Breast cases
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Transcript of Breast cases
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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
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ABOUT BREAST STELLATE IMAGES
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CASE N°1
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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)
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MAMMOGRAPHYMedio-lateral views
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Cranio-caudal views)
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Lateral views
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Spot compression focalized at UQ in CC view of the right breast
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ULTRASOUND
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CASE N°1
A spiculated dense center mass with skin retraction No calcificationHypoechoic mass with long thick spicules
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CASE N°1
• Classification on the BIRADS OF ACR• ACR4 ?• ACR 5?
• Managment?• Surveillance• Cytology• Needle core biopsy• Surgical biopsy
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CASE N°2
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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.
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BREAST ULTRASOUND
Irregular ill-defined hypoechoic pre- pectoral mass
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BREAST MRI
A spiculated tissular mass associated to an architectural distorsion
T2
T1
T1 gado
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BREAST MRI
A slow progressive and continuous increase enhancement
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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
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CASE N° 3
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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
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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
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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
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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 ?
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PATHOLOGY OF MICRO-BIOPSY( PATIENT 1/2/3)
Pathology revealed a fuso-cellular proliferation without nuclear atypia or increased mitotic activity
suggesting
fibromatosis
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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
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HISTOPATHOLOGIC FINDINGS
Immunohistochemistry for smooth muscle actin:
Fusocellular proliferation positive to smooth muscle actin
Immunohistochemistry for vimentin
Fusocellular proliferation positive tovimentin
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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
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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
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• 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
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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*
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• 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
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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