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Case report: ossifying fibromatosis of the breast
ClinicalRadiology(1994) 49, 211-212
Case Report: Ossifying Fibromatosis of the Breast M. M. M A Y E R S , P. E V A N S * a n d D. M a c V I C A R
Departments of Radiology and Pathology, Royal Marsden Hospital, Sutton, Surrey We report the first described ease of ossifying fibromatosis of the breast. This condition warrants consideration as a rare differential diagnosis of carcinoma of the breast and dense calcification on mammography. M a y e r s , M . M . , Evans, P. & M a c V i c a r , D. (1994). Clinical Radiology 49, 211-212. Case R e p o r t : Ossifying F i b r o m a t o s i s o f the Breast
CASE REPORT A 70-year-old lady presented with a short history of a hard, nontender lump in her right breast, clinically thought to be a carcinoma. Mammography revealed a 2 cm dense, homogenous area of calcification associated with a surrounding lobulated soft tissue mass (Fig. 1). These appearances were considered indeterminate and the mass was excised
without complications. Fibrofatty tissue 70 • 50 x 35 mm was received, containing a hard calcified mass 30 • 26 x 15 mm. The specimen was decalcified in formic acid for histological examination. This showed the typical changes of fibromatosis, namely moderately cellular bands of mature fibroblastic cells with collagen production and occasional normal mitotic figures. The lesion had an infiltrating margin and extended to the surgical resection edge. An unusual feature was the large central area of ossification (Fig. 2).
DISCUSSION
Fig. 1 - Mammograms showing dense calcification with a surrounding soft tissue mass in the right breast.
Fig. 2 - On the left are bundles of cytologically-benign infiltrating fibroblasts (F). On the right there is bone formation in which osteocyte nuclei can be seen in small lacunae (small arrows) within the dark staining calcified bone matrix (B). Haematoxylin and Eosin (medium power). Correspondence to: D. MacVicar, Department of Radiology, Royal Marsden Hospital, Sutton, Surrey SM2 5PT. * Present address: Department of Radiology, Kingston Hospital, Surrey.
Heavily calcified lesions in the b r e a s t are usually benign. A d e g e n e r a t i n g f i b r o a d e n o m a typically exhibits ' p o p c o r n ' calcification b u t m a y result in large very dense calcifications. F a t necrosis a n d oil cysts ( l i p o d y s t r o p h y m a c r o c y s t i c a calcificans) are associated with calcification which is frequently extensive a n d dense. T r a u m a m a y result in h a e m a t o m a f o r m a t i o n which s u b s e q u e n t l y calcifies a n d calcified soft tissue h a e m a n g i o m a t a are occasionally seen. C a r c i n o m a , s a r c o m a a n d p h y l l o i d e s t u m o u r s m a y calcify a l t h o u g h dense solid calcification is unusual; these c o n d i t i o n s rarely u n d e r g o osseous m e t a p l a s i a [1]. M a m m o g r a p h y is u n a b l e to distinguish true ossification f r o m dense calcification. W h i l e there m a y be clinical a n d r a d i o l o g i c a l features to s u p p o r t a benign aetiology, the presence o f bizarre calcification in a s s o c i a t i o n with a soft tissue mass, as seen in o u r patient, w a r r a n t s surgical intervention. F i b r o m a t o s i s o f the b r e a s t is one o f the g r o u p o f deep fibromatoses. These are proliferative d i s o r d e r s o f fibrous tissue t h a t m a y be locally aggressive b u t d o n o t rnetastasize. Origin in the b r e a s t is rare a n d o n l y two cases were f o u n d in a series o f 1129 benign a n d m a l i g n a n t b r e a s t t u m o u r s [2]. O c c a s i o n a l a s s o c i a t i o n s with genetic diso r