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Acta Oncologica Turcica 2022; 55: 180-185183The aetiology of IMT is unknown [1,2]. Atfirst, researchers thought that IMT was anautoimmune or reparative postinflammatorycondition. Currently, IMT is defined aneoplastic process with potential recurrenceand rarely metastasis.[3]. Recent molecularstudies showed that chromosome 2p23 ofanaplastic lymphoma kinase (ALK) rearrangementsin 50% of IMTs patients [4].IMTs have been encountered virtually in anyanatomical location. The most common site ofinvolvement is in the lung. Extrapulmonarysites include the mesentery and omentum, softtissue, pelvis, mediastinum, bone, larynx,central nervous system [5]. IMTs rarely occurin the breast [2].Most patients with IMT on the breast presentwith a palpable mass, which is sometimesdetected in screening mammography [5, 6].IMT on the breast is primarily seen in women,sometimes in men [4]. IMT can be observedin both breasts simultaneously [7]. In addition,it has been reported that the