BREASTCASES

ARC 5 , V I PA IRS MEET INGHAMMAMET-TUN IS IA 27 APR IL 2012

S.Mezghani- boussetta ,S.Kechaou*, S.Melliti, M.Gadri, M.Chaabene*

Ben Arous , Ariana*, TUNISIA

ABOUT BREAST STELLATE IMAGES

CASE N°1

CLINICAL FUNDINGS

• A 49-year-old woman• G3, P2• no personal or family risk factors of breast cancer• a skin retraction of the union of lower quadrant of

the right breast• Physical examination: a 5 x 5mm firm nodule in

front to the skin retraction was palped (sub-mammary fold)• No other abnormalities were found (neither

nipple discharge nor axillary adenopathy)

MAMMOGRAPHYMedio-lateral views

Cranio-caudal views)

Lateral views

Spot compression focalized at UQ in CC view of the right breast

ULTRASOUND

CASE N°1

A spiculated dense center mass with skin retraction No calcificationHypoechoic mass with long thick spicules

CASE N°1

• Classification on the BIRADS OF ACR• ACR4 ?• ACR 5?

• Managment?• Surveillance• Cytology• Needle core biopsy• Surgical biopsy

CASE N°2

CLINICAL PRESENTATION

• A single 26 year-old woman with no personal or family risk factors of brest cancer

• Presented with a right paraareolar skin retraction

• Physical examination showed no other abnormalities.

BREAST ULTRASOUND

Irregular ill-defined hypoechoic pre- pectoral mass

BREAST MRI

A spiculated tissular mass associated to an architectural distorsion

T2

T1

T1 gado

BREAST MRI

A slow progressive and continuous increase enhancement

CASE 2

A 26- year-old womanA spiculated tissular mass with architectural distorsion of the right breast infiltrating the pectoral muscle

Right Breast: ACR 5, Left breast ACR 1needle core biopsy guided by ultra-sound

CASE N° 3

CLINICAL PRESENTATION

Healthy 42-year-old manNo history of trauma or prior surgery to the chest wall Presented with self detected right breast mass.Physical examination: a 1 cm hard nodule in union of inner quadrants was palpedNo axillary adenopathy were found

MAMMOGRAPHY AND US

An ill-defined and spiculated margins mass that was markedly hypoechoic with good sonic transmissionRB: ACR 5 ,LB: ACR 1 Cytology / needle core biopsy guided by ultrasound

COMMENTARIES

Patients: woman (2), male (1)Age: 49,26,42 year-oldclinical findings and imaging features

suspicious breast lesions:• firm or hard masses ± skin retraction • stellate masses • no calcification• Architectural distorsion• no adenopathy

STELLATE IMAGESMalignant stellate images• Invasive ductal carcinoma

with fibrosis+++(reactive stroma: fibrosis

and elastosis)• Tubular carcinoma± radial

scar

Benign stellate images (3,6%)*

• False stellate image• Post operative scars• Inflammatory pseudo-tumors• Various types of tumors:• Hyalinized fibroadenoma

with fibrosis• Fibromatosis• Granular cell tumor

• Fibrocystic disease: sclerosing changes, sclerosis adenosis, radial scar+++

72/1978: 3,6%

*

what about the 3 cases that we are presented ?

PATHOLOGY OF MICRO-BIOPSY( PATIENT 1/2/3)

Pathology revealed a fuso-cellular proliferation without nuclear atypia or increased mitotic activity

suggesting

fibromatosis

TREATEMENT

•A wire localization guided by ultrasound was made (Patient 2)

•A wide surgical excision with wide margins was performed (patients 1/2/3), (excision of the pectoral muscle for patient 2)

•Patients (2/3) evolved favorably and respectively 15 and 24 months after with no showed signs of local recurrence

Patient 3 : macroscopy of surgical tumoral excision specimen

HISTOPATHOLOGIC FINDINGS

Immunohistochemistry for smooth muscle actin:

Fusocellular proliferation positive to smooth muscle actin

Immunohistochemistry for vimentin

Fusocellular proliferation positive tovimentin

BREAST FIBROMATOSIS• Breast fibromatosis: desmoid tumors of the

breast• Uncommon benign breast lesion;• 0,2% primary breast tumor;

• A proliferation of fibroblast rich in collagen without atypia with ill-defined borders having stellate extensions in the fatty tissue• Mean age for diagnosis: 35 -50,3 (37) years• occurs predominantly in women, it can rarely

affect the male breast

BREAST FIBROMATOSIS

• The etiology: unknown• Sporadic cases+++• the main risk factor: trauma, after surgical procedures (breast implant)

• Rarely, breast fibromatosis related with FAP,gardner syndrome

• A potential for local infiltration and recurrence, so excision must cover a large area, no metastatic potential

• The clinical and radiologic findings think for carcinoma;• A Firm palpable mass suspicious of malignancy• Adherence to the chest wall, dimpling or skin retraction• irregular shape ,high density, spiculated margins without

calcifications• A solid microlobulated or spiculated mass on ultrasound

hypoechoic with echogenic rim, irregular margin, no posterior acoustic shadowing, a straightening of the cooper ligament

BREAST FIBROMATOSIS

Clinical history

US MAMMOGRAPHY

MRI US GUIDED BIOPSY

CASE 1 Women 49ASelf detected right breast mass with skin retraction

Hypoechogenic mass

Stellate mass with a dense center

0 +

CASE 2 Women 26ARight para areolar skin retraction

Hypoechogenic mass

Focal asymmetric density

Spiculated mass with architectural distorsion and progressive enhancement

+

CASE 3* Men 42ASelf palpated righy breast mass (union of inner quadrants)

Ovoid shaped mass with spiculated margins

Irregularly shaped, high-density mass with spiculated margins

0 +

CASE 4* Women 22ASelf palpated righy breast mass (upper inner quadrant)

Hypoechogenic mass with hyperechoic rim

0 0 +

CASE 5* Women 47ALymphoma of the mediastinumLeft breast lymphangitis

No individualized mass

Focal asymmetric density (upper inner quadrant)

0 +

A table summarizing radio-clinical findings for 5 cases referred at Regional Hospital of Ben Arous and Ariana*

• MRI: to determine with accuracy the boundaries of the tumor and chest wall involvment

• Differential diagnosis on cytology examination: Nodular fasciitis (NF), Scar biopsy site reaction, Metaplastic carcinoma, Fibrosarcoma, Low-grade fibromyxoid sarcoma (LGFS), Smooth muscle tumors (SMTs), Benign neural tumors (BNTs).

• The treatment of choice: a primary surgical excision with wide clear margins (reduce the recurrence rate)

BREAST FIBROMATOSIS

CONCLUSION

• The breast fibromatosis: • an extremely rare benign tumor• Must be added to the differential diagnosis

of breast lesion with clinical and radiological signs of malignancy• Can only be confirmed by histological study• A potential for local infiltration and

recurrence, so excision must cover a large area