European Journal of Radiology. 12 (1991) 130-131 Elsevier
130
EURRAD
00145
Nontraumatic myositis ossificans in the breast Erich Salomonowitz ‘, Soraya Youssefzadeh *, Angelika Reiner2, Emile A. Heilbron 3 and Christoph L. Zollikofer 3 ‘Clinic of Radiology and the 21nstituteof Pathology, Universityof Vienna Hospital,Allgemeines Krankenhaus Wien and ‘Institute of Radiology, Kantonsspital Winterthur,Switzerland (Received 9 June 1990; accepted
Key words: Breast, myositis ossificans;
after revision 1 December
Breast neoplasm,
diagnosis;
1990)
Breast, radiography
Introduction We report the first case of a healthy female who developed a rapidly growing mass in her left breast which proved to be a nonprogressive form of myositis ossificans* originating in fat tissue. This rare entity may be important to radiologists because the clinical symptoms are suspicious of a malignancy. Case report A 21-year-old patient presented a large and tender lump in the upper outer quadrant of her left breast. The tumor developed rapidly and was first noticed 10 days before hospital admission. Clinically the tumor appeared to measure more than 6 cm in length and showed all signs of carcinoma, such as skin fixation, edema and large veins. Sonographically, the inhomogeneous and ill-defined mass measured 3 cm in length (Fig. 1). Mammography revealed only a slight parenchymal asymmetry (Fig. 2). Laboratory fmdings were normal and there was no history of trauma or inflammation. The histological specimen showed heterotopic metaplastic ossitication of the mammary fatty tissue (Fig. 3). At lumpectomy the tumor had to be excised from the invaded
* This case was reviewed by Dr. Reiner (Vienna), Dr. SalzerKuntschik (Vienna), Dr. Huvos (Memorial Sloan Kettering Cancer Center, New York), Dr. Unni (Mayo Clinics, Rochester) and Dr. Weiss (AFIP) and diagnosed as myositis ossiticans by all. Address for reprints: Christoph L. Zollikofer, M.D., Institute of Radiology, Kantonsspital Winterthur, Brauerstrasse 15, CH-8401 Winterthur, Switzerland. 0720-048X/91/$03.50
0 1991 Elsevier Science Publishers
Fig. 1. Sonogram of palpable mass in left breast showing ill-defined inhomogeneous lesion of 3 cm in length.
pectoralis muscle. uneventful.
The
postoperative
course
was
Discussion Reactive heterotopic metaplastic calcification and ossification is commonly called myositis ossilicans, an osseous tumor of soft tissue originating in muscle, tendon, fascia, periosteum and subcutaneous fat [l-3]. It is a self-limiting ossifying process following trauma or infection and is also reported in association with neurological disorders. It has to be distinguished from myositis ossiticans progressiva, also called tibrodysplasia ossiticans progressiva, which is a congenital
B.V. (Biomedical
Division)
131
Fig. 2. Oblique mammograms demonstrating subtle difference in parenchymal density of upper outer quadrants, the left appearing denser than the right.
abnormality with characteristic malformation of the great toes, early onset of metaplastic bone formation and fatal prognosis [ 31. Circumscript, nontraumatic, nonprogressive myositis ossificans predominates in males under 30 years of age. Most of the lesions arise in the limbs, especially in their anterior parts. Tumors originating in the subcutaneous fat, as in our case, are rare and commonly afflict the upper extremity of women [ 11. The patients present with a painful softtissue swelling which gradually develops into a circumscribed, firm tumor within 2 or 3 weeks. Tumor calcification may be discovered at the end of the third week, typically starting in the periphery. Whereas Enzinger [ 41 found the center of the lesion to remain uncalcified, Anger&l [5] expected the whole tumor to become ossified. To our knowledge, no report has been published about this tumor entity in the fatty tissue of the breast. It should be included in the differential diagnostic gamut of rapidly growing tumors in young women. Diagnostic is the zonal pattern under the microscope (Fig. 3). The central part consists of an immature fibroblastic tissue with mild cellular pleomorphism and mitotic activity. The intermediate zone shows a mixture of fibroblasts, osteoblasts and osteoid. The periphery of the tumor is characterized by cancellous bone formation which gradually involves the remaining parts. Biopsy specimens from the very center might be confused with malignant tumors such as extraskeletal osteosarcoma because of their nuclear pleomorphism and mitotic activity [ 11. That is why biopsies should be taken from the periphery if one suspects myositis ossificans. Histological demonstration of the truly benign nature of the mass is imperative as well as radical excision, as there are suggestions for the possibility of malignant change in a benign tumor [ 11. The development of sarcoma in myositis ossificans has not been documented perhaps due to the early surgical ablation of the soft-tissue masses. Our patients tumor was histologically nonmalignant. In this case we see no need for further therapy. References
Fig. 3. Myositis ossificans characterized by inner plexiform cells (left bottom) and outer osteoid and calcification zone, Hematoxylin -Eosin, 45 x
1 Fine G, Stout AP. Osteogenic sarcoma of the extraskeletal soft tissues. Cancer 1956; 9: 1027-1043. 2 Ackerman L, Ramamurthy S, Jablokow V, Van Drunen M, Kaplan E. Case report 488. Skeletal Radio1 1988; 17: 310-314. 3 Samuelson KM, Coleman SS. Nontraumatic myositis ossificans in healthy individuals. JAMA 1976; 235: 1132-l 133. 4 Enzinger FM, Weiss SW. Soft tissue tumors, 2nd Edn. St. Louis: CV Mosby Co., 1988: 882-890. 5 Angervall L, Stener B, Stener I, Ahren C. Pseudomalignant osseous tumor of soft tissue. J Bone J Surg 1969; 51B: 654-663.
130
EURRAD
00145
Nontraumatic myositis ossificans in the breast Erich Salomonowitz ‘, Soraya Youssefzadeh *, Angelika Reiner2, Emile A. Heilbron 3 and Christoph L. Zollikofer 3 ‘Clinic of Radiology and the 21nstituteof Pathology, Universityof Vienna Hospital,Allgemeines Krankenhaus Wien and ‘Institute of Radiology, Kantonsspital Winterthur,Switzerland (Received 9 June 1990; accepted
Key words: Breast, myositis ossificans;
after revision 1 December
Breast neoplasm,
diagnosis;
1990)
Breast, radiography
Introduction We report the first case of a healthy female who developed a rapidly growing mass in her left breast which proved to be a nonprogressive form of myositis ossificans* originating in fat tissue. This rare entity may be important to radiologists because the clinical symptoms are suspicious of a malignancy. Case report A 21-year-old patient presented a large and tender lump in the upper outer quadrant of her left breast. The tumor developed rapidly and was first noticed 10 days before hospital admission. Clinically the tumor appeared to measure more than 6 cm in length and showed all signs of carcinoma, such as skin fixation, edema and large veins. Sonographically, the inhomogeneous and ill-defined mass measured 3 cm in length (Fig. 1). Mammography revealed only a slight parenchymal asymmetry (Fig. 2). Laboratory fmdings were normal and there was no history of trauma or inflammation. The histological specimen showed heterotopic metaplastic ossitication of the mammary fatty tissue (Fig. 3). At lumpectomy the tumor had to be excised from the invaded
* This case was reviewed by Dr. Reiner (Vienna), Dr. SalzerKuntschik (Vienna), Dr. Huvos (Memorial Sloan Kettering Cancer Center, New York), Dr. Unni (Mayo Clinics, Rochester) and Dr. Weiss (AFIP) and diagnosed as myositis ossiticans by all. Address for reprints: Christoph L. Zollikofer, M.D., Institute of Radiology, Kantonsspital Winterthur, Brauerstrasse 15, CH-8401 Winterthur, Switzerland. 0720-048X/91/$03.50
0 1991 Elsevier Science Publishers
Fig. 1. Sonogram of palpable mass in left breast showing ill-defined inhomogeneous lesion of 3 cm in length.
pectoralis muscle. uneventful.
The
postoperative
course
was
Discussion Reactive heterotopic metaplastic calcification and ossification is commonly called myositis ossilicans, an osseous tumor of soft tissue originating in muscle, tendon, fascia, periosteum and subcutaneous fat [l-3]. It is a self-limiting ossifying process following trauma or infection and is also reported in association with neurological disorders. It has to be distinguished from myositis ossiticans progressiva, also called tibrodysplasia ossiticans progressiva, which is a congenital
B.V. (Biomedical
Division)
131
Fig. 2. Oblique mammograms demonstrating subtle difference in parenchymal density of upper outer quadrants, the left appearing denser than the right.
abnormality with characteristic malformation of the great toes, early onset of metaplastic bone formation and fatal prognosis [ 31. Circumscript, nontraumatic, nonprogressive myositis ossificans predominates in males under 30 years of age. Most of the lesions arise in the limbs, especially in their anterior parts. Tumors originating in the subcutaneous fat, as in our case, are rare and commonly afflict the upper extremity of women [ 11. The patients present with a painful softtissue swelling which gradually develops into a circumscribed, firm tumor within 2 or 3 weeks. Tumor calcification may be discovered at the end of the third week, typically starting in the periphery. Whereas Enzinger [ 41 found the center of the lesion to remain uncalcified, Anger&l [5] expected the whole tumor to become ossified. To our knowledge, no report has been published about this tumor entity in the fatty tissue of the breast. It should be included in the differential diagnostic gamut of rapidly growing tumors in young women. Diagnostic is the zonal pattern under the microscope (Fig. 3). The central part consists of an immature fibroblastic tissue with mild cellular pleomorphism and mitotic activity. The intermediate zone shows a mixture of fibroblasts, osteoblasts and osteoid. The periphery of the tumor is characterized by cancellous bone formation which gradually involves the remaining parts. Biopsy specimens from the very center might be confused with malignant tumors such as extraskeletal osteosarcoma because of their nuclear pleomorphism and mitotic activity [ 11. That is why biopsies should be taken from the periphery if one suspects myositis ossificans. Histological demonstration of the truly benign nature of the mass is imperative as well as radical excision, as there are suggestions for the possibility of malignant change in a benign tumor [ 11. The development of sarcoma in myositis ossificans has not been documented perhaps due to the early surgical ablation of the soft-tissue masses. Our patients tumor was histologically nonmalignant. In this case we see no need for further therapy. References
Fig. 3. Myositis ossificans characterized by inner plexiform cells (left bottom) and outer osteoid and calcification zone, Hematoxylin -Eosin, 45 x
1 Fine G, Stout AP. Osteogenic sarcoma of the extraskeletal soft tissues. Cancer 1956; 9: 1027-1043. 2 Ackerman L, Ramamurthy S, Jablokow V, Van Drunen M, Kaplan E. Case report 488. Skeletal Radio1 1988; 17: 310-314. 3 Samuelson KM, Coleman SS. Nontraumatic myositis ossificans in healthy individuals. JAMA 1976; 235: 1132-l 133. 4 Enzinger FM, Weiss SW. Soft tissue tumors, 2nd Edn. St. Louis: CV Mosby Co., 1988: 882-890. 5 Angervall L, Stener B, Stener I, Ahren C. Pseudomalignant osseous tumor of soft tissue. J Bone J Surg 1969; 51B: 654-663.
