and low-grade myofibroblastic sarcoma arising in the breast parenchyma. The pathologist should be aware of each single lesion to achieve a correct diagnosis to ensure patient a correct prognostic information and therapy. Accordingly representative illustrations and morphological/immunohistochemical diagnostic clues will be provided.

Desmoid Type Fibromatosis of the Breast: Ten-Year Institutional Results of Imaging, Histopathology, and Surgery

Background

Desmoid type fibromatoses has proven to be a diagnostic and therapeutic challenge, as they often appear primarily as a carcinoma of the breast with a high recurrence risk.

Patients

A digital archive search was performed for the period from 2009 to the end of 2018. Inclusion criteria consisted of histological examination of at least the surgical specimen in the reference pathology department and at least a second opinion diagnosis in the reference radiology department.

Results

A total of 14 women and 1 man underwent surgery on desmoid type fibromatosis of the breast. The average patient age was 49 years (range: 22-72 years). The mean tumor size was 2.2 cm (range: 0.8-4.2 cm). The tumor was detectable in mammography in 12 out of 13 patients and in all 15 patients in sonography. MRI was performed preoperatively in 6 patients; in all of the patients, the tumor was visualized with inhomogeneous contrast enhancement. In the imaging procedures, all desmoid type fibromatoses were classified as suspicious. Performing the core biopsy, preoperative histology confirmed desmoid fibromatosis in 12 out of 15 patients. Nuclear stain for ß-catenin was positive in 7 out of 10 patients. Negative staining was found for AE1/A3 in 10 out of 10 and CD34 in 12 out of 12 patients. In all of the patients, a single-stage operation without the detection of border-forming tumor margins was performed. The follow-up interval ranged from 16 to 96 months (mean: 44.86 months, median: 43 months). In this follow-up period, no patient was diagnosed with desmoid tumor recurrence.

Conclusion

In imaging, desmoid type fibromatosis of the breast has typical malignancy-related criteria. Extensive preoperative diagnostics enable the planning of complete primary excision of the lesion and reduce the recurrence risk.

Dermatofibrosarcoma protuberans: a tumor in the wide spectrum of the bland-looking spindle cell lesions of the breast

Dermatofibrosarcoma protuberans (DFSP) is a soft tissue tumor, usually occurring as a cutaneous lesion localized to the trunk or extremities; although it has a high rate of local recurrence, its metastatic potential is very low and complete surgical excision is frequently curative. Most of the cases reported as “DFSP of the breast” are tumors arising in the subcutaneous tissue infiltrating the underlying breast parenchyma. To the best of our knowledge, only 5 cases of DFSP of the breast have been reported to date. We herein present a rare case of DFSP of the breast parenchyma in a 41-year-old female with emphasis on the diagnostic clues and the differential diagnosis with other benign and malignant spindle cell lesions of the breast.

Differential Diagnosis of Benign Spindle Cell Lesions

Spindle cell lesions of the breast cover a wide spectrum of diseases ranging from reactive tumor-like lesions to high-grade malignant tumors. The recognition of the benign spindle cell tumor-like lesions (nodular fasciitis; reactive spindle cell nodule after biopsy, inflammatory pseudotumor/inflammatory myofibroblastic tumor; fascicular variant of pseudoangiomatous stromal hyperplasia) and tumors (myofibroblastoma, benign fibroblastic spindle cell tumor, leiomyoma, schwannoma, spindle cell lipoma, solitary fibrous tumor, myxoma) is crucial to avoid confusion with morphologically similar but more aggressive bland-appearing spindle cell tumors, such as desmoid-type fibromatosis, low-grade (fibromatosis-like) spindle cell carcinoma, low-grade fibrosarcoma/myofibroblastic sarcoma and dermatofibrosarcoma protuberans.

Fibromatosis of the Breast: Diagnostic Accuracy of Core Needle Biopsy

OBJECTIVES

Fibromatosis of the breast is an uncommon neoplasm with potential for local recurrence. Treatment has traditionally been surgical excision with current trends toward conservative management. Given the option of observation after diagnosis by core needle biopsy (CNB), we sought to evaluate the accuracy of CNB for diagnosing fibromatosis.

METHODS

We identified a total of 31 cases in which fibromatosis had been diagnosed or included in the differential diagnosis on a CNB, an excision, or both. Morphology and immunohistochemical results were reviewed.

RESULTS

Aberrant nuclear immunoreactivity for β-catenin and absent staining for CD34 were the most useful studies to diagnose fibromatosis, and one or both were performed in 21 (68%) cases. High molecular weight cytokeratins and p63 were helpful to exclude spindle cell carcinoma. Of 26 cases confirmed as fibromatosis on excision, 22 (85%) were diagnosed as fibromatosis or fibromatosis was favored in the differential diagnosis on CNB. More frequent use of immunohistochemistry would likely have resulted in a greater number of definitive diagnoses. Fibromatosis was rarely mistaken for other nonmalignant stromal lesions, with no cases misdiagnosed as carcinoma.