d e r s such as G a r d n e r ' s s y n d r o m e or familial multicentric f i b r o m a t o s i s have been r e p o r t e d [3-5]. F e m a l e s within a wide age range are affected, m e a n age in v a r i o u s studies being given as 37, 43 a n d 48.7 y e a r s [6-8]. T h e c o n d i t i o n presents as a h a r d o r firm mass which m a y be discrete o r ill-defined a n d clinically m a y m i m i c c a r c i n o m a . M a m m o g r a p h y is r e p o r t e d as showing an illdefined stellate m a s s w i t h o u t calcification; a suspicion o f m a l i g n a n c y is usually raised [4,7-10]. H i s t o l o g i c a l e x a m ination is essential for diagnosis. M i c r o s c o p i c a l l y , b u n dles o f m a t u r e fibroblasts f o r m an interlacing p a t t e r n with v a r i a b l e a m o u n t s o f collagen. M i t o t i c figures are inconspicuous or absent. I n f l a m m a t o r y cells are n o t usually f o u n d . The b o r d e r is infiltrative a n d m a y ' t r a p ' nerves o r o t h e r structures in the fibrosing process. W h i l e one case o f extensive ossification has been r e p o r t e d in infantile f i b r o m a t o s i s [11], osseous m e t a p l a s i a in a d u l t f i b r o m a t o sis is stated to be rare a n d never a p r o m i n e n t feature [12].
212
CLINICAL RADIOLOGY
T o the authors, knowledge, this is the first reported case of extensive b o n e f o r m a t i o n in fibromatosis o f the breast. Wide local excision is the t r e a t m e n t of choice as the c o n d i t i o n m a y be locally aggressive a n d is associated with a significant rate o f local recurrence. A t surgery, the edge o f the lesion is difficult to appreciate a n d if excision is histologically incomplete, re-excision should be considered even t h o u g h s p o n t a n e o u s regression has been described [8]. I n conclusion, fibromatosis should be considered in the differential diagnosis of m a l i g n a n t neoplasms of the breast. We report the first case of extensive ossification of such a lesion, leading to dense calcification o n m a m m o graphy. The tendency to local aggressiveness a n d recurrence necessitates wide excision of the affected breast. REFERENCES
1 Haagensen CD. Diseases of the breast, 3rd ed. Philadelphia: WB Saunders, 1986:843 850. 2 Cameron CT, Adair FE. The clinical features and diagnosis of the common breast tumours. Medical Journal of Australia 1965;2: 651-654.
3 Zayid I, Dihmis C. Familial mutticentric fibromatosis-desmoids. Cancer 1969;24:786-795. 4 Haggitt RC, Booth JL. Bilateral fibromatosis of the breast in Gardner's Syndrome. Cancer 1970;25:161-166. 5 SimpsonRD, Harrison EG, Mayo CW. Mesenteric fibromatosis in familial polposis: a variant of Gardner's Syndrome. Cancer 1964;17:526 534. 6 Rosen PP, Ernsberger D. Mammary fibromatosis.A benign spindlecelt tumour with significant risk for local recurrence. Cancer 1989;63:1363-1369. 7 Wargotz ES, Norris HJ, Austin RM, Enzinger FM. Fibromatosis of the breast. American Journal of Surgical Pathology 1987;11(1): 38-45. 8 Gump FE, Sternschein MJ, Wolff M. Fibromatosis of the breast. Surgery, Gynecology and Obstetrics 1981;152:57-60. 9 Kalisher L, Long JA, Peyster RG. Extra-abdominal desmoid of the axillary tail mimicking breast carcinoma. American Journal of Roentgenology 1976;126:903 906. 10 Cederlund CG, Gustavsson S, Linell F, Moquist-Olsson I, Anderson I. Fibromatosis of the breast mimicking carcinoma at mammography. British Journal of Radiology 1984;57:98-101. 11 Enzinger FM, Weiss SW. Soft tissue tumours, 2rid ed. St Louis: CV Mosby, 1983:139. 12 Fromowitz FB, Hurst LC, Nathan J, Badalamente P. Infantile (desmoid type) fibromatosis with extensive calcification. American Journal of Surgical Pathology 1987;11(1):66-75.
