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Fig 1

Case History

Patient is a 35 year old female with multiple masses in the left breast measuring 3.0 cm, 3.7 cm and 2.5 cm in greatest dimensions. Ultrasound imaging describes the 3.0 cm lesion as a hypoechoic mass of moderate suspicion for malignancy, while both the 3.7 cm and 2.5 cm nodules likely representing lymph nodes with metastasis. Ultrasound-guided fine-needle aspiration biopsies of the 3.0 cm and 3.7 cm masses are performed.

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Diagnosis & Discussion
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Figure 5
     

Image Figs:

  • Figure 1: FNA smear of 3.0 cm breast mass, Diff-Quik stain, 100x
  • Figure 2: FNA smear of 3.0 cm breast mass, Diff-Quik, 400x
  • Figure 3: FNA smear of 3.7 cm breast mass, Diff-Quik stain, 100x
  • Figure 4: FNA smear of 3.7 cm breast mass, Diff-Quik stain, 600x
  • Figure 5: Surgical excision of thigh mass, H&E stain, 200x

Questions:

  1. What is the diagnosis?
    1. Phyllodes tumor
    2. Myxoid fibroadenoma
    3. Metaplastic carcinoma
    4. Metastatic myxoid liposarcoma
  2. Characteristic cytologic features of this entity include all of the following EXCEPT:
    1. Chicken-wire vasculature
    2. Branching clusters of ductal epithelium
    3. Vacuolated lipoblasts, especially along capillaries
    4. Abundant myxoid matrix
  3. Which stain is negative in this tumor?
    1. TTF-1
    2. Vimentin
    3. CD34 for prominent vasculature
    4. S100
  4. Which is the most common translocation associated with this tumor?
    1. t(11;22)(q24;q12)
    2. t(2;13)(q37;q14)
    3. t(12;16)(q13;p11)
    4. t(X;18)(p11;q11)

    Discussion: Myxoid/round cell liposarcoma is a soft tissue tumor most often found in the deep tissue of the thigh. These tumors are classified as either well-differentiated/low grade myxoid liposarcoma or round cell liposarcoma. Although pure low grade tumors only rarely metastasize, those with at least 5% round cells tend to be aggressive with poor outcome. The patient in our case had a history of a myxoid liposarcoma of the thigh four years prior to current presentation. The tumor was surgically resected and the patient had no recurrence until she felt the palpable breast masses. Ultrasound imaging and clinical presentation suggested that the lesions were possible primary breast carcinoma with associated lymph node metastasis. Cytologic sampling confirmed that the lesions were in fact metastatic myxoid liposarcoma.

    Fine-needle aspiration biopsy of myxoid liposarcoma shows a background of abundant granular myxoid matrix with delicate, branching, “chicken-wire” vasculature. The cells are spindle to oval-shaped with occasional small cytoplasmic vacuoles and bland uniform nuclei. The lipoblasts, with their indented nuclei and optically clear cytoplasm, are often located along the capillaries. If the tumor is higher-grade, the smears tend to show more isolated and loosely clustered cells with large, round nuclei and prominent nucleoli.

    Histologically, low-grade myxoid liposarcomas are composed of monomorphic stellate cells without atypia. They show prominent “chicken-wire” vasculature and numerous lipoblasts in a background of mucoid-rich matrix. Higher-grade round cell liposarcomas show an increased number of small round/spindled cells with frequent mitotic figures.

    Myxoid liposarcomas are associated most commonly with t(12;16)(q13;p11)—seen in 90% of tumors. Less often, they are also associated with t(12;22)(q13;p11). These tumors stain positively for S100 and vimentin, while the prominent vasculature stains positively for CD34. They tend to metastasize to the retroperitoneum, pleural cavity, soft tissue, or bone (less often to the lungs). Although there are a few case reports of primary myxoid liposarcoma in the breast, to our knowledge this is the first case of metastatic myxoid liposarcoma to the breast reported in English medical literature.

Answers

  1. d
  2. b
  3. a
  4. c

REFERENCES

  1. Sheah K, Ouellette H, Torriani M, et al. Metastatic myxoid liposarcomas: imaging and histopathologic findings. Skeletal Radiol. 2008; 37: 251-8.

  2. Pant I, Kaur G, Joshi, S, Khalid I. Myxoid liposarcoma of the breast in a 25-year-old female as a diagnostic pitfall in fine needle aspiration cytology. Diagn Cytopathol. 2008; 36: 674-7.

  3. Pantanowitz L, Otis C. Myxoid liposarcoma. Diagn Cytopathol. 2007; 35: 283-4.

  4. Klijanienko J, Caillaud JM, Lagace R. Fine-needle aspiration in liposarcoma: cytohistologic correlative study including well-differentiated, myxoid, and pleomorphic variants. Diagn Cytopathol. 2004; 30: 307-312.

  5. Kilpatrick S, Ward W, Bos G. The value of fine-needle aspiration biopsy in the differential diagnosis of adult myxoid sarcoma. Cancer Cytopathol. 2000; 90: 167-177.

  6. Tse G, Tan P, Lui P, Putti T. Spindle cell lesions of the breast—the pathologic differential diagnosis. Breast Cancer Res Treat. 2008; 109: 199-207.

Contributed by Drs. Ji-Weon Park and Aylin Simsir, Department of Cytopathology, New York University, New York, NY

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