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A Case Report on Liposarcoma of Breast

ABSTRACT

Background: Liposarcoma of the breast is a rare entity accounting for 0.3% of breast sarcomas
which in turn are responsible for less than 1% of breast malignancies. We present this case for rarity
and for its being a histological surprise.
Case Summary: We are reporting a case of 60 years female presenting with painless,
progressively increasing lump in the right breast for 4 months. Examination revealed a 6*5 cm, firm,
nontender, mobile, lump with smooth surface and clear margins in the right upper outer quadrant.
Ultrasonography of breasts and mammography were suggestive of BIRADS III lesion. Trucut biopsy
was suggestive of fibroepithelial lesion with cellular stroma. Keeping in view the age of the patient
and size of the lump, excision biopsy was done. Histopathology report revealed liposarcoma arising
nd
in the fibrocellular stroma. Completion surgery with re-excision of the margins was done in the 2
stage. Patient was asymptomatic with no evidence of recurrence after 1.5 years of follow up.
Discussion: Most of the liposarcomas have been found to arise in malignant phyllodes tumors, as
opposed to primary liposarcomas of the breast which arise de novo from fibrocellular stroma. Our
case was liposarcoma of breast which was identified on histopathology after excisional biopsy and
was managed well with re-excision of the margins as per NCCN guidelines.
Conclusion: Liposarcoma of breast is rare. It can present as a benign lesion clinically. Treatment is
by wide local excision with tumour-free margins or re-resection of margins in case of a histological
surprise.
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Keywords: Liposarcoma; phyllodes; breast sarcoma; WHOOPS tumour; fibroepithelial lesion.

1. INTRODUCTION position with heterogeneous echotexture,

mild internal vascularity and no calcification
Liposarcoma of breast are rare tumors. Less as shown in Figs. 2 and 3. Axillary lymph
than 1% of breast malignancies are sarcomas of nodes were unremarkable (Fig. 1).
which only 0.3% are liposarcomas. Soft tissue b) Bilateral mammography showed 5.5*3*4 cm
sarcomas (STS), as such, amount to only less well defined homogeneous opacity in upper
than 1% of all malignant tumors with an outer quadrant of right breast with lobulated
incidence estimated at 2-5 cases per 100,000 [1]. contour with no calcification in the breast
There are over 50 subtypes of STS. Liposarcoma parenchyma A prominent vessel was seen in
comes under adipocytic group (WHO its vicinity with no evidence of any internal
classification) [2] and the exact diagnosis of STS calcification, likely BIRADS III (Figs. 2 and
or Liposarcoma may pose a significant 3).
challenge. Primary liposarcomas of the breast c) Trucut biopsy was suggestive of
arise de novo from fibro-cellular stroma. However fibroepithelial lesion with cellular stroma.
most of the liposarcomas are seen to arise in d) X-ray Chest and Ultrasonography of
malignant phyllodes tumors. Because of the abdomen were normal.
rarity of the disease, there are no randomized
trials specifically addressing treatment modalities 2.4 Treatment
in breast sarcoma. The largest series of 20 cases
of breast liposarcomas was published by Austin a) Keeping in view the age of the patient, size
and Dupree [3] in 1986. The treatment guidelines of the lump and discordance between
are thus based on data from non-breast soft imaging and histopathological findings,
tissue sarcoma trials. We present a case of excisional biopsy of the lump was done
breast lump which threw a histopathological after appropriate informed consent. A fragile
surprise of liposarcoma after excision. mass of size around 5*5*4cm was excised.
To our surprise the histopathological report
2. CASE PRESENTATION came out as lesion suggestive of
liposarcoma arising in fibro-cellular stroma of
2.1 Patient Information phyllodes tumor. There was a predominant
stromal component with hypercellularity and
A 60 years old post-menopausal lady presented abrupt foci of well differentiated liposarcoma,
with painless, progressively increasing lump in showing focal areas of bizarre multinucleated
the right breast for 4 months. There was no lipoblasts (Fig. 4). MDM2 expression
history of nipple discharge or any other swelling. was seen in the lipoblasts.
She was multipara with cumulative breastfeeding b) There was no residual lump in the breast on
of 2yrs. There was no high risk factor. clinical examination or imaging. But in
view of the histopathology report of
2.2 Clinical Findings Liposarcoma, a revision surgery was
done excising the scar and 2cm area
Examination of breasts revealed a nontender, around it. Histopathological examination
firm, ovoid, 6*5 cm mobile lump with smooth of this specimen showed a tiny residual
surface and regular margins in the right upper lesion comprising of spindle cell proliferation.
outer quadrant. There were no dilated veins. The IHC was performed and was S100,
Bilateral Nipple Areolar Complex and Axillae SMA, Pan CK negative, ruling out neural
were normal. and myogenic differentiation as well as
metaplastic carcinoma. The proliferative
2.3 Investigations marker Ki67 showed a very high expression,
These cells showed MDM2 expression,
a) Ultrasonography of Bilateral breasts revealed confirming Dedifferentiated Liposarcoma.
5.7*3.4*5.4 cm well marginated, solid mass c) At 1.5 years of follow up, there is no
lesion in right breast at 8 to 10 O’clock evidence of recurrence.

