Sections were stained with hematoxylin and eosin, ... positive and negative controls were included in all staining ... tive with Masson's trichrome stain (arrows).
ANATOMIC
PATHOLOGY
Original
I n c l u s i o n Two
B o d y Cases and
Article
F i b r o m a t o s i s With
o f
t h e
B r e a s t
Immunohistochemical
Ultrastructural
Findings
GUIDO PETTINATO, MD,1 J. CARLOS MANIVEL, MD,2 EDWIN W. GOULD, MD,3 AND JORGE ALBORES-SAAVEDRA, MD4
Two cases of fibromatosis of the breast, characterized by a proliferation of spindle cells containing intracytoplasmic, spherical, eosinophilic inclusion bodies, are reported. The light and electron microscopic features, as well as the immunohistochemical features, are indistinguishable from those found in infantile digital fibromatosis. The proliferating spindle cells are characterized as myofibroblasts, whereas the inclusion bodies show an immunohistochemically nonreactive, hollow-like pat-
tern with peripheral reactivity for actin filaments. This lesion, observed for the first time in the breast, expands the number of extradigital inclusion body fibromatoses. (Key words: Electron microscopy; Fibromatosis of the breast; Immunohistochemistry; Infantile digital fibromatosis; Inclusion body fibromatosis) Am J Clin Pathol 1994; 101:714-718.
Fibromatosis of the breast is an uncommon lesion; characterized by a locally aggressivefibroblasticand myofibroblastic proliferation arising in the mammary gland. In recent years, many case reports'"16 and three series17"19 on this subject have been published. Fibromatosis accounts for less than .2%20 of all primary breast lesions. It has occurred in patients aged 11 months to 80 years. This lesion generally presents as a painless, firm, poorly circumscribed mass that sometimes shows retraction of the overlying skin; it may therefore mimic carcinoma both clinically and radiographically.2,3,5"8,1617-20 The diagnosis of fibromatosis of the breast is rarely suspected before histologic examination; in four cases, however, a fine-needle aspiration cytologic examination suggested the correct diagnosis.5"15 Microscopic examination has detected a uniform population of spindle cells arranged in interlacing bundles and fascicles, similar to that of musculoaponeuroticfibromatoses,that surrounds and entraps mammary ducts and lobules.19 In this paper, we describe two cases of mammary fibromatosis characterized by proliferating spindle cells with intracytoplasmic inclusion bodies showing immunohistochemical and ultrastructural features identical to those found in recurrent digital fibromatosis of childhood.
CASE REPORTS Case I A 24-year-old woman had an asymptomatic mass in the right breast. Past history was noncontributory. Mammographic examination suggested malignancy, and a histologic examination was advised. Physical examination revealed an ill-defined, 1.5-cm firm mass in the upperouter quadrant of therightbreast, 2 cm from the areola; results from the remainder of the examination were negative. A biopsy was performed. Two weeks later, a simple excision of the upper-outer quadrant was performed, and no residual lesions were found. The patient was free of disease 16 months after the excision. Case 2 A 53-year-old woman had a 1.5 cm mass in the right breast. A biopsy specimen revealed fat necrosis. One year later, a painless mass was found in the periareolar region of the left breast, at 6 o'clock position. On physical examination, a tender, mobile, ill-defined, 2-cm mass was present. Mammographic examination showed a dominant mass in a "fibrocystic" breast. An excisional biopsy was performed. Eighteen months after surgery, the patient was free of disease.
From the 'Department of Pathology, University of Naples Federico MATERIALS AND METHODS II. Italy,;2 Department of Laboratory Medicine and Pathology, Univer3 sity of Minnesota Hospital, Minneapolis, Minnesota; Department The of specimens were fixed in 10% formalin. Tissue blocks Pathology. University of Miami, Florida; and ^Department of Patholwere processed by conventional methods and embedded in ogy, University of Texas Southwestern Medical Center, Dallas, Texas. paraffin. Sections were stained with hematoxylin and eosin, periodic acid-Schiff (PAS), and Masson's trichrome. ImmunoManuscript received March 4, 1993; revision accepted June 7, 1993. histochemical studies were performed on formalin-fixed, parAddress reprint requests to Dr. Manivel: Department of Laboratory affin-embedded sections with the avidin-biotin-peroxidase Medicine and Pathology, University of Minnesota Hospital, Box 76 complex (ABC) technique.21 The antibodies and dilutions UMHC, 420 Delaware Street, S.E., Minneapolis, MN 55455. used, and the suppliers, are shown in Table 1. Appropriate Dr. Pettinato was a Research Fellow at the University of Minnesota, positive and negative controls were included in all staining Division of Surgical Pathology, through a grant from the Associazione runs. For ultrastructural examination, tissue was retrieved Italiana per la Ricerca sul Cancro, Milan, Italy. 714
