CASE REPORT

Pleomorphic Liposarcoma of the Breast Mimicking Breast Abscess in a 19-Year-Old Postpartum Female: a Case Report and Review of the Literature
Kalyana C. Nandipati, MD, Hrishikesh Nerkar, MD, James Sattereld, MD, Manasa Velagapudi, MD, Usha Ruder, MD, and Kae-Jae Sung, MD
Department of Surgery and Department of pathology; Mary Immaculate Hospital, New York Hospital Queens, Queens, New York

n Abstract: Sarcomas of the breast constitutes <1% of primary malignant breast tumors. Liposarcoma of the breast represents 324% of the primary breast sarcomas. Liposarcoma can arise from pre-existing benign lesions like broadenoma or from lipoid tissue in the breast. There are only few cases of liposarcoma of the breast in young females reported in the literature. Liposarcoma of the breast typically involves women with age after 50 years. In this article, we present a young woman with liposarcoma of the breast. n Key Words: breast cancer, liposarcoma, pleomorphic liposarcoma of breast and mastectomy

onepithelial malignant tumors of the breast are rare and they constitute less than 1% of all breast malignancies.(1) Apart from malignant phyllodes tumors other stromal sarcomas are the angiosarcoma, leiomyosarcoma and liposarcoma of the breast. Liposarcoma of the breast are reported to be 324% of the primary sarcomas of the breast.(2) Nearly 100 cases have been reported after rst case was presented by Neumann in 1862.(3) The incidence of liposarcoma peaks between the fourth and seventh decades of life. The youngest reported case of liposarcoma of the breast is a 16-year-old as reported by Carpanelli.(4) In this article, we report a case of liposarcoma mimicking breast abscess and review the literature.

CASE REPORT A 19-year-old primipara female, 5 months postpartum presented to our hospital with painful swelling of right breast for the past 2 months. The right breast swelling rapidly increased for the past 2 weeks associated with low grade fever. There was no history of
Address correspondence and reprint requests to: Kalyana C. Nandipati, MD, Department of Surgery, 56-45 Main street, New York Hospital Queens, Flushing, Queens, NY 11355, USA, or e-mail: kalyana.nandipati@ gmail.com. DOI: 10.1111/j.1524-4741.2010.00949.x 2010 Wiley Periodicals, Inc., 1075-122X/10 The Breast Journal, Volume 16 Number 5, 2010 537540

any nipple discharge. The patient previously presented to another Hospital emergency room a month ago with similar complaints and was attributed to the lactational changes in the breast. She was given antibiotics and discharged home with the diagnosis of mastitis. On examination she had approximately 8 7 cm rm retroareolar fullness in the right breast with no overlying skin changes or nipple discharge. A single, non-tender mobile lymph node was palpable in the right axilla. The left breast and axilla were normal. Labs: WBC count was elevated to 13000 cc. Ultrasound showed right breast complex mass, echogenic with areas cystic and solid in nature (Fig. 1). Tru cut biopsy was performed and revealed a feature suggestive of pleomorphic liposarcoma. CT-Scan of chest and abdomen revealed a large (10 8 cm) mass in the right breast (Fig. 2). All the metastatic workup including bone scan and PET scan was negative for metastatic spread of the tumor. The patient underwent simple mastectomy with the excisional biopsy of the palpable lymph node in axilla. Frozen section of the axillary lymph node was negative for any metastasis. Intra-operatively the mass was close to the deep margin. A cuff of pectoralis major was also removed around the deep margin. The tumor was 7.1 8.2 cm of size with areas of necrosis (Fig. 3). The histopathology revealed pathological features similar to Pleomorphic liposarcoma (Fig. 4). The

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Figure 1. Showing sonogram of the breast with cystic and solid areas.

Figure 3. Cut specimen showing tumor with areas of necrosis.

Figure 2. CT- Scan of the chest showing large solid mass in the right breast.

Figure 4. Histology composed lipoblasts showing variations in size of the cells with nuclei.

nearest margin to the neoplasm was 2 mm at the deep margin. The tumor is pathological stage of T3N0M0 with high grade features. Re-excision of the pectoralis major muscle was performed at a later date. No residual tumor was noted in the pathology. Patient was discharged without any complication. The patient received chemotherapy consisting of adriamycin and ifosfamide. After 1 year follow-up no evidence of any local or distant recurrence was noted.

