Desmoid tumor occurring after reconstruction mammaplasty for breast carcinoma

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.

Low to Intermediate (Borderline) Grade Breast Spindle Cell Lesions on Needle Biopsy: Diagnostic Approach and Clinical Management

Spindle cell proliferations of the breast are a heterogeneous group of lesions ranging from benign or reactive lesions to aggressive malignant neoplasms. Diagnosis on core biopsy can be particularly challenging as lesions displaying different lineages associated with variable outcomes share overlapping morphologies (scar vs. fibromatosis-like metaplastic carcinoma) whereas individual entities can exhibit a large variety of appearances (myofibroblastoma). In this review, lesions are grouped into lineage, when possible, including those showing fibroblastic/myofibroblastic differentiation, ranging from entities that require no additional management, such as scar and nodular fasciitis, to those with unpredictable clinical outcomes such as fibromatosis and solitary fibrous tumor or locally aggressive behavior such as dermatofibrosarcoma protuberans. The review of low-grade vascular lesions includes atypical vascular lesion and low-grade angiosarcoma. Also discussed are various adipocytic lesions ranging from lipoma to liposarcoma, and rare smooth muscle and neural entities more commonly encountered in locations outside the breast, such as leiomyoma, neurofibroma, schwannoma, or granular cell tumor. Optimal histological evaluation of these entities merges clinical and radiologic data with morphology and ancillary testing. We present our approach to immunohistochemical and other ancillary testing and highlight issues in pathology correlation with imaging. Recent updates in the management of breast spindle cell lesions are addressed. In a well-sampled lesion with radiographic concordance, the core biopsy diagnosis reliably guides management and we advocate the inclusion of management recommendations in the pathology report. Precise characterization using up to date guidelines is important to identify a subset of patients who may safely avoid unnecessary surgical procedures. A multidisciplinary approach with close collaboration with our clinical colleagues is emphasized.

Recurrent desmoid tumor arising from latissimus dorsi flap: A case report

Fibromatosis or desmoid tumor in the breast is a very rare benign soft tissue tumor. We report a case of recurrent desmoid tumor arising from latissimus dorsi flap after lumpectomy for breast carcinoma. To our knowledge, this is the first case of desmoid tumor arising from the latissimus dorsi flap. Despite its benignity, desmoid tumor is often locally aggressive, therefore timely diagnosis and proper management are very important. Imaging and pathological diagnosis as well as treatment management are discussed. High clinical suspicion and multidisciplinary approach are essential for prompt diagnosis and management. Wide surgical resection is required, but there is no consensus regarding treatment due to limited data.

Aggressive breast fibromatosis following augmentation mastoplasty: a series of case reports

Aggressive fibromatosis comprises connective tissue tumours that represent 0.03% of all bodily neoplasms, occurring more often in the abdominal wall, mesentery, and extremities; its location in the breast constitutes a very infrequent type of lesion. Its pathogenesis is diverse and its relationship with augmentation mastoplasty is still unclear. Four cases of aggressive breast fibromatosis following augmentation mastoplasty are reported in this article.

Desmoid Tumor and Silicone Breast Implant Surgery: Is There Really a Connection? A Literature Review

BACKGROUND

Desmoid tumors are borderline tumors of the connective tissue, arising in the musculo-aponeurotic stromal elements. A desmoid tumor (DT) has an infiltrative and locally aggressive growth pattern and usually does not metastasize; however, it has a high recurrence and complication rate. DT located in the breast (BDT) represents a rare extra-abdominal form. Recently, the presence of breast silicone implants was suggested by several researchers as a risk factor for developing BDT.

OBJECTIVES

The goal of this review is to investigate the possible correlation between BDT and breast implant surgery.

METHODS

We conducted a literature review of BDT-reported cases, associated with breast implant surgery.

RESULTS

The search revealed 36 cases of BDT associated with silicone breast implants.

CONCLUSIONS

Based on the reviewed data, the incidence of BDT following breast implant surgery is lower than BDT in the general population. At the moment, a possible association between breast implants and the development of breast desmoid tumors cannot be unequivocally confirmed. A world registry with accurate documentation of each case of BDT associated with breast implant surgery should be performed for future investigation.