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Fig. 1. Ultrasound picture of the right breast

Fig. 2. Mammography (craniocaudal view)

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Fig. 3. Mammography (mediolateral-oblique view)

Fig. 4. Histopathological examination (10x) showing liposarcoma arising in fibrocellular stroma

of phyllodes tumor

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3. DISCUSSION Diagnosis can be confirmed on histopathology

and IHC staining for MDM2/CDK4 Protein
Liposarcomas of the breast may occur either as expression. Treatment is like soft tissue
pure primary liposarcoma or arise in sarcomas of trunk. Complete surgical excision of
cystosarcomas phyllodes. STS are often found tumor with tumor-free margins is associated with
as histological surprise after surgery [4] as was in favourable outcome. Re-resection of margins is
our case; and are also termed as WHOOPS indicated if it comes as a histological surprise.
tumour because of the unexpected malignancy.
MRI done after surgery does not predict residual DISCLAIMER
tumour with sufficient sensitivity and specificity
[5]. Given the rarity of the disease, there are no The authors have completed the CARE reporting
randomized trials specifically addressing checklist. All authors declare that there are no
treatment modalities in breast liposarcoma or conflicts of interest. The authors are accountable
breast sarcomas. Breast liposarcomas are for all aspects of the work in ensuring that
treated on the lines of soft tissue sarcomas of the questions related to the accuracy or integrity of
trunk [6]. As per the NCCN treatment guidelines, any part of the work are appropriately
surgical resection with appropriately negative investigated and resolved.
margin of 1 cm or more is the standard primary
treatment for most soft tissue sarcomas. CONSENT
Complete surgical excision of tumor with tumor-
All authors declare that “written informed consent
free margins is associated with favorable survival
was obtained from the patient for publication of
[3,7]. In the largest series with 20 cases of breast
this case report and accompanying images. A
liposarcomas published in 1986 by Austin and
copy of the written consent is available for review
Dupruee, follow-up data also indicated that
by the Editorial office/Chief Editor/Editorial Board
complete surgical excision of tumor with tumor-
members of this journal."
free margins is necessary for long term survival
[3]. Axillary lymph node dissection or sentinel ETHICAL APPROVAL
node biopsy is not recommended in the absence
of clinical evidence of lymph node involvement All procedures performed in the study involving
[8]. If surgical margins are positive on final human participants were in accordance with the
pathology, re-resection to obtain negative ethical standards of the institution.
margins should be strongly considered [9]. Re-
resection is also indicated in WHOOPS tumor
wherein the STS are found as histological
surprise after surgery of a benign tumour [4] as
the residual tumour is not detected by imaging
with sufficient sensitivity and specificity [5]. Our REFERENCES
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