CONCLUSIONS

CNB can be an accurate method of diagnosing fibromatosis, allowing observation for a select group of patients.

Medical treatment of mammary desmoid-type fibromatosis: which benefit?

Background

Breast fibromatosis is a rare disease characterized by monoclonal fibroblast proliferation. It has no ability to metastasize but has a high local recurrence rate and often infiltrates surrounding tissues. Surgical treatment is the reference, but recently, new targeted therapies have emerged. We report an original case of a patient with breast fibromatosis who received exclusive medical treatment. Our aim was to analyze these treatments based on the clinical and radiological outcome, iatrogenic effects, and pharmacological action.

Case presentation

We report the case of a 19-year-old woman who developed a desmoid-type fibromatosis of the lower inner quadrant of the right breast, measuring 50 × 25 mm (i.e., a volume of 27.4 cm³). Initial surgery was not possible because of potential esthetic and functional prejudice. Thus, she had an exclusive medical treatment including several lines: NSAIDs with tamoxifen and triptorelin, followed by sorafenib, then interferon α2b, and finally sunitinib. With tyrosine-kinase inhibitors (TKIs) (sunitinib), a significant partial response was observed (57% reduction of the maximal tumoral volume). For each treatment, we provided the clinical and radiological outcome in association with known pharmacological action.

Conclusions

TKI had been an interesting alternative option to initial surgery, providing at least a partial response and potentially allowing less mutilating surgery. However, no pharmacological mechanism can unequivocally explain TKI efficacy. In general, breast fibromatosis should be treated along with oncologist and interventional radiologists in a trans-disciplinary modality, thus offering an adapted treatment for this particular desmoid-type fibromatosis localization.

Inflammatory Myofibroblastic Tumor of the Breast Coexisting with Pseudoangiomatous Stromal Hyperplasia

Inflammatory myofibroblastic tumors (IMTs) are uncommon breast lesions that consist of spindle cells accompanied by plasma cell-rich inflammatory infiltration, which may mimic breast cancer clinico-radiologically. A woman aged 38 years with a breast mass was referred to our general surgery clinic. The physical examination revealed a mass with irregular borders in the upper outer quadrant of the left breast. In mammography, the lesion was 15 mm in diameter with a spheric form and high density. Ultrasonographically, the mass was solid, heterogeneous, and hypoechoic with posterior enhancement. Histopathologic examination of a core needle biopsy revealed a proliferation of spindle cells with eosinophilic cytoplasm and mild nuclear atypia, which showed negative immunostaining for pancytokeratin, HMWCK, CAM5.2, p63, CD34, β-catenin, and ALK but diffuse positivity for smooth muscle alpha (SMA). The lesion was reported as a "spindle cell lesion" and excision with clear margins was recommended. In the lumpectomy specimen, the lesion consisted of spindle cells that formed fascicles and infiltrated the surrounding breast parenchyma. Lymphocytes and plasmocytes scattered among spindle cells were noted. Necrosis, increased mitotic activity, nuclear pleomorphism and hyperchromasia were not detected. Immunohistochemical findings were the same in the core needle biopsy. The Ki-67 proliferation index was below 5%. With these findings, differential diagnoses were ruled out and the tumor was reported as IMT. In close proximity to this lesion, areas of columnar cell lesion with atypia and surrounding pseudoangiomatous stromal hyperplasia were seen. Patient has a follow-up of 16 months without recurrence.

[Rare benign breast tumors including Abrikossoff tumor (granular cell tumor), erosive adenomatosis of the nipple, cytosteatonecrosis, fibromatosis (desmoid tumor), galactocele, hamartoma, hemangioma, lipoma, juvenile papillomatosis, pseudoangiomatous hyperplasia, and syringomatous adenoma: Guidelines for clinical practice]

OBJECTIVES

To provide guidelines for clinical practice from the French College of Gynaecologists and Obstetricians (CNGOF), based on the best evidence available, concerning rare benign breast tumors: Abrikossoff (granular cell tumor), erosive adenomatosis of the nipple, cytosteatonecrosis, fibromatosis (desmoid tumor), galactocele, hamartoma, hemangioma, lipoma, juvenile papillomatosis, pseudoangiomatous hyperplasia, and syringomatous adenoma.

METHODS

Bibliographical search in French and English languages by consultation of Pubmed, Cochrane and international databases.

RESULTS

For erosive adenomatosis of the nipple, surgical excision is recommended to exclude Paget's disease or cancer (grade C). When surgery is performed for breast desmoid tumor or syringomatous adenoma, free margins are recommended (grade C). Without clinico-radio-histologic discordance, surgical abstention may be proposed for Abrikossoff tumor (granular cell tumor), cytosteatonecrosis, galactocele, hamartoma, hemangioma, lipoma, juvenile papillomatosis, pseudoangiomatous hyperplasia, and syringomatous adenoma (grade C).