LEVEL OF EVIDENCE II

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Radiologic images of an aggressive implant-associated fibromatosis of the breast and chest wall: case report and review of the literature

Fibromatosis of the breast is a rare benign disease compromising <0.2% of all primary breast tumors. Although the chest wall is a common location, occurrences of implant-associated fibromatosis of the breast are extremely rare; only 33 cases have been reported. We present a case of a 42-year-old female who underwent breast augmentation with silicone breast implants, and 2 years later developed an aggressive implant-associated fibromatosis of the breast and chest wall. On imaging studies, the tumor mimicked breast carcinoma, and despite chemotherapy, the fibromatosis rapidly enlarged and was locally invasive requiring wide surgical excision. Unlike previously reported imaging findings, magnetic resonance imaging revealed an oval circumscribed mass with fringe-like internal architecture. We provide a review of the literature and discuss the imaging features of implant-associated fibromatosis of the breast.

Desmoid tumor following abdominally-based free flap breast reconstruction

Desmoid tumors are fibroblastic connective tissue tumors that most commonly develop within the anterior abdominal wall. The etiology of desmoid tumors has not been well defined; however, hereditary, hormonal, traumatic, and surgery-related causes have been implicated. Desmoid tumors are believed to arise from musculoaponeurotic structures. Development in the breast is very rare. Several reports of desmoid tumors arising in the vicinity of the fibrous capsule of a breast implant have been described, but to date, the authors are not aware of any published cases following autologous breast reconstruction. This report describes a desmoid tumor developing after a muscle-sparing free transverse rectus abdominis musculocutaneous (TRAM) flap for breast reconstruction and subsequent surgical management.

Complex reconstruction of desmoid tumor resections does not increase desmoid tumor recurrence

BACKGROUND

The propensity of desmoid tumors to develop in scars has led some surgeons to limit the complexity of desmoid defect reconstruction as a strategy for avoiding desmoid recurrence. We hypothesized that desmoid recurrence rates are similar despite the magnitude of reconstruction.

STUDY DESIGN

We retrospectively compared recurrence rates between patients who underwent reconstruction and patients who underwent primary closure without reconstruction after desmoid tumor resection in consecutive patients for 15 years. Univariate and multivariate regression analyzed associations between patient, tumor, and treatment characteristics and outcomes.

RESULTS

We included 164 consecutive patients (80 [49%] reconstructions vs 84 [51%] primary closures). Mean follow-up duration was 7.1 ± 4.5 years. Patients who underwent reconstruction had more desmoids in an area of earlier trauma or surgery (p < 0.001), greater defect volume (p < 0.01), longer operative time (p < 0.001) and hospital stay (p < 0.001), and more postoperative complications (p = 0.015) compared with the primary closure group. Despite these differences, desmoid recurrence rates were similar for the reconstruction and primary closure groups (30% and 29%, respectively; p = 0.7), as was mean time to tumor recurrence, and no tumors recurred within flap donor sites. Multivariate regression analysis demonstrated the 45F mutation to be the only independent predictor of recurrence (hazard ratio = 1.87; p = 0.04).

CONCLUSIONS

Rates of desmoid recurrence in resection defects are similar for primary closures and complex reconstructions. Therefore, surgeons should not limit the magnitude of reconstructions in an attempt to avoid tumor recurrence. However, given the propensity of desmoids to recur, reconstructions should allow for the possibility of future resections and reconstructions, particularly in tumors with 45F gene mutations.

Spinal fibromatosis: a report of two cases and review of the literature

BACKGROUND CONTEXT

Spinal fibromatosis is a unique subset of fibromatosis that is only anecdotally described in the literature in sporadic case reports. According to our review of the literature, only 11 cases of spinal fibromatosis have been previously documented. This paucity of clinical data limits our understanding of its presentation and treatment.

PURPOSE

The authors present the first two cases of spinal fibromatosis encountered at their institution, and review the literature of reported cases to elucidate the presentation and outcomes of patients with this rare tumor.

STUDY DESIGN

A report of two cases and review of the literature.

METHODS

The two patients in our case report were women aged 45 and 38 years. Both of the patients presented to our clinic after previous excisional biopsy of a spinal mass, 17 years and 1 year later, respectively, with pain and paresthesias that recapitulated their former symptoms. Thirteen cases, including the two described in the current article, were culled from the literature.

