Breast spindle cell tumours: about eight cases

Intraparenchymal breast leiomyoma and atypical leiomyoma

Background

Breast leiomyoma is a rare benign mesenchymal tumor, accounting for less than 1% of all breast neoplasms. Cases of breast atypical leiomyoma is even more rarely reported and its diagnostic criteria together with its clinical courses is not cleared defined.

Case presentation

We described two patients with breast leiomyomas. One has unilateral benign breast leiomyoma, the other one has bilateral breast leiomyomas. For the bilateral case, the left-side tumor was diagnosed as benign leiomyoma while the right-side tumor was diagnosed as atypical leiomyoma. The morphological features that lead to the diagnosis of atypical leiomyoma are its invasive growth pattern, mild nuclear atypia, and mitotic figures up to 3mitoses/10HPF.

Conclusions

Atypical breast leiomyoma appears to behave like benign leiomyoma without recurrence in our study with nine-year follow-up. Due to the limited experience, cases presented as atypical intraparenchymal breast leiomyoma should be closely followed.

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.

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.

Rare variant of metaplastic carcinoma of the breast: a case report and review of the literature

Background

Metaplastic carcinoma encompasses a group of neoplasms characterized by differentiation of the neoplastic epithelium into squamous cells and/or mesenchymal-looking elements. Spindle cell carcinoma is a rare variant of this special histological type. Its prognosis remains poor, with a high rate of local recurrence and distant metastasis. To date, only a small number of cases have been described. There is no clear agreement on this histological subtype.

Case presentation

We report a case of a 53-year-old Moroccan woman who consulted our institution following palpation of a nodule of the left breast. Mammography in combination with breast ultrasonography revealed a lesion classified as Breast Imaging Reporting and Data System 4 with microcalcification. The patient was diagnosed with spindle cell carcinoma of the breast. The diagnosis was based primarily on histological and immunohistochemical studies of the breast biopsy and secondarily on the surgical specimen. No local or distant metastasis was found. The treatment used was total surgical excision followed by radiotherapy.

Conclusions

We describe the features (epidemiological, clinical, histological, immunohistochemical, and therapeutic outcomes) of our patient’s case and compare them with literature data.

Malignant Myoepithelioma of the Breast Clinically and Histologically Masquerading as Angiosarcoma: Cytological Findings and Review of the Literature

BACKGROUND

Malignant myoepithelioma of the breast is an exceptionally rare, aggressive tumor with a diverse morphology, the cytological features of which have only occasionally been described.

CASE REPORT

Our case comprises a 74-year-old woman who was admitted to our hospital with an erythematous, inflammatory-like mass of her left breast with nipple ulceration, and clinically fixed to the chest wall. The woman underwent fine-needle aspiration and biopsy. The aspirates consisted mainly of loose aggregates of large, highly pleomorphic, polygonal epithelioid cells as well as aggregates of spindle cells with prominent, easily detectable mitoses and single, multinucleated pleomorphic giant cells. The cytological diagnosis was consistent with high-grade malignancy. Histologically, the lesion consisted broadly of eosinophilic epithelioid cells with globoid cytoplasm in a reticulated, angiomatoid pattern and of spindle (sarcomatoid) cells in a storiform pattern, highly suspicious of angiosarcoma. A final diagnosis of malignant myoepithelioma was made.

CONCLUSION

We present the cytological findings in comparison with the unusual histological features of a malignant myoepithelioma of the breast. A high degree of suspicion with a keen eye for morphological details coupled with relevant immunohistochemistry will aid in arriving at the correct diagnosis.

Cavernous Hemangioma in the Breast

Although the observation of breast vascular tumors is rare, the most common tumor is hemangıoma in the benign group, and these tumors are observed incidentally in lumpectomy or mastectomy specimens during histological examinations. They are classified into capillary, cavernous, and venous hemangıomas. Cavernous hemangıoma is the most common subtype. Cavernous hemangıomas are benign vascular tumors, which malformatıon from mature blood vessels. Hemangıomas ın the benıgn group may show a suspicion of ductal carcinoma in situ (DCIS) in mammographic analysis. Ultrasonography (US) and magnetic resonance ımagıng (MRI) are the most useful imaging methods for analyzing the structure of breast vessels. In this case, a 54-year-old female who have any complaint. Scanning mammography (MG) detected the tumor, but physıcal examınatıon and US could not identify the mass. According to the MG analysis, the lesion was evaluated as BIRADS 4b, and the patient underwent excisional biopsy after wire localization. Pathological analysis revealed cavernous hemangıoma.

Rare breast malignancies and review of literature: A single centres experience

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Lymphoma of the breast is best managed with chemotherapy rather than surgery.

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Supradiaphragmatic metastases of ovarian cancer to breast can significantly alter prognosis.

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Osteosarcoma requires total excision with adequate margins in order to determine tumour size which is a valuable prognostic factor for survival.

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Immunohistochemistry is helpful to distinguish metaplastic carcinoma which are aggressive and are associated with poor outcomes.

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Adenoid cystic carcinoma of the breast are associated with favourable prognosis that only require surgery.

Introduction

Breast cancer is a heterogeneous condition, with variants which are less common but still very well defined by the World Health Organization (WHO) classification. With the small number of cases each year large trials are difficult to perform. This series aims to discuss the rare breast malignancies encountered within a breast department and the evidence based approached to their management.

Method

Literature search of electronic databases via PubMed and the search engines Google/Google Scholar were used. Emphasis on keywords: breast cancer and the type of histology used to limit search. Searches were screened and those articles suitable had full text versions retrieved. The references to all retrieved texts were searched for further relevant studies.

Conclusion

Due to the rarity of some of these breast cancers, systematic evaluation of patient with detailed histopathology will aid accurate diagnosis and management. The series hopes to add the existing understanding of this small percentage of cases.

Multinucleate Giant Cells in FNAC of Benign Breast Lesions: Its Significance

BACKGROUND

Multinucleate giant cells are described in breast aspirates. However, due to its rarity very few cases have been described cytologically. Hence recognition and correct interpretation of their presence is difficult, yet crucial for accurate diagnosis.

MATERIALS AND METHODS

The prospective study of FNAC (fine needle aspirate cytology) of breast lumps was conducted for a period of six months. Direct smears were prepared from the material aspirated. In case of fluid aspirates, centrifuge done and cell sediment was used for making smears. Smears were alcohol fixed and stained with PAP/H&E or air dried smears were stained with Leishman stain. Further smears were subjected to immunocytochemistry using vimentin and CD34 markers to know the origin of multinucleate giant cells.

RESULTS

We have reported 11 cases of breast lesions, which showed multinucleate giant cells on FNAC. Out of the 11 cases, Cytologically six cases showed granuloma debris with relative proportion of epithelioid histiocytes, lymphocytes, neutrophils and multinucleate giant cells. Two cases were diagnosed as acute suppurative granulomatous mastitis. Two cases of fibroadenoma and one case of fat necrosis showed multinucleate giant cells. Immunocytochemistry showed vimentin positivity in both stromal and histiocytic type of multinucleate giant cells and in isolated histiocytes. CD34 was focally positive in histiocytic type of giant cells.

CONCLUSION

An effort is made to distinguish between the stromal and histiocytic type giant cells in non-neoplastic breast lesions. Further molecular studies have to be done to know the exact histogenesis and role of these multinucleate giant cells in benign lesions.

Intranodal palisaded myofibroblastoma: a review of the literature

Intranodal palisaded myofibroblastoma is a rare benign primary mesenchymal neoplasm originating from differentiated smooth muscle cells and myofibroblasts. The precise etiology and pathogenesis has not been adequately explained as yet. Very few series and cases have been reported in the literature. Though inguinal region is the commonest site of this rare tumor, but the tumor at other diverse sites have been reported. Because of its rarity, it can be often misdiagnosed and confused with other disorders and more commonly with metastasis. We report an extensive review of literature about intranodal palisaded myofibroblastoma--its characteristics, presentations, features, and management.

Indeterminate and erroneous fine-needle aspirates of breast with focus on the 'true gray zone': a review

OBJECTIVE

To review our experience and the literature on inconclusive/erroneous fine-needle aspirates (FNAs) of breast with the focus on the 'true gray zone'. To describe the cytology, differential diagnosis, pitfalls and limitations of common and rare lesions.

STUDY DESIGN

We conducted a literature search focusing on breast FNAs with statistical data of C3 and C4 categories including false-positive and false-negative cases. Similar data from 2003 to 2009 was obtained from our institution.

RESULTS

C3 and C4 categories account for 3-17% of breast FNAs. Contributing factors are technical difficulties, inexperienced pathologists interpreting FNAs of breast and overlap of cytologic features of certain benign and malignant conditions; this last, 'true gray zone' accounts for 2% of cases. Fibroadenoma, proliferative breast lesions, gynecomastia, infiltrating and in situ low-grade adenocarcinomas and tubular, cribriform, lobular and mucinous carcinomas are the most common problematic lesions. Granular cell tumor, adenomyoepithelioma, pregnancy-related lesions, fat necrosis, inflammatory and radiation changes, adenoid cystic carcinoma, spindle-cell lesions and Phyllodes tumor are less common.

CONCLUSION

Inconclusive/erroneous FNAs of breast due to the 'true gray zone' are rare. Most are due to the overlapping cytologic features of some benign and malignant conditions. Practical features that may help arrive at the correct diagnoses are elucidated.

Myoepithelioma breast: clinically masquerading as breast carcinoma

Pure myoepithelioma of breast is an extremely rare tumor. Only a few cases have been reported in the literature so far. A 30-year old female presented with a large fungating mass arising from the areolar region of her right breast of six months duration. A clinical diagnosis of breast carcinoma was made and a mastectomy was performed. The specimen measured 23×22×9 cm with attached skin, and showed a large white ulcerated growth with areas of necrosis and hemorrhage. No normal breast tissue, nipple or areolar region was seen. Histopathological examination showed oval to spindle cells arranged in fascicles and bundles with whorling pattern in places showing mild pleomorphism with oval to spindle-shaped vesicular nuclei, prominent eosinophilic nucleoli, eosinophilic cytoplasm and clear cell changes in places, along with perivascular hyalinization and collagenization. Differential diagnosis of pleomorphic hyalinizing angiectatic tumor, solitary fibrous tumor, perivascular epithelioid cell tumor, mammary type myofibroblastic tumor and myoepithelioma were all considered. Immunohistochemistry for vimentin, smooth muscle actin, calponin, caldesmon, p63, epithelial membrane antigen, S-100, CD-31, CD-34, muscle specific antigen, myogenin, desmin, and pancytokeratin was carried out. On the basis of positive staining for vimentin, actin, p63 (nuclear), calponin and caldesmon (focal), a final diagnosis of myoepithelioma was considered; however, cytokeratin negativity was an unusual finding. This case was considered worthy of documentation because of its rarity, and because it highlights the importance of proper clinical examination and radiological examination to prevent misdiagnosis.

Breast fibromatosis response to tamoxifen: dynamic MRI findings and review of the current treatment options

Breast fibromatosis is a rare entity responsible for 0.2% of all solid breast tumors. It has been associated with scars, pregnancy, implants, and familial adenomatous polyposis. We present an interesting case of breast fibromatosis in a 29 year old woman which encroached upon her saline implant and subsequently filled its cavity once the implant was removed. The patient was put on tamoxifen therapy and at 14 month follow-up there was a significant decrease in the size of the mass. Dynamic MRI images are offered for review and current treatment options are discussed.

Intranodal palisaded myofibroblastoma originating from retroperitoneum: an unusual origin

Background

Intranodal palisaded myofibroblastoma is one of the primary mesenchymal tumours. The inguinal region is the commonest site of this rare tumour. As there are only about 55 such cases reported in the literature, the precise aetiology and pathogenesis have yet to be explained adequately. Here we report a case of a 72 year old man presented with incidental finding of intranodal palisaded myofibroblastoma in the retroperitoneal region.

Case Presentation

A 72-year old man presented with abdominal pain in right upper quadrant with an incidental finding of abdominal mass in the right flank. The computerised tomogram scan of abdomen confirmed acute cholecystitis with a 5 x 5 cm retroperitoneal mass. He underwent cholecystectomy with excision of this mass. He recovered well following his operation and was discharged from the hospital. Histological examination confirmed the diagnosis of intranodal palisaded myofibroblastoma.

Conclusion

To our knowledge, this is the first case of intranodal palisaded myofibroblastoma originating from retroperitoneum. Along with the rarity of this case, we also discussed its typical histopathological findings, aetiology and pathogenesis.

Primary stromal sarcoma of breast with malignant fibrous histiocytoma-like features causing diagnostic dilemma on fine-needle aspiration cytology in a patient with squamous cell carcinoma of cervix: a case report

A variety of malignant spindle-cell tumors are known to occur in the breast, which are collectively referred to as "breast spindle-cell tumors." Their interpretation on fine-needle aspiration cytology (FNAC) can be highly tricky. Here, we report a case. A 47-year-old female presented with a hard, mobile lump in the right breast for 4 months. Five years previous to this, she was treated with radiotherapy for squamous-cell carcinoma (SCC) of cervix. FNA of the breast lump showed high-cell yield with clusters, fascicles, and dissociated cells displaying spindle-cell morphology, with marked pleomorphism, many bizarre uninucleate/multinucleate giant cells, and a striking mitotic activity. At places, the cells in a necrotic background simulated keratinized squamous cells. Considering the past history of SCC of cervix, the first possibility of metastatic SCC with a differential diagnosis of metaplastic carcinoma, malignant phylloides, and a primary sarcoma of the breast was considered. Subsequent trucut/excision biopsy with appropriate immunomarkers revealed it to be a case of primary stromal sarcoma of the breast with malignant fibrous histiocytoma (MFH)-like features. Malignant spindle-cell tumor of breast in a patient with SCC of cervix (which also has a tendency to manifest with spindle cell morphology) can cause genuine diagnostic difficulty. In such patients, use of appropriate panel of markers is mandatory for distinguishing between the metastatic SCC from cervix and other more commonly occurring spindle-cell malignancies of the breast.

Intranodal palisaded myofibroblastoma (intranodal hemorrhagic spindle cell tumor with amianthoid fibers): a case report and literature review

Intranodal palisaded myofibroblastoma (IPM) is a benign mesenchymal neoplasm originating from smooth muscle cells and myofibroblasts. It is characterized by spindle cells, amianthoid fibers, and by the proliferation of hemosiderin-containing histiocytes in the lymph node. A nodular lesion was excised from the inguinal region of an 80-year-old male patient. Macroscopic examination of a section of the lesion demonstrated a solid appearance with hemorrhagic areas. Microscopic examination revealed spindle cell proliferation, amianthoid fibers, hemosiderin pigment, and extravasated erythrocytes. Nuclei of the spindle cells displayed a palisaded appearance. Compressed lymphoid tissue was observed around the lesion. With Masson's trichrome, spindle cells stained as smooth muscle, whereas collagen staining was observed in homogeneous eosinophilic accumulations. Neoplastic cells were identified by the presence of vimentin and SMA. The Ki67 index was less than 1%. In light of these results, the case was diagnosed as "intranodal palisaded myofibroblastoma." IPM is an uncommon neoplasm originating from the stromal component of the lymph node. Although IPM is benign, it is frequently confused with metastatic lesions.

Benign spindle cell tumor not otherwise specified (NOS) in a male breast

Breast spindle cell tumors (BSCTs), although uncommon, constitute a heterogeneous group of benign and malignant lesions, often necessitating different therapeutic approaches. This study describes the case of a 62-year-old man who displayed a gradually growing retroareolar tumor of the left breast. The mass was well circumscribed, unilateral, and grossly nodular. The patient eventually underwent wide local excision of the mass. The lesion was made up of spindle cells arranged in fascicular clusters, separated by bands of collagen. No mitotic figures were observed. Immunohistochemically, the mass expressed strong and diffuse cytoplasmic staining for vimentin, CD34, CD10, and bcl-2, whereas it was negative for cytokeratins, smooth muscle actin, desmin, S-100 protein, p53, Ki-67, estrogen and progesterone receptors. Diverse histological results and immunohistochemical features established the diagnosis of benign BSCT, not otherwise specified. The patient remains disease-free 12 months after lumpectomy. This case report adds to the spectrum of the benign BSCTs and delineates the nature of different types of these lesions, in order to carefully select optimal therapeutic regimes.

A diagnostic dilemma in breast pathology--benign fibroadenoma with multinucleated stromal giant cells

Fibroadenomas are common benign breast tumours that display a characteristic pathological morphology, although several epithelial and stromal variations exist. A very rare histological finding is the presence of multinucleated giant cells throughout the stroma of a benign fibroadenoma. Cells of this type, which are more commonly found incidentally within the interlobular stroma of breast tissue, are benign and should not be mistaken for malignant cells on microscopic examination. Unfortunately a lack of awareness of this pathological entity can lead to diagnostic confusion amongst pathologists resulting in the multinucleate giant cells being mistaken for highly mitotic cells and consequently the fibroadenoma being mistaken for a malignant lesion. This may have serious implications for the subsequent management of the patient. The presence of this unusual cell type in the stroma does not alter the prognosis of otherwise benign lesion. We encountered two such cases at our institution in a six month period recently. We present their histories along with relevant radiological, microscopic and immunohistochemical features, followed by a discussion of this unusual pathological entity.

Primary leiomyosarcoma of the nipple-areola complex: report of a case and review of literature

Primary leiomyosarcoma of the nipple-areola complex is extremely rare. Less than ten such cases have been reported in English literature so far. Herein we describe a 52-year-old female presenting with a 1.5 cmx1.1 cmx0.7 cm nodular lesion over her left nipple, and leiomyosarcoma was proved by pathological examination of the excised specimen. Positron emitted tomogram (PET) revealed no abnormal signal other than the primary site. Microscopically, this poorly circumscribed tumor was composed of interlacing bundles of smooth muscle cells with bizarre and pleomorphic nuclei, as well as prominent nucleoli. Its mitotic count was up to 7 mitoses per 10 high power fields (HPF). Immunohistochemical study of tumor cells revealed positive stain for alpha-smooth muscle actin and vimentin; and negative for cytokeratin, CD34 and S-100. Left simple mastectomy was undertaken and no residual mass lesion was noted on the resected specimen. Related literatures about the diagnosis and treatment for breast leiomyosarcoma will be presented here.