Toward a new strategy in desmoid of the breast?

AIM

To report initial results of observation as well as surgery in patients with desmoid tumors (DTs) of the breast, a rare tumor for which data are scarce.

PATIENTS AND METHODS

The initial approaches were categorized as either front-line loco-regional treatment [(surgery or radiotherapy group, SRG) n = 20] or initial observation [(no surgery/no radiotherapy group, NSRG) n = 11].

RESULTS

A total of 27 women and 4 men were assessed between 1992 and 2013 and included in this study. Patient characteristics were adequately balanced in the 2 groups. Fifteen patients (48.4%) had a past history of breast surgery in the previous 24 months. The median initial DT size on MRI was 50 mm. The median follow-up was 36 months. In the SRG, 8/20 patients (40%) experienced recurrence. The median time to recurrence was 29 months. During the study period, 6 patients in the SRG (30%) received a mastectomy at the time of diagnosis (n = 3) or at relapse (n = 3), 7 patients (35%) received a thoracic wall resection and 8 patients (40%) received radiotherapy at the time of diagnosis (n = 2) or at recurrence (n = 5). In the NSRG, the median tumor size change was -4 mm (range -13 to +20). Three patients changed treatment strategies during the observation period; one received surgery, and 2 were administered anti-hormonal treatment.

CONCLUSIONS

Loco-regional treatments of breast DTs resulted in undesired disfigurement. Front-line observation yielded encouraging results and could enable the identification of patients who require loco-regional treatment. This strategy needs further evaluation.

Fibromatosis of the breast: a pictorial review of the imaging and histopathology findings

Fibromatosis of the breast is a rare condition that predominantly affects middle-aged women. It is locally aggressive, and exhibits a high incidence of local recurrence. The clinical presentation and radiological appearance are highly suspicious for carcinoma. Definitive diagnosis is made by diagnostic open biopsy. The aim of this review is to illustrate the main radiological and histopathological characteristics of this rare disease to increase awareness of this entity and discuss the role of magnetic resonance imaging (MRI) in its management.

Breast fibromatosis mimicking breast carcinoma

Fibromatosis arising from the breast, also referred to as desmoid tumor, aggressive fibromatosis, or low-grade fibrosarcoma, is a rare benign entity, accounting for only 0.2% of all breast tumors. Associations with familial multicentric fibromatosis and trauma, including that resulting from surgical intervention, have been reported. Awareness of this lesion is important, as the diagnosis has often been confused with that of breast carcinoma. We present the case of a 30-year-old white woman who presented with a palpable mass within the medial portion of her right breast. She reported breast carcinoma in both her paternal grandmother and maternal aunt. Subsequent mammographic and sonographic evaluation demonstrated an irregular solid mass within the posteromedial portion of the right breast. Ultrasound-guided core needle biopsy revealed low-grade myofibroblastic proliferation consistent with breast fibromatosis. The lesion was surgically resected via wide local excision. Follow-up mammograms performed 1 and 2 years after resection demonstrated no radiographic evidence of recurrence.

Prevalence of the CTNNB1 mutation genotype in surgically resected fibromatosis of the breast

AIMS

To investigate CTNNB1 mutation and β-catenin expression in resected breast fibromatosis and to identify potential molecular markers of fibromatosis of the breast.

METHODS AND RESULTS

We selected 12 patients with fibromatosis of the breast who underwent surgical resection and were confirmed by histological examination. Ultrasonography findings for 10 patients were reviewed and only two cases were suspicious for fibromatosis on imaging. On core needle biopsy for pre-operative diagnoses, only three cases were histologically suspicious for fibromatosis. Mutations in exon 3 of CTNNB1 were detected by direct DNA sequencing in nine (75.0%) cases: all were c.121G>A (p.T41A), which was much more frequent in breast fibromatoses than in other soft tissue lesions. Nuclear β-catenin expression was observed in all cases and the level of expression was higher in cases with mutation. In eight of nine cases, the matched biopsy specimen showed the same CTNNB1 mutation status as the pre-operative specimen.

CONCLUSIONS

In the majority of cases, clinical presentation and breast imaging are highly suspicious for carcinoma. Definitive pre-operative pathological diagnosis by core needle biopsy is difficult. CTNNB1 mutation and nuclear β-catenin expression are frequently detected in sporadic breast fibromatoses, suggesting their potential as a useful tool to distinguish breast fibromatoses from other neoplasms.