PETTINATO ET AL. is of the Breast Inclusion Body
715
TABLE 1. ANTIBODIES USED Antibody
Dilution
AE1-AE3 cytokeratin Vimentin Muscle specific actin Desmin S-100 protein Alpha-1-antitrypsin
1:50 1:800 1:200 1:2 1:1,600 1:700
Alpha-1 -antichymotrypsin
1:1,600
Source Hybritech, San Diego, CA ICN, Cleveland, OH Biogenex, Dublin, CA Biogenex Dakopatts, Carpinteria, CA Behring Diagnostics, San Diego, CA Dakopatts
from paraffin, postfixed in 1.5% osmium tetroxide, dehydrated in ethanol, and embedded in resin. Thin sections were stained with uranyl acetate and lead citrate and studied with a Philips 201 electron microscope (Philips, Eindhoven The Netherlands). RESULTS Histologic Findings In both cases, the specimens consisted of firm tissue and measured 1.5 X 1 cm and 2 X 1.6 cm, respectively. The cut surface showed a grayish-white, glistening, ill-defined mass extending into a thin peripheral rim offibrofattytissue. Histologically, both lesions were composed of uniform, plump, spindleshaped cells arranged in streaming and interlacing fascicles separated by abundant collagen fibers (Fig. 1). These fascicles surrounded and entrapped mammary ducts and lobules. Both lesions were predominantly collagenous, with focal areas of hyalinization and edema. The spindle cells had pale eosinophilic wavy cytoplasm and elongated nuclei with sparse chromatin and inconspicuous nucleoli. Atypia, mitoticfigures,and necrosis were not seen. At the periphery, the tumors had infiltrating,finger-likeextensions into adjacent adipose and breast tissue. A striking feature was the presence of round eosinophilic cytoplasmic inclusions in many spindle cells (Fig. 2). The inclusion bodies were 3-10 iim in diameter and were easily recognizable in hematoxylin and eosin-stained sections. They fre-
FIG. 2. A, Case 1. Proliferating spindle cells are arranged in interlacing fascicles; numerous cytoplasmic and extracellular round inclusion bodies are recognizable (arrows). Entrapped ducts show mild epithelial hyperplasia. B, Case 2. Spindle cells contain round inclusion bodies; note ductal epithelium at lower right corner.
quently occupied ajuxtanuclear position, pushing the nuclei to the periphery and producing nuclear molding. They stained bright red with Masson's trichrome (Fig. 3) and were PAS-negative. Some inclusions appeared to be in extracellular location. The entrapped breast tissue consisted of ductal and lobular structures that showed moderate epithelial hyperplasia with no atypia. The epithelial and spindle cell elements were clearly unrelated, and we did not detect areas of transition. Immunohistochemical
Findings
On immunohistochemical examination, the proliferating spindle cells showed strong and diffuse cytoplasmic reactivity for vimentin and muscle-specific actin (Fig. 4). Focally, the spindle cells were positive for desmin (Fig. 4, inset), a-1-antitrypsin, and a-1-antichymotrypsin; they were negative foranticytokeratin antibodies and S-100 protein. Inclusion bodies were negative for these markers and were seen as nonreactive, rounded areas in paranuclear position. However, a marked, ring-like immunoreactivity for muscle-specific actin was ob-
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FIG. 3. Intra- and extracytoplasmic inclusion bodies are strongly positive with Masson's trichrome stain (arrows).
served at the periphery of the inclusion bodies. Epithelial cells were reactive for cytokeratin, and myoepithelial cells expressed muscle specific actin and S-100 protein.
FIG. 5. Myofibroblasts cell displays paranuclear cytoplasmic inclusion and scattered profiles of rough endoplasmic reticulum. Abundant, mature collagenfibersare visible in the extracellular space. Inset, Inclusion body is free in the cytoplasm and shows a central granular and peripheralfibrillarystructure.
DISCUSSION Electron Microscopic Findings On ultrastructural examination, the spindle cells showed oval undulating nuclei with marginated chromatin and small nucleoli. The cytoplasm had well-developed, rough endoplasmic reticulum, bundles of microfilaments with interspersed dense bodies, few mitochondria, and free ribosomes. The inclusion bodies were round and free in the cytoplasm (Fig. 5) and were composed of a core of granular material. The periphery, however, showed a microfibrillary structure, sometimes in continuity with the cytoplasmic filaments (Fig. 5, inset). Collagen fibers were abundant in the intercellular space.
FIG. 4. Spindle cells show cytoplasmic reactivity for muscle-specific actin; inclusion bodies are nonreactive but show a ring-like positivity at the periphery (arrows). Myoepithelial cells are decorated by the antibody (asterisk). Inset, Desmin is focally positive in the spindle cells.