DISCUSSION Sarcoma commonly involves extremities and retroperitoneum. Breast has been an uncommon primary

site of sarcoma. They constitute <1% of primary breast neoplasms.(1) Only few cases of the liposarcomas have been described in the young females. The current report represents the second youngest patient described in the literature; the youngest being 16 years old described by Carpanelli.(4) Our case report is unique in many aspects. The initial presentation with pain and swelling in the postpartum period simulated mastitis. This led to delay in the diagnosis and allowed the tumor to reach considerable size. Age at presentation and tumor involving pregnant or lactating women are the factors implicated in the prognosis. Austin and Dupree (2) reported a case of liposarcoma (5) in 28-year-old pregnant woman with documented pulmonary metastasis. The patient

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expired in the rst month of postpartum period due to metastatic disease. Livendahl (6) in another case report presented a rapidly progressive bilateral liposarcoma detected initially in lactating woman. In both cases, liposarcoma was either diagnosed after metastasized to lungs or rapidly progressed to metastatic disease in short follow-up indicating high malignant potential of the disease in this subset of population. Similarly, our case also had rapid progression of her breast lump over the period of 2 months. Literature regarding Pleomorphic liposarcoma in pregnant patients is limited and it is difcult to make any generalized consensus with this limited case reports. However, these limited case reports do suggest that liposarcomas are aggressive in pregnant and lactating women. Increased vascularity facilitating early hematogenous spread might be a possible reason attributed to the poor prognosis. Treatment of the liposarcoma of the breast has not been clearly dened. Various surgical procedures have been described in the literature ranging from simple excision, wide local excision of the tumor to the radical mastectomy. Austin and Dupree (2) reviewed their experience of 20 cases with liposarcoma of breast. In this study, reported that routine axillary dissection is not recommended since the

tumor rarely metastasizes to the axilla. In several recent case series, wide local excision with 2cm margin was reported to be adequate with no recurrence after short term follow-up (Table 1 (920)). Neither reported series able to provide any clear advantage of RM over SM or LE. In our case, whole breast tissue is almost completely occupied by the sarcoma. Simple mastectomy was performed with clinically adequate margins, however the microscopic deep margin was 2 mm from the tumor. Re-excision of the deep margin with complete excision of pectoralis muscle was performed. Chemotherapy and radiotherapy are adjuvant treatments available for a subset of population with positive margins. However, complete surgical excision is the cornerstone in the management of liposarcomas whenever feasible. Radiotherapy should be considered in inoperable tumors and tumors which are left behind. In summary, liposarcoma of the breast is rare in young women. It can progress very rapidly in pregnant and lactating women and so patients with complaints of breast mass should be carefully evaluated with ultrasound and biopsy if needed before ascribing them to lactational changes. The more radical treatment is justied in these young women with the aggressive form of liposarcoma of the breast.

Table 1. Showing Treatment and Follow-Up of Liposarcoma of the Breast

Author (year) Livendahl RA (1930) (6) Neal MP (1933) (8) Adair FE and Herrmann JB (1946) (1) Treatment (n=) Bilateral Simple Mastectomy Radical Mastectomy Simple Mastectomy Simple Mastectomy Local Excision Radical Mastectomy Simple Mastectomy Radical Mastectomy Radical Mastectomy Radical mastectomy Radical Mastectomy plus radiotherapy Radical Mastectomy plus radiotherapy Bilateral Simple Mastectomy Radical Mastectomy (8) Local Excision (7) Simple Mastectomy (6) Simple Mastectomy Simple Mastectomy plus Radiotherapy Excision Simple mastectomy (2) Wide local excision Wide local excision Outcome Died after 3 months No recurrence Well 4 months postoperatively Expired 10 years after surgery No recurrence 4.5 years No recurrence 4.5 years Well 9 months postoperatively Well 3 months postoperatively Died 5 years postoperatively Died 5 months postoperatively Died 5 years postoperatively No recurrence 4 months After 6 months, one expired of recurrence while seven are free 6 7 no recurrence in 6 months, 1 7 recurred at 1 year Half the patients had recurrence Well after 8 months No recurrence on follow-up No recurrence on follow-up Patient expired due to recurrence after 14 months and 21 years later No recurrence after 20 months No recurrence after 5 months

De Navasquez S and Horton RE (1947) (9) Michalang J (1951) (10) Brickenridge RL (1954) (11) Cuthbertson AN (1957) (12) Jackson AV (1962) (13) Carpanelli JB (1963) (4)] Hummer CD and Burkart TJ (1967) (7) Austin and Dupree (1986) (2)

Menon and Velthoven (1974) (14) Rangabashyam and Rajamuthian (1980) (15) Foust RL et al. (1994) (16) Kristensen & Kerger (1978) (18) Mazaki T et al. (2002) (19) Parikh BC et al. (2007) (20)

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