Desmoid tumour of the breast as a manifestation of Gardner's syndrome

INTRODUCTION

Desmoid tumours of the breast are rare. Although benign, they can mimic breast cancer on physical examination, mammography and breast ultrasound and can also be locally invasive. Even though they occur sporadically, they can also be seen as a part of Gardner's syndrome. We describe a case of desmoid tumour in a woman with Gardner's syndrome where the lesion was mammographically occult.

PRESENTATION OF CASE

A 63-year old woman presented with four months history of a painful left breast lump. She had a screening mammogram seven months ago which was normal. She is known to have Gardner's syndrome and had a total colectomy, she has also had multiple abdominal desmoids excised in the past. On examination there was a 4cm×5cm firm, mobile lump in the left breast. Her mammograms in the clinic were also normal. Ultrasound suggested a benign lesion of the breast and a core biopsy showed it to be a benign spindle cell lesion. She underwent wide local excision of the lump, the intraoperative mammograms of the excised specimen also failed to detect the lesion. Histopathology of the excised specimen confirmed the tumour to be a benign desmoid tumour. She has now been offered radiotherapy and nonsteriodal anti-inflammatory drugs (NSAIDs) to reduce her chances of a local recurrence.

CONCLUSION

A high index of suspicion and a thorough triple examination protocol is necessary to detect rare lesions like a desmoid tumour which can masquerade as breast carcinoma.

Bilateral breast fibromatosis: case report and review of the literature

Fibromatosis or desmoid tumor is a benign, slow-growing fibroblastic neoplasm originating from musculoaponeurotic stromal elements. These tumors are characterized by an infiltrative and locally aggressive growth pattern, frequent recurrences, but no metastatic potential. The etiology is unknown, but these tumors have been associated with trauma and genetic disorders. Breast fibromatosis is exceedingly rare and often misdiagnosed, comprising only 0.2% of breast tumors. Clinically, it might mimic other breast lesions, such as carcinoma. Only approximately 6 case series and 100 case reports of this disorder affecting the breast are documented, and only 5 cases of bilateral breast fibromatosis have been reported. We describe the case of a 20-year-old woman who presented to our institution with firm, nontender masses palpable in both breasts. Prior ultrasound was suspicious for carcinoma, and breast core biopsies were suggestive of phyllodes tumor. An excisional biopsy was necessary to establish the diagnosis of breast fibromatosis for both masses. A review of articles published on desmoid tumors and breast fibromatosis was performed with emphasis on articles published in the last 10 years. Fibromatosis should be considered in the differential diagnosis of patients presenting with hard breast lumps suspicious of other diseases.

Desmoid tumors of the bilateral breasts in a patient without Gardner syndrome: a case report and review of literature

Desmoid tumors constitute 0.02% to 0.03% of all tumors. Consequently, few case reports exist for breast desmoids, even fewer identifying bilateral disease. We present a case report of a patient with bilateral breast desmoids and shoulder desmoid without evidence of FAP or Gardner syndrome. This case report explores the clinical, radiographic, pathologic, and treatment elements for desmoid tumors as well as a review of the literature.

Fibromatosis of the male breast with concurrent florid-type gynecomastia: Report of a case and review of literature

Fibromatosis is a soft tissue lesion with infiltrative capacity, and is formed of proliferation of fibroblastic and myofibroblastic cells with a significant risk for local recurrence, but no metastatic potential. Fibromatosis is uncommon in the mammary gland, and accounts for less than 0.2% of all primary breast lesions. To the best of our knowledge, it has not been described in the setting of male breast with concurrent florid-type gynecomastia. We report a rare case of a 45-year-old male presenting with a palpable breast mass that was suspicious of carcinoma clinically. Failure of exclusion of metaplastic carcinoma and other lesions in repeated core biopsies lead to excision, which documented the intra-mammary origin of the lesion and established the diagnosis of fibromatosis. The current case demonstrates that fibromatosis in the male breast may have features and a presentation that can be confused with breast cancer. When obvious breast changes and history do not correlate with routine diagnostic measures, the presence of an unusual breast or chest wall tumor, such as a fibromatosis, should be considered in the differential diagnosis.

[Desmoid tumor of the breast in a 9 years old little girl]

Aggressive fibromatosis (desmoid tumour) of the breast is a rare tumour that accounts only for 0.2% of primary breast tumours. This is a benign mesenchymal tumour that develops from muscular fasciae and aponeuroses. It is characterized by its local evolution and its tendency to relapse without metastasizing. Wide radical resection should be attempted whenever possible. Positive margins at resection and reoperation are associated with a high risk of local recurrence. The role of radiotherapy and of medical treatments- especially anti-estrogens - remains unclear. We report here the case of desmoid tumour of the breast arising in a 9-year-old little girl.