Case Report: Ossifying Fibromatosis of the Breast M. M. M A Y E R S , P. E V A N S * a n d D. M a c V I C A R
Departments of Radiology and Pathology, Royal Marsden Hospital, Sutton, Surrey We report the first described ease of ossifying fibromatosis of the breast. This condition warrants consideration as a rare differential diagnosis of carcinoma of the breast and dense calcification on mammography. M a y e r s , M . M . , Evans, P. & M a c V i c a r , D. (1994). Clinical Radiology 49, 211-212. Case R e p o r t : Ossifying F i b r o m a t o s i s o f the Breast
CASE REPORT A 70-year-old lady presented with a short history of a hard, nontender lump in her right breast, clinically thought to be a carcinoma. Mammography revealed a 2 cm dense, homogenous area of calcification associated with a surrounding lobulated soft tissue mass (Fig. 1). These appearances were considered indeterminate and the mass was excised
without complications. Fibrofatty tissue 70 • 50 x 35 mm was received, containing a hard calcified mass 30 • 26 x 15 mm. The specimen was decalcified in formic acid for histological examination. This showed the typical changes of fibromatosis, namely moderately cellular bands of mature fibroblastic cells with collagen production and occasional normal mitotic figures. The lesion had an infiltrating margin and extended to the surgical resection edge. An unusual feature was the large central area of ossification (Fig. 2).
DISCUSSION
Fig. 1 - Mammograms showing dense calcification with a surrounding soft tissue mass in the right breast.
Fig. 2 - On the left are bundles of cytologically-benign infiltrating fibroblasts (F). On the right there is bone formation in which osteocyte nuclei can be seen in small lacunae (small arrows) within the dark staining calcified bone matrix (B). Haematoxylin and Eosin (medium power). Correspondence to: D. MacVicar, Department of Radiology, Royal Marsden Hospital, Sutton, Surrey SM2 5PT. * Present address: Department of Radiology, Kingston Hospital, Surrey.
Heavily calcified lesions in the b r e a s t are usually benign. A d e g e n e r a t i n g f i b r o a d e n o m a typically exhibits ' p o p c o r n ' calcification b u t m a y result in large very dense calcifications. F a t necrosis a n d oil cysts ( l i p o d y s t r o p h y m a c r o c y s t i c a calcificans) are associated with calcification which is frequently extensive a n d dense. T r a u m a m a y result in h a e m a t o m a f o r m a t i o n which s u b s e q u e n t l y calcifies a n d calcified soft tissue h a e m a n g i o m a t a are occasionally seen. C a r c i n o m a , s a r c o m a a n d p h y l l o i d e s t u m o u r s m a y calcify a l t h o u g h dense solid calcification is unusual; these c o n d i t i o n s rarely u n d e r g o osseous m e t a p l a s i a [1]. M a m m o g r a p h y is u n a b l e to distinguish true ossification f r o m dense calcification. W h i l e there m a y be clinical a n d r a d i o l o g i c a l features to s u p p o r t a benign aetiology, the presence o f bizarre calcification in a s s o c i a t i o n with a soft tissue mass, as seen in o u r patient, w a r r a n t s surgical intervention. F i b r o m a t o s i s o f the b r e a s t is one o f the g r o u p o f deep fibromatoses. These are proliferative d i s o r d e r s o f fibrous tissue t h a t m a y be locally aggressive b u t d o n o t rnetastasize. Origin in the b r e a s t is rare a n d o n l y two cases were f o u n d in a series o f 1129 benign a n d m a l i g n a n t b r e a s t t u m o u r s [2]. O c c a s i o n a l a s s o c i a t i o n s with genetic diso r d e r s such as G a r d n e r ' s s y n d r o m e or familial multicentric f i b r o m a t o s i s have been r e p o r t e d [3-5]. F e m a l e s within a wide age range are affected, m e a n age in v a r i o u s studies being given as 37, 43 a n d 48.7 y e a r s [6-8]. T h e c o n d i t i o n presents as a h a r d o r firm mass which m a y be discrete o r ill-defined a n d clinically m a y m i m i c c a r c i n o m a . M a m m o g r a p h y is r e p o r t e d as showing an illdefined stellate m a s s w i t h o u t calcification; a suspicion o f m a l i g n a n c y is usually raised [4,7-10]. H i s t o l o g i c a l e x a m ination is essential for diagnosis. M i c r o s c o p i c a l l y , b u n dles o f m a t u r e fibroblasts f o r m an interlacing p a t t e r n with v a r i a b l e a m o u n t s o f collagen. M i t o t i c figures are inconspicuous or absent. I n f l a m m a t o r y cells are n o t usually f o u n d . The b o r d e r is infiltrative a n d m a y ' t r a p ' nerves o r o t h e r structures in the fibrosing process. W h i l e one case o f extensive ossification has been r e p o r t e d in infantile f i b r o m a t o s i s [11], osseous m e t a p l a s i a in a d u l t f i b r o m a t o sis is stated to be rare a n d never a p r o m i n e n t feature [12].