RESULTS

Magnetic resonance imaging revealed an enhancing lesion in the posterior elements of the spinal column in the first case and a paraspinal soft tissue mass in the second case. The tumors were histologically defined by haphazardly arranged, elongated, and slender spindle cells separated by abundant collagen without mitoses or necrosis. Surgical management resulted in intralesional resection in the first case and en bloc resection in the second case. By 40 and 10 months after surgery, both patients remain without neurologic deficits.

CONCLUSIONS

Among 13 cases of spinal fibromatosis, pain with or without a mass is the most common symptom at presentation. Tumor etiology is evenly distributed between de novo origin and surgical trauma. Treatment outcomes, although, cannot be determined from the limited data currently available.

Huge intrathoracic desmoid tumor

Desmoid tumors are soft-tissue neoplasms arising from fascial or musculo-aponeurotic structures. Most reported thoracic desmoid tumors originate from the chest wall. However, intrathoracic desmoid tumors are rare. We present a case of a 35-year-old male patient complaining of mild shortness of breath. The patient was diagnosed to have a huge intrathoracic desmoid tumor, which was successfully resected.

Desmoid tumour of the breast

Desmoid tumour of the breast is a rare fibroblastic tumour whose spectrum ranges from being locally inert to aggressive and destructive, and represents 0.2% of all breast tumours. A 22-year-old woman, 2 years post-cosmetic augmentation mammoplasty with silicone implants, presented with a 6-month history of an enlarging mass in her left breast. Ultrasound showed a well-defined, hypoechoic mass arising within the muscles of the anterior chest, deep beneath the implant and not involving the underlying rib. Fine needle aspiration (FNA) showed features in keeping with changes associated with silicone implants. A provisional diagnosis of scarring and fibroblastic proliferation was made. The lesion was excised and the implant, noted to be intact, was exchanged. Immunochemistry showed strong positivity for vimentin and variable positivity for SMA and desmin, and patchy positivity for beta catenin. A final diagnosis of aggressive fibromatosis was made. Although the association of desmoid tumour and breast implants has been described, this case is unique as the FNA was highly suggestive of a silicone granuloma and the diagnosis of desmoid tumour was made on definitive pathology. The aetiology of desmoid tumours is reviewed and current treatment modalities discussed.

The relationship of silicone breast implants and cancer at other sites

BACKGROUND

Although most attention regarding the effects of silicone breast implants on cancer risk has focused on breast cancer, there have also been concerns regarding effects on other cancers. This includes malignancies that could occur as a result of foreign-body carcinogenesis (sarcomas) or immune alterations (hematopoietic malignancies), or cancers suggested as possibly elevated on the basis of previous epidemiologic studies (cancers of the cervix, vulva, lung, and brain).

METHODS

Searches of the English language literature on the topic of silicone breast implants and cancer risk were conducted and reviewed to determine relationships that might have etiologic relevance.

RESULTS

Epidemiologic studies provide no support for an increased risk of either sarcoma or multiple myeloma among breast implant recipients, disputing clinical and laboratory findings suggesting such a link. Although a number of epidemiologic studies have demonstrated elevated risks of cervical, vulvar, and lung cancers among breast implant patients, it is likely that these excesses relate more to lifestyle characteristics (e.g., cigarette smoking, sexual behavior) than to the effects of the implants. Brain cancer excesses, suggested in one study, have not been confirmed in either an update of the mortality experience in this study or on the basis of other investigations.

CONCLUSIONS

At present, there is no convincing evidence that breast implants alter the risk of nonbreast malignancies. Breast implant patients should continue to be monitored for longer term risks and to assess whether cancer risk is influenced by various patient and implant characteristics.

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 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.

Aggressive postoperative lumbar fibromatosis after the placement of instrumentation for treatment of spondylolisthesis

✓ This 50-year-old woman presented with a paravertebral lumbar fibromatosis (desmoid tumor) after undergoing the placement of instrumentation for lumbar spondylolisthesis. The tumor developed just cranial to the previous skin incision. Fibromatoses, or desmoid tumors, are uncommon infiltrative lesions that affect musculoaponeurotic structures, most often of the trunk and limbs. They are known to occur in association with surgery-related scars or implants and only rare examples appear in the neurosurgical and spine-related literature. In cases involving well-defined tumors in which radical resection is possible, surgery is the treatment of choice; however, the recurrence rate is high. The patient in the present case was followed for 14 months postoperatively and did not undergo radiotherapy; there was no recurrence.

Although rare, this distinctive tumor should be considered in the differential diagnosis of postoperative paravertebral bulgings after neurosurgical and spinal operations.

Desmoid Tumor: A Case of Mistaken Identity

Desmoid tumors are rare tumors accounting for only 0.03% of all neoplasms. Mainly occurring in the fourth and fifth decades of life, these tumors originate in musculoaponeurotic tissues of the limbs, neck, trunk, abdominal wall, and mesentery. We present a rare case of a chest wall desmoid tumor that was mistaken for breast cancer on both physical examination and mammography, which highlights the unique risk these tumors present for confusion with other malignant processes. Although past literature contains numerous reports of other misdiagnoses, this case is unique in reporting the potential for misdiagnosis between chest wall desmoid tumors and breast cancer. In cases where suspicious breast findings do not correlate to usual diagnostic measures, such as fine-needle aspiration or core needle biopsy, the possibility of another pathology such as a chest wall desmoid tumor mimicking breast cancer should be considered in the differential diagnosis.

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.

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.

Aggressive fibromatosis of the breast: a case report and literature review

Aggressive fibromatosis is a rare, locally aggressive disease. It constitutes 0.3% of all solid tumors, but the tumor is rarely seen in the breast, particularly without pectoral muscle and fascial involvement. The etiology is unknown, but an association with Gardner's syndrome has been described. Clinical and imaging findings simulate breast carcinoma. A case in a 53-year-old female patient is reported.

Fibrous Lesions of the Breast: A Review

Fibrous lesions of the breast are challenging for a number of reasons. They occur infrequently and there is significant clinical, radiologic, and histologic overlap between reactive and neoplastic lesions, as well as with some nonfibrous lesions. Pure fibrous lesions of the breast encompass reactive conditions, such as scars and nodular fasciitis, and neoplastic entities, such as the distinct benign mammary myofibroblastoma, locally aggressive fibromatosis, and rare true sarcomas. In this review, we focus on nodular fasciitis, mammary myofibroblastoma, and primary mammary fibromatosis. We also briefly discuss spindle cell metaplastic carcinoma because it represents the most important differential diagnosis through its ability to closely simulate nodular fasciitis and fibromatosis. Caution should be exercised in the interpretation of fibrous lesions of the breast, especially if the tissue sample is limited. Int J Surg Pathol 8(2):99-108, 2000

Development of postoperative fibromatosis after resection of an intraspinal meningioma. Case report

The authors report the case of an adult female patient who developed a paraspinous thoracic fibromatosis (desmoid tumor) after undergoing resection of an intraspinal thoracic meningioma that was complicated by postoperative wound infection. To the best of the authors' knowledge, this is the first report of such a tumor occurring after resection of a spinal meningioma. Awareness of the development of postoperative fibromatosis and recognition of its association with wound sepsis is important. Although rare, this distinctive lesion should be considered in the differential diagnosis of the apparent rapid regrowth of otherwise indolent lesions including meningioma.

Breast implants and cancer

BACKGROUND

Although silicone breast implants have been linked to various short-term complications, less is known about their long-range effects. Most attention has focused on connective tissue disorders, but the range of immunologic disturbances observed in women with implants suggests that consideration also be given to other chronic diseases, including cancer. The greatest attention has focused on breast cancer, given clinical reports suggesting an association and observations that mammographic visualization is deterred by implants. Findings from epidemiologic studies, however, actually suggest that breast cancer risk might be reduced among women with implants, although the biologic mechanism remains undefined. In addition, most studies do not suggest that women with breast implants have more advanced breast cancer at diagnosis or a worse prognosis than those without implants. The majority of studies have focused on women who received implants for cosmetic reasons, with little previous investigation of women who received implants for breast reconstruction following cancer surgery. In terms of other cancers, animal as well as clinical data suggest potential risks of sarcomas and hematologic cancers, including multiple myeloma. The risk of these cancers has not yet been adequately addressed by epidemiologic studies, although several ongoing studies should provide insights. It will be important for studies to consider effects of other lifestyle factors as well as to analyze relationships according to duration of implantation, a demonstrated determinant of implant deterioration. In addition, consideration should be given to type of implant, including implants with polyurethane foam covers, which can leak toluene diamine, a demonstrated carcinogen in animals.