Myoepithelial Carcinoma: A Rare Neoplasm of the Breast

BACKGROUND: Malignant myoepitheliomas of the breast are extremely rare. There has been a limited number of published reports of myoepithelial carcinomas originating from the breast. CASE REPORT: We describe a malignant myoepithelioma of the breast in a 56-year-old woman. Histological examination showed polygonal epithelioid cells and spindle cells with moderate to marked nuclear atypia. Immunohistochemistry showed reactivity in the spindle cells for smooth muscle actin, cytokeratin (AE1/AE3), and p63, indicating a myoepithelial cell lineage of tumor cells. The patient underwent radical surgical excision of the lesion and axillary lymph node dissection. She demonstrated no evidence of recurrence over an 11-month follow-up. CONCLUSIONS: We suggest myoepithelial carcinomas of the breast be managed with appropriate surgical clearance. A multidisciplinary approach is usually required.

Nipple-sparing skin-sparing mastectomy and vertical latissimus dorsi flap reconstruction for bilateral fibromatosis of the breast

Fibromatosis of the breast results in aggressive, infiltrative lesions with a tendency for local recurrence. A case of bilateral fibromatosis of the breast treated with nipple-sparing skin-sparing mastectomy and vertical latissimus dorsi flap reconstruction occurring in 22-year-old woman is described herein.

[Breast fibromatosis: An uncommon benign breast disease]

Extra-abdominal fibromatosis is an uncommon benign breast lesion resembling an infiltrative carcinoma in its clinical and radiological presentation. Surgical excision with wide margins remains the treatment of choice to avoid recurrence of this locally aggressive tumor. We present a case in which surgical biopsy allowed the diagnosis of a breast fibromatosis and we discuss its clinical, diagnostic, pathological and therapeutic particularities.

Postoperative spindle cell nodule of the breast: Pseudosarcomatous myofibroblastic proliferation following endo-surgery

Despite the frequent use of fine-needle aspiration, core biopsy and surgery, postoperative spindle cell nodule (PSCN) is a rare pathological complication that may be diagnostically treacherous. Presented herein is the case of a 52-year-old woman who developed a 7 mm mammary nodular lesion 66 days after removal of an area of columnar cell hyperplasia involving cellular and architectural atypia, performed with the Mammotome Breast Biopsy System. The lesion was highly cellular and composed of intersecting fascicles of plump spindle cells with blunt-ended elongated nuclei and nucleoli easily visible. Interspersed mononuclear cells and hemosiderin-laden macrophages were evident. PSCN is a reactive, benign myofibroblastic proliferation. Differential diagnosis includes benign and malignant spindle cell lesions of the breast. Recognition of this reactive lesion will avoid overdiagnosis of spindle cell malignant tumor. Attention to clinicopathological and histological features should result in accurate recognition of this lesion.

Mammary Myofibroblastoma: A Tumor With a Wide Morphologic Spectrum

Context.—Myofibroblastoma (MFB) of the breast is an unusual benign tumor that belongs to the family of the “benign spindle cell tumors of the mammary stroma.” The name MFB reflects its cellular composition, comprising mainly stromal cells with fibromyofibroblastic and, less frequently, myoid differentiation. Since the original description, the morphologic spectrum of MFB has been expanded by the recognition of several unusual morphologic variants, such as the cellular, infiltrative, epithelioid, deciduoid-like, lipomatous, collagenized/fibrous, and myxoid variants.

Objective.—To review the literature on mammary MFB, discussing the main clinical, radiologic, and pathologic features helpful for diagnosis. Since MFB may show alarming morphologic features, which can lead to a misdiagnosis of malignancy, histologic figures of this tumor, including its more unusual variants, are provided to offer pathologists a practical approach to a correct diagnosis. Histogenesis and pathogenesis of this tumor are also proposed.

Data Sources.—Clinicopathologic data on MFB were extracted from all identified articles through PUB Medline– based research. Histologic figures have been taken from the personal archive of the author.

Conclusions.—The incidence of MFB diagnosis has increased in recent years, likely due to the mammographic screening. Accordingly, this unusual benign tumor may represent a potential diagnostic pitfall, especially when interpreting fine-needle aspiration and/or needle core biopsy. Pathologists should be aware of the wide morphologic spectrum exhibited by MFB to avoid a misdiagnosis of malignancy.

Recent developments in the histological diagnosis of spindle cell carcinoma, fibromatosis and phyllodes tumour of the breast

This article reviews recent advances in the diagnosis of these three unusual tumours of the breast. Spindle cell carcinoma needs to be considered in the differential diagnosis of many mammary spindle cell lesions: it is important to be aware of the wide range of appearances, including the recently described fibromatosis-like variant. Immunohistochemistry using a broad panel of cytokeratin antibodies is needed to exclude spindle cell carcinoma; there is frequent expression of basal cytokeratins and p63. CD34 is often expressed by the stroma of phyllodes tumours, but does not appear to be expressed by spindle cell carcinoma or fibromatosis. Nuclear beta-catenin is found in about 80% of fibromatoses, but can also be seen in spindle cell carcinomas and phyllodes tumours. Two recent studies have described features useful in the distinction of phyllodes tumour and fibroadenoma on core biopsy, including increased cellularity, mitoses and overgrowth of the stroma, adipose tissue in the stroma and fragmentation of the biopsy specimen. Periductal stromal tumour is a recently described biphasic tumour composed of spindle cells around open tubules or ducts (but no leaf-like architecture) with frequent CD34 expression. The overlap of morphology with phyllodes tumour suggests that it may be best regarded as a variant of phyllodes tumour.