212
CLINICAL RADIOLOGY
T o the authors, knowledge, this is the first reported case of extensive b o n e f o r m a t i o n in fibromatosis o f the breast. Wide local excision is the t r e a t m e n t of choice as the c o n d i t i o n m a y be locally aggressive a n d is associated with a significant rate o f local recurrence. A t surgery, the edge o f the lesion is difficult to appreciate a n d if excision is histologically incomplete, re-excision should be considered even t h o u g h s p o n t a n e o u s regression has been described [8]. I n conclusion, fibromatosis should be considered in the differential diagnosis of m a l i g n a n t neoplasms of the breast. We report the first case of extensive ossification of such a lesion, leading to dense calcification o n m a m m o graphy. The tendency to local aggressiveness a n d recurrence necessitates wide excision of the affected breast. REFERENCES
1 Haagensen CD. Diseases of the breast, 3rd ed. Philadelphia: WB Saunders, 1986:843 850. 2 Cameron CT, Adair FE. The clinical features and diagnosis of the common breast tumours. Medical Journal of Australia 1965;2: 651-654.
3 Zayid I, Dihmis C. Familial mutticentric fibromatosis-desmoids. Cancer 1969;24:786-795. 4 Haggitt RC, Booth JL. Bilateral fibromatosis of the breast in Gardner's Syndrome. Cancer 1970;25:161-166. 5 SimpsonRD, Harrison EG, Mayo CW. Mesenteric fibromatosis in familial polposis: a variant of Gardner's Syndrome. Cancer 1964;17:526 534. 6 Rosen PP, Ernsberger D. Mammary fibromatosis.A benign spindlecelt tumour with significant risk for local recurrence. Cancer 1989;63:1363-1369. 7 Wargotz ES, Norris HJ, Austin RM, Enzinger FM. Fibromatosis of the breast. American Journal of Surgical Pathology 1987;11(1): 38-45. 8 Gump FE, Sternschein MJ, Wolff M. Fibromatosis of the breast. Surgery, Gynecology and Obstetrics 1981;152:57-60. 9 Kalisher L, Long JA, Peyster RG. Extra-abdominal desmoid of the axillary tail mimicking breast carcinoma. American Journal of Roentgenology 1976;126:903 906. 10 Cederlund CG, Gustavsson S, Linell F, Moquist-Olsson I, Anderson I. Fibromatosis of the breast mimicking carcinoma at mammography. British Journal of Radiology 1984;57:98-101. 11 Enzinger FM, Weiss SW. Soft tissue tumours, 2rid ed. St Louis: CV Mosby, 1983:139. 12 Fromowitz FB, Hurst LC, Nathan J, Badalamente P. Infantile (desmoid type) fibromatosis with extensive calcification. American Journal of Surgical Pathology 1987;11(1):66-75.