DOI:10.2214/AJR.04.1453
AJR 2005; 185:1595-1597
© American Roentgen Ray Society
Leiomyoma of the Breast Parenchyma
Aysin Pourbagher1,
M. Ali Pourbagher1,
Nebil Bal2,
Levent Oguzkurt1 and
Ali Ezer3
1 Department of Radiology, Baskent University Adana Teaching and Medical
Research Center, Dadaloglu Mah. 39 sk, Yuregir, Adana 01250, Turkey.
2 Department of Pathology, Baskent University Adana Teaching and Medical
Research Center, Yuregir, Adana 01250, Turkey.
3 Department of General Surgery, Baskent University Adana Teaching and Medical
Research Center, Yuregir, Adana 01250, Turkey.
Received September 14, 2004;
accepted after revision December 6, 2004.
Address correspondence to A. Pourbagher
(aysin73{at}hotmail.com).
Introduction
Leiomyoma of the breast is one of the rarest benign nonepithelial
tumors [1]. Most leiomyomas
that do occur in the breast are found in the subareolar region
[2]. Leiomyoma of the breast
parenchyma in the absence of periareolar lesions is uncommon
[3]. Only 13 cases of
parenchymal leiomyoma of the breast have been reported to date
[4]. We present a 14th case,
which is the first to be reported, to our knowledge, in Turkey. The patient
was initially diagnosed with fibroadenoma and was followed for 2 years before
she underwent surgery. Our report documents the mammography, sonography, and
histopathology findings in this case.
Case Report
A 47-year-old woman underwent routine mammography at our hospital in July
2001. She had no family history of breast cancer and was experiencing no
problems with either breast at the time. Physical examination revealed no
palpable masses in either breast. Three years earlier, the woman had undergone
total abdominal hysterectomy as treatment for uterine leiomyoma. She had
started a program of annual mammography and breast sonography examinations in
2001. The mammogram from 2001 revealed a well-defined 15-mm-long mass located
in the middle portion of the medial half of the patient's left breast
(Fig. 1A). The mass showed no
calcification, and no other lesions were detected in the left or right breast.
In addition, no axillary lymphadenopathy was noted on the mammogram.
Sonography of the left breast in 2001 showed a well-defined solid oval mass
that was hypoechoic compared with the breast parenchyma
(Fig. 1B). The lesion was
interpreted as a fibroadenoma, and the patient was asked to return for
follow-up sonography 6 months later. At this repeat examination in January
2002, the lesion size was unchanged. After the initial follow-up sonography
evaluation, the patient started taking sibutramine (Meridia, Knoll
Pharmaceutical Company) and orlistat as treatment for obesity. She took both
these drugs regularly until her most recent mammography examination in August
2003.
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Fig. 1A —47-year-old woman with leiomyoma of breast parenchyma.
Mammogram (A) and sonogram (B) at time of patient's first visit
in 2001. Craniocaudal mammogram shows well-circumscribed dense mass in
parenchyma of medial half of left breast. On sonography, mass appears oval,
hypoechoic, and well-circumscribed, all of which suggest fibroadenoma. There
was no acoustic enhancement.
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Fig. 1B —47-year-old woman with leiomyoma of breast parenchyma.
Mammogram (A) and sonogram (B) at time of patient's first visit
in 2001. Craniocaudal mammogram shows well-circumscribed dense mass in
parenchyma of medial half of left breast. On sonography, mass appears oval,
hypoechoic, and well-circumscribed, all of which suggest fibroadenoma. There
was no acoustic enhancement.
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Mammography performed 1 year after the first mammography examination (July
2002) revealed a moderate increase in the size of the mass and no other lesion
in either breast. However, the mammogram at 2 years (August 2003) showed that
the mass had enlarged considerably in 12 months
(Fig. 1C). At that stage, the
lesion measured 20 x 25 mm on sonography
(Fig. 1D). It was not palpable
on physical examination, so we located it using a Homer Mammolock needle
(Medical Device Technologies) under sonographic guidance. Considering the
speed and degree of expansion, we recommended that the mass be removed. The
patient consented, and the lesion was surgically excised with the patient
under local anesthesia.
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Fig. 1C —47-year-old woman with leiomyoma of breast parenchyma.
Mammogram (C) and sonogram (D) 2 years after patient's first
visit (August 2003) show significant enlargement of lesion but no change in
its imaging features.
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Fig. 1D —47-year-old woman with leiomyoma of breast parenchyma.
Mammogram (C) and sonogram (D) 2 years after patient's first
visit (August 2003) show significant enlargement of lesion but no change in
its imaging features.
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Gross examination of the surgical specimen revealed a well-circumscribed 27
x 20 x 15 mm mass. The cut surface was whorled, whitish, and
homogeneous in appearance. Histopathologic examination showed a growth pattern
of interlacing fascicles of smooth-muscle cells
(Fig. 1E). Immunohistochemical
staining for desmin (Dako, N1538, Clone DE-R-M) and smooth-muscle actin (Dako,
N1567, Clone HHF35) revealed positivity for both in the tumor cell cytoplasm
(Fig. 1F). On the basis of
these histopathologic and immunohistochemical findings, we diagnosed this case
as leiomyoma of the breast parenchyma.
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Fig. 1E —47-year-old woman with leiomyoma of breast parenchyma.