Desmoid Tumors (Fibromatoses) of the Breast: A 25-Year Experience

BACKGROUND

Breast desmoid tumors are rare and often clinically mistaken for carcinoma. We reviewed our 25-year institutional experience with breast desmoid tumors.

METHODS

A search of pathology and sarcoma databases (1982-2006) identified 32 patients with pathologically confirmed breast desmoids. Records were retrospectively reviewed.

RESULTS

Median presentation age was 45 years (range, 22-76). Eight patients (25%) had prior history of breast cancer and 14 (44%) of breast surgery, with desmoids diagnosed a median of 24 months postoperatively. All presented with physical findings. Mammography visualized the mass in 6/16, ultrasound in 9/9, and magnetic resonance imaging (MRI) in 8/8 patients in whom it was performed. In 15 patients with attempted needle biopsy, fine needle aspiration was inconclusive (9/9 patients), and core biopsy demonstrated a spindle cell lesion (6/7 patients). Treatment was surgical, with median tumor size of 2.5 cm (range, 0.3-15). Eight patients (29%) had recurring tumors at a median 15 months. Patients with recurring tumors were younger (median age: 28 vs. 46 years, p = 0.03). A trend toward more frequent recurrences in patients with positive (5/9 patients) versus negative (3/19 patients) margins (p = 0.07) and larger tumors (p = 0.12) was observed.

CONCLUSIONS

In our series, breast desmoids presented as palpable masses suspicious for carcinoma clinically and radiographically. Therapy remains primarily surgical, and core biopsy aided in operative planning. Recurrences are common, with younger age and possibly positive margin status and larger tumor size associated with increased risk of recurrence. As 5/9 patients with positive and 3/19 patients with negative margins experienced recurrences, clinical judgment should be used prior to extensive and potentially deforming resections.

Fibromatosis (desmoid tumor) of the breast mimicking a case of ipsilateral metachronous breast cancer

Background

Fibromatosis or desmoid tumor of the breast is an extremely rare entity. While it lacks a metastatic potential, it can grow aggressively in a locally infiltrating pattern. The failure to recognize this as a finite entity within the breast can lead to local recurrence after incomplete excision.

Case presentation

We report a case of a 70 year old patient with a remote history of invasive breast cancer (treated twelve years earlier by lumpectomy, axillary lymph node dissection, postoperative radiation therapy, and five years of tamoxifen) who developed fibromatosis within another quadrant of the same breast that clinically, mammographically, and sonographically mimicked that of the development of an ipsilateral metachronous breast cancer. After the initial diagnosis of fibromatosis was made on a minimally invasive ultrasound guided biopsy, it was successfully treated by wide local excision.

Conclusion

After appropriate recognition, wide local excision can be the appropriate surgical management strategy for fibromatosis of the breast.

Management of a patient with multiple recurrences of fibromatosis (desmoid tumor) of the breast involving the chest wall musculature

Background

Fibromatosis or desmoid tumor is a rare soft tissue tumor that lacks a metastatic potential, but is characterized by a locally aggressive and infiltrating growth pattern and a high propensity toward local recurrence if incompletely excised.

Case presentation

We report a patient with three post-surgical recurrences of fibromatosis of the breast over a seven year period. The fibromatosis was found to be involving the chest wall musculature and causing persistent and worsening pain. An aggressive operative strategy was undertaken, consisting of mastectomy with en bloc resection of the underlying chest wall musculature, ribs, and parietal pleura.

Conclusion

Aggressive surgical management of fibromatosis of the breast with suspected chest wall involvement is appropriate to attempt to obtain a long-term durable cure.

Steroid hormone receptor expression in nasopharyngeal angiofibromas. Consistent expression of estrogen receptor beta

Nasopharyngeal angiofibroma is an uncommon tumor arising in adolescent males, suggesting that the tumor may be hormonally responsive. Previous studies have found androgen receptor (AR) expression but variable expression of estrogen receptor (ER). The recently described ss receptor for estrogen has not been analyzed in angiofibroma. We analyzed 13 cases of nasal angiofibroma by immunohistochemical analysis for the presence of ARs, progesterone receptors (PR), and ER-a and ER-ss. All 13 cases were positive for ER-ss, in stromal pericytic and endothelial cells, and 12 of 13 stained strongly. Five cases were positive for AR in stromal cells, most staining weakly, and with no staining in endothelial or pericytic cells. None of the cases displayed staining for ER-a or PR. The findings confirm that nasopharyngeal angiofibromas express ER and suggest that new modulators of ER-ss activity may provide an alternative therapy for these lesions.