The spindle cells in the two lesions described above showed immunohistochemical and ultrastructural features of myofibroblasts,22 which are the basic proliferating cells in fibromatoses23 and in certain pseudosarcomatous proliferations.24 Approximately 100 cases of fibromatosis of the breast have been reported, including three large series.17"19 The lesion has typically been unilateral, although bilateral cases have been described.1518,20 Rarely, fibromatosis of the breast may occur in association with a genetic disorder, such as Gardner's syndrome or familial multicentric fibromatosis.20,25 In contrast to fibromatosis of the abdominal wall, this lesion is not associated with childbearing.6 Estrogen and progesterone receptors have been reported in one case of mammary fibromatosis.12 Although histologically bland,fibromatosisof the breast is locally invasive and may recur in up to 27% of cases17"19; multiple recurrences have also been reported.1,18,19 The lesions reported in this paper showed histologic characteristics that, to our knowledge, have not been described before in cases of fibromatosis of the breast. In these two patients, the proliferating myofibroblasts contained eosinophilic cytoplasmic inclusion bodies, which were indistinguishable from those seen in infantile digital fibromatosis, a well-characterized lesion first described in 1965 by Reye.26 Infantile digital fibromatosis is a form of dermohypodermal fibromatosis that tends to involve fingers and toes of infants and children27"31 and is characterized by the presence of intracytoplasmic inclusion bodies. In recent years, however, similar intracytoplasmic inclusion bodies have been observed in myofibroblastic tumors in sites other than the digits and in patients beyond infancy.32"37 Moreover, inclusion body myofibroblasts were reported in four patients in Spain, aged 14 to 46 years, affected by a peculiar form of sclerodermalike changes that appeared in the course of toxic oil epidemic syndrome (TOES).38 Table 2 shows the main clinicopathologic features of reported extradigital inclusion body fibromatosis (IBF). This term, proposed by Zardawy and Earley,39 under-
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PETTINATO ET AL. Inclusion Body Fibromatosis of the Breast
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TABLE 2. REPORTED CASES OF EXTRADIGITAL INCLUSION BODY FIBROMATOSIS (IBF): CLINICOPATHOLOGIC FEATURES Reference (year) Sarma and Hoffman36 (1980) Patron et al.34 (1980) Purdy and Colby35 (1984) Cachazaetal.32(1986) Miyamoto et al.33 (1986) Vialeetal.37(1987) Case 1 Case 2 IBF in toxic oil epidemic syndrome Navas-Palacios and CondeZurita38(1984)
Site
Age (yr)
Sex
44 1.6 2.5 32 11 35 42 24 53
M M M F F F M F F
Left upper arm Nose Right upper arm Endocervix Left thigh Right leg Right arm Right breast Left breast
14
F
27
M
32
M
46
F
Generalized scleroderma; skin biopsy, abdomen Generalized scleroderma; skin biopsy, abdomen Generalized scleroderma; skin biopsy, left ankle Generalized scleroderma; skin biopsy, abdomen
scores the morphologic features of this lesion and is appropriate for this disorder. The nature of the cytoplasmic inclusions of IBF has been the subject of considerable research and debate. Most authors agree that these inclusions are the product of disturbed metabolism of the proliferating myofibroblasts.39,40-42 Recent evidence has shown that the inclusion bodies are related to cytoplasmic actin filaments,43"45 suggesting that a defective regulation of cellular filament meshwork architecture plays a role in the development of the inclusions.43,46 Indeed, continuity of the inclusions with cytoplasmic filaments observed in our study supports this contention. The cause of this metabolic derangement is not known. In patients showing scleroderma-like changes of TOES, however, it may be caused by the toxic action of the adulterated oil.38 In some cases of infantile digital fibromatosis, a posttraumatic origin has been proposed.33,47 The lesions that we observed in the breasts of the two patients described in this paper expand the histologic spectrum of thefibromatosesof the breast and the number of extradigital inclusion bodyfibromatoses.The follow-up of our cases is too short (16 months and 18 months, respectively) to speculate about the potential risk of recurrence of IBF of the breast. In fact, cases of extradigital IBF in adults have not recurred after surgical excision, whereas classic fibromatosis of the breast has a high rate of recurrence. Acknowledgments. The authors gratefully acknowledge the assistance of Diane Perez in the preparation of the manuscript. Note added in proof. One year after submission of this manuscript, Bittesini and colleagues published a similar case (Am J Surg Pathol 1994; 18:296-301). The authors coined the term "fibroepithelial tumor of the breast with digitalfibroma-likeinclusions in the stromal component," which describes the elements present in this lesion. We believe that the process is basically a neoplastic proliferation of myofibroblasts; when it occurs in the breast, it may stimulate focal epithelial hyperplasia. We do not believe the epithelium is a neoplastic component of this lesion. We have also seen a third case in which the presence of cytoplasmic inclusions was a focal change in an otherwise typical fibromatosis of the breast.
Size (cm)
Follow-up
1.0 — 2.7 X 1.4 1.0X0.8 2.5 X 1.5 1.0 1.2 1.5 X 1.0 2.0
No recurrence, 48 mo Recurrence, 6 mo Recurrence, 7 mo No recurrence, 14 mo No recurrence, 19 mo No recurrence, 36 mo No recurrence, 24 mo No recurrence, 16 mo No recurrence, 18 mo
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