Photomicrograph of surgical specimen shows interlacing fascicles of spindle
cells with abundant cytoplasm and oval nuclei with blunt ends. (H and E,
x200)
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Fig. 1F —47-year-old woman with leiomyoma of breast parenchyma.
Photomicrograph of surgical specimen shows uniform cytoplasmic staining for
smooth-muscle actin in leiomyoma. (Smooth-muscle actin stain, x200)
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Discussion
Leiomyomas are extremely rare breast tumors
[5]. Strong published the first
description of this tumor in the breast parenchyma in 1913
[3]. Most mammary leiomyomas
occur in subareolar locations
[2]. Various theories have been
proposed about the origin of these neoplasms. Kaufman and Hirsch
[2] suggested that they arise
from the smooth-muscle cells that surround capillaries in the subcutaneous
tissues of the breast. Diaz-Arias et al.
[3] proposed five sources:
teratoid origin with extreme overgrowth of the myomatous elements,
embryologically displaced smooth muscle from the nipple, angiomatous smooth
muscle, a multipotent mesenchymal cell, and myoepithelial cells
[3]. The frequent occurrence of
these tumors near the nipple may be related to the abundance of smooth-muscle
cells around the nipple and areola, but the histogenesis of these lesions
remains controversial [1].
Only a few reports have described the radiologic features of breast
leiomyoma. Some of them note sonography findings of a well-circumscribed solid
mass similar to a fibroadenoma. The only distinction from fibroadenoma noted
in these cases has been a lack of distal attenuation on sonography
[1,
3,
4]. The radiologic findings in
our case were consistent with those in other reports. Although the patient's
radiologic findings throughout 2 years of follow-up suggested the lesion was a
fibroadenoma, unexplained significant expansion over the course of 1 year made
it necessary to excise the mass en bloc. This enlargement was the only imaging
feature that suggested a lesion other than fibroadenoma preoperatively.
Histologic examination of the surgical specimen identified the mass as a
leiomyoma. The common histopathologic features of leiomyomas of the breast are
identical to those observed in leiomyomas at other sites: groups of
interlacing bundles of spindle-shaped cells with blunt-ended nuclei and
eosinophilic cytoplasm [2]. On
immunoperoxidase staining, most leiomyomas are positive for vimentin, desmin,
and muscle-specific actin [3].
In our patient, all histopathologic and immunohistochemical findings indicated
the mass was a leiomyoma.
Most breast leiomyomas are diagnosed in women of late middle age, and they
usually occur in the right breast
[5]. Our patient was in this
age category, but the leiomyoma developed in the parenchyma of her left
breast. The histopathologic differential diagnoses for leiomyoma of the breast
include adenoleiomyoma, cystosarcoma phyllodes, fibroadenoma with prominent
smooth muscle, fibromatosis, benign spindle cell tumor of the breast, fibrous
histiocytoma, myoepithelioma, myoid hamartoma, and leiomyosarcoma.
Perhaps the most important differential diagnosis is leiomyosarcoma of the
breast [3]. These tumors can
develop deep within the breast parenchyma or can occur superficially in
association with the nipple-areola complex. The typical mammographic
appearance of leiomyosarcoma is a dense, circumscribed non-invasive lesion.
Frequently, the tumor exhibits a slow rate of growth. The divergent
cytogenetic profiles of leiomyoma and leiomyosarcoma indicate that different
molecular genetic mechanisms are responsible for these smooth-muscle tumors
[6]. Histologically,
leiomyosarcomas feature prominent cytologic atypia, with 2-16 mitotic figures
per 10 high-power fields, atypical mitoses, vascular invasion, and necrosis
[7].
It is particularly important to differentiate these two neoplasms because
of the risk of local recurrence or distant spread with leiomyosarcoma. In most
cases of breast leiomyosarcoma reported to date, neither axillary lymph node
involvement nor metastatic lesion was present at the time of diagnosis.
However, the possibility of spread must be monitored long term because there
is potential for local recurrence or distant metastasis later; metastases can
even be found more than 10 years after excision of a breast leiomyosarcoma. A
long period of disease-free survival is no guarantee of a cure. Recurrence
tends to be local or to occur via hematogenous spread
[8].
Tamoxifen therapy has been shown to result in sudden and rapid growth of
uterine leiomyomas, a change that may necessitate hysterectomy. One study
indicated that this drug promotes formation of parenchymal leiomyomas of the
breast and causes these masses to enlarge
[1]. Our patient's breast mass
began to increase in size after a 6-month stable period. The start of
expansion coincided with initiation of sibutramine and orlistat treatment for
obesity. No study has yet investigated the effects of either of these agents
on leiomyoma in the breast or any other part of the body. However, the
possibility of a link between leiomyoma of the breast (and perhaps those in
other parts of the body) and antiobesity agents needs to be studied.
In conclusion, leiomyoma of the breast parenchyma is a rare benign neoplasm
that appears similar to fibroadenoma on sonography and mammography. When a
leiomyoma of this type is examined with these two techniques, the findings
usually suggest a benign breast tumor. In the case reported here, the only
preoperative finding that suggested a lesion other than fibroadenoma was the
relatively rapid enlargement detected by mammography and sonography in the
second year after initial detection. Histologic examination helps distinguish
leiomyoma from malignant lesions. Further investigation will be required to
obtain reliable information about the effects that antiobesity drugs have on
leiomyoma.
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Introduction
Case Report
