A 50 year old woman detected a mass in her left breast on self-exam (figure ). Diagnostic mammography showed a well-circumscribed, oval mass which was hypoechoic on ultrasound and measured 3.5 × 1.4 × 2.8 cm. Family history of breast or ovarian cancer was not present. She experienced menarche at the age of 10, and early onset of menopause at age 40. She is gravida 1 and para 0, and denied past use of oral contraceptives or hormonal replacement therapy. On clinical breast exam the patient had a well circumscribed mass in her left upper outer quadrant and no regional lymphadenopathy. She then underwent ultrasound guided core biopsy which revealed a spindle cell neoplasm.
Breast Imaging. (A) Digital mammogram (B) ultrasound showing dominant mass in the upper central portion of the breast.
The patient's medical history was significant for SLE, diabetes mellitus type 2, rheumatoid arthritis, and asthma. Her medications include cyclophosphamide, accolade, cimetidine, etodolac, tramadol, halcion, flexeril, advair, albuterol, iron supplements, benadryl, and zofran. Her cyclophosphamide exposure was intermittent over a ten year history. The patient's past surgical history was significant for a tubal ligation and appendectomy. She currently works as an office manager and denies alcohol or tobacco use.
The diagnosis of spindle cell neoplasm raised the possibility of metaplastic carcinoma, a subtype of invasive ductal carcinoma; therefore a nodal staging procedure with sentinel lymph node biopsy was incorporated into the surgical plan. Lumpectomy was considered as there were no definite contraindications to radiotherapy with this type of SLE. However, concerns regarding cosmetic outcome and radiation tolerance in collagen vascular disease presenting with skin involvement, swayed the patient toward mastectomy. A tissue expander was placed at time of mastectomy. Unfortunately the postoperative course was complicated by wound infection and loss of expander.
Final pathology revealed a 3.2 cm tumor comprised of spindle cells with abundant eosinophilic cytoplasm arranged in fascicles, with marked pleomorphism with no epithelial glandular elements (Figure ). The tumor cells stained positive for desmin, smooth muscle actin, and calponin although negative for S100, HMB45, CKMIX, and p63: defining this lesion as a leiomyosarcoma. Metastatic workup with CT scan of the chest, abdomen, and pelvis were negative. Eleven months after her mastectomy the patient continues to do well and has no evidence of recurrent disease.
Microphotograph of leiomyosarcoma. Hematoxylin and eosin stain demonstrates a highly cellular, pleomorphic, and spindle shaped tumor with few mitotic figures (40×).