1. BREAST CASES ARC 5, VI PAIRS MEETING HAMMAMET-TUNISIA 27 APRIL 2012 S.Mezghani- boussetta,S.Kechaou*, S.Melliti, M.Gadri, M.Chaabene* Ben Arous, Ariana*, TUNISIA

2. ABOUT BREAST STELLATE IMAGES

3. CASE N°1

4. 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)

5. MAMMOGRAPHY Medio-lateral views

6. Cranio-caudal views)

7. Lateral views

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

9. ULTRASOUND

10. CASE N°1 A spiculated dense center mass with skin retraction No calcification Hypoechoic mass with long thick spicules

11. CASE N°1 Classification on the BIRADS OF ACR ACR4 ? ACR 5? Managment? Surveillance Cytology Needle core biopsy Surgical biopsy

12. CASE N°2

13. 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.

14. BREAST ULTRASOUND Irregular ill-defined hypoechoic pre- pectoral mass

16. BREAST MRI A spiculated tissular mass associated to an architectural distorsion T2 T1 T1 gado

17. BREAST MRI A slow progressive and continuous increase enhancement

18. CASE 2 A 26- year-old woman A spiculated tissular mass with architectural distorsion of the right breast infiltrating the pectoral muscle Right Breast: ACR 5, Left breast ACR 1 needle core biopsy guided by ultra-sound

19. CASE N° 3

20. CLINICAL PRESENTATION Healthy 42-year-old man No 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 palped No axillary adenopathy were found

21. MAMMOGRAPHY AND US An ill-defined and spiculated margins mass that was markedly hypoechoic with good sonic transmission RB: ACR 5,LB: ACR 1 Cytology / needle core biopsy guided by ultrasound

22. COMMENTARIES Patients: woman (2), male (1) Age: 49,26,42 year-old clinical findings and imaging features suspicious breast lesions: firm or hard masses ± skin retraction stellate masses no calcification Architectural distorsion no adenopathy

23. STELLATE IMAGES Malignant 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 ?

24. PATHOLOGY OF MICRO-BIOPSY ( PATIENT 1/2/3) Pathology revealed a fuso-cellular proliferation without nuclear atypia or increased mitotic activity suggesting fibromatosis

25. 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

26. HISTOPATHOLOGIC FINDINGS Immunohistochemistry for smooth muscle actin: Fusocellular proliferation positive to smooth muscle actin Immunohistochemistry for vimentin Fusocellular proliferation positive to vimentin

27. 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

28. 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

29. 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

30. Clinical history USMAMMOG RAPHY MRIUS GUIDED BIOPSY CASE 1 Women 49A Self detected right breast mass with skin retraction Hypoechogenic mass Stellate mass with a dense center 0+ CASE 2 Women 26A Right para areolar skin retraction Hypoechogenic mass Focal asymmetric density Spiculated mass with architectural distorsion and progressive enhancement + CASE 3* Men 42A Self 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 22A Self palpated righy breast mass (upper inner quadrant) Hypoechogenic mass with hyperechoic rim 00+ CASE 5* Women 47A Lymphoma of the mediastinum Left 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*

31. 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

32. 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