Fibromatosis of the breast: case report and current concepts in the management of an uncommon lesion

Fibromatosis is an uncommon breast lesion that can mimic breast carcinoma in its clinical presentation. We present a case in which excisional biopsy was necessary to establish a diagnosis of fibromatosis. Clinical, diagnostic imaging, and pathologic features are discussed. Magnetic resonance imaging (MRI) has emerged as a tool for further characterization of breast lesions and as a screening modality in high-risk patient populations. Ours marks the second case in which dynamic MRI has been correlated with histologically confirmed primary mammary fibromatosis. Unlike the previous report, MRI in this case mimics breast carcinoma in its morphologic and pharmacokinetic features of enhancement. Wide local excision with clear margins remains the treatment of choice. Current data on radiotherapy and pharmacologic therapy for mammary fibromatosis are reviewed.

Estrogen receptor-β expression in extraabdominal fibromatoses

BACKGROUND

Early experiments using ligand-binding assays demonstrated the presence of estrogen receptor (ER) in fibromatoses. These findings were not confirmed by later studies using immunohistochemical analysis.

METHODS

To verify the expression of ERs in fibromatosis as well as to clarify the inconsistency between radioligand and early immunohistochemical studies, the authors examined a series of 40 extraabdominal fibromatoses using antibodies raised against ERbeta.

RESULTS

All 40 cases of extraabdominal fibromatosis were at least focally positive for ERbeta. Thirty-three of 40 (83%) displayed 3+ (>50%) expression, 5 of 40 (12%) were 2+ (11-50%), and 2 of 40 (5%) cases showed 1+ (<10%) expression. All cases were negative for ERalpha.

CONCLUSIONS

Although extraabdominal fibromatosis does not express ERalpha, there appears to be nearly uniform expression of ERbeta. This finding clarifies discrepancies in the literature regarding estrogen expression in fibromatosis, and provides a biological mechanism for the action of antiestrogenic compounds in the treatment of fibromatosis. Estrogen antagonists may have a role in the treatment of refractory or recurrent extraabdominal fibromatoses.

Inflammatory myofibroblastic tumor of the breast

Three patients developed firm, mobile, nontender masses in their breasts. Two were discovered by the patients and one after mammography. Macroscopically, the nodules were firm, circumscribed, yellow on cut sections, and composed of interlacing cytologically bland spindle cells admixed with chronic inflammatory cells, the latter predominantly of lymphocytes and plasma cells. Immunohistochemistry yielded strong smooth-muscle actin reactivity within the spindle cells; 2 lesions were negative for pankeratin, 1 was focally and weakly positive. No lesions were positive for anaplastic lymphoma kinase-1, desmin, S-100, CD34, CD21, or CD35. In each case, a diagnosis of inflammatory myofibroblastic tumor was made (aka, inflammatory pseudotumor). After conservative excision with apparently negative margins, there have been no recurrences, except in one patient who developed a recurrence after 3 months. The latter recurrence was managed successfully with a second excision. We report these patients to emphasize the diagnostic features of inflammatory myofibroblastic tumor of the breast and discuss how they can be distinguished from other spindle-cell breast lesions with which they can be confused, especially spindle-cell carcinoma.

Fibromatosis: The Breast Cancer Imitator

Fibromatosis of the breast is a rare benign tumor that should be included in the differential diagnosis for breast cancer. It is usually indistinguishable from malignancy on ultrasound, mammography, physical examination, and on gross evaluation. Distinction is easily made by histologic findings. This benign tumor does not metastasize, but is locally aggressive and tends to recur postoperatively, which accounts for considerable morbidity. We present two cases and a discussion from the perspective of the radiologist, the surgeon, and the pathologist.

Benign and malignant spindle cell lesions of the breast

Spindle cell lesions of the breast constitute a wide spectrum of benign and malignant proliferations. Myofibroblasts, normal cellular constituents of the mammary intra- and interlobular stroma, compose many of these lesions, which include reactive proliferations and benign or locally aggressive neoplasms. Because of its morphology, low-grade metaplastic spindle cell carcinoma, "fibromatosis-like" is also considered together with spindle cell lesions of the breast. Although certain of the lesions do not occur commonly, they represent diagnostic challenges. This review outlines the morphology of certain spindle cell lesions of the breast including pseudoangiomatous stromal hyperplasia, reactive spindle cell nodule, nodular fasciitis, myofibroblastoma, primary mammary fibromatosis, and low-grade metaplastic spindle cell carcinoma, "fibromatosis-like." The differential diagnosis and diagnostic work-up of these lesions is discussed, and their clinical treatment and prognosis briefly summarized.

Primary fibromatosis of the breast in a patient with multiple desmoid tumors--report of a case with evaluation of estrogen and progesterone receptors

Fibromatosis (or desmoid tumor) is an infiltrative fibroblastic/myofibroblastic lesion presenting a moderate risk for local recurrence and no metastatic potential. Classically, these lesions are classified whether in abdominal or extra-abdominal sites, and may be multicentric or familial. Primary fibromatosis of the breast (PFB) is an uncommon lesion that shows histological similarities with abdominal fibromatosis (AF), and frequently poses difficulties in the differential diagnosis with other spindle cell tumors of the breast. It has been demonstrated that AF usually shows immunoreactivity for estrogen (ER) and progesterone (PR) receptors; conversely, in most of the studies, the cells from PFB are consistently negative for both receptors. We report on a case of a 41-year-old female with two desmoid tumors, affecting the abdominal wall and the breast tissue. To the best of our knowledge, there is no previous report in which hormonal receptors were evaluated in abdominal and mammary desmoid tumors in the same patient. We assessed the immunohistochemical expression of ER and PR in both lesions; while the AF showed immunoreactivity for both receptors, the cells from PFB were all negative. Although we have considered just this case, we still believe that these findings could support a distinctive etiopathogenesis of abdominal and mammary fibromatosis.

Benign spindle cell tumors of the mammary stroma: diagnostic criteria, classification, and histogenesis

Purely benign mesenchymal spindle cell neoplasms of the breast are currently labeled under various terms in the literature (benign spindle cell tumor, fibroma, spindle cell lipoma, myofibroblastoma, solitary fibrous tumor, myogenic stromal tumor). The lack of strict diagnostic criteria to clearly indicate such mesenchymal neoplasms is the main reason which generated the risk of terming the same lesion under different names or, conversely, of collecting different types under the same term. Although such neoplasms exhibit morphological and immunophenotypical heterogeneity, they actually represent variations of the same tumor entity, likely arising from the uncommitted vimentin+/CD34+ fibroblasts of the mammary stroma, capable of multidirectional mesenchymal differentiation. To cover the entire spectrum of such lesions, the term "benign spindle cell tumors (BSCTs) of the mammary stroma" is advocated. BSCTs can be subtyped into four main groups by light microscopy (LM) and immunocytochemistry (ICC): fibroblastic, myofibroblastic, fibrohistiocytic, and mixed forms. A simple and practical approach to a nosologically correct diagnosis and a list of differential diagnoses are presented. The awareness of the diversity of morphological and immunophenotypical features of BSCTs of the mammary stroma, including uncommon variants, is helpful to avoid confusion with other monomorphic bland-looking benign and malignant spindle cell tumors and tumor-like lesions of the breast.

Fibromatosis of the breast and mutations involving the APC/beta-catenin pathway

Fibromatoses of the breast are nonmetastasizing tumors, but can be infiltrative and locally recurrent. Breast fibromatoses are rare, and their specific genetic alterations have not been elucidated. However, their occasional occurrence in patients with familial adenomatous polyposis (FAP) and their morphologic identification with other deep fibromatoses (desmoid tumors) suggest that alterations of the APC/beta-catenin pathway might be involved in the pathogenesis of sporadic and FAP-associated breast fibromatoses. We analyzed somatic beta-catenin and APC gene mutations in 33 breast fibromatoses (32 sporadic and 1 FAP-associated) using immunohistochemistry for beta-catenin, 5q allelic loss assays, and direct DNA sequencing for exon 3 of the beta-catenin gene and the mutation cluster region of the APC gene. Nuclear accumulation of beta-catenin was present in the stromal tumor cells in most (82%) cases but not in normal stroma or mammary epithelial cells. Somatic alterations of the APC/beta-catenin pathway were detected in 79% of breast fibromatoses, including activating beta-catenin gene mutations in 15 cases and somatic APC alterations (mutation or 5q allelic loss or both) in 11. These findings indicate that alterations of the APC/beta-catenin pathway with resultant nuclear translocation of beta-catenin are important in the pathogenesis of both sporadic and FAP-associated breast fibromatosis. The spectrum of beta-catenin and APC alterations is similar to that described for desmoid tumors of the abdomen, paraspinal region, and extremities.

[Primary fibromatosis of the breast]

Primary fibromatosis of the breast is a very rare pathology which looks like a malignant tumor, clinically and radiologically. Fibromatosis of the breast is characterised by a local invasion and a risk of recurrence. Positive diagnosis is provided by histology and its treatment is surgical. The aim of this study was to report one case and to emphasize the difficulties encountered in the diagnosis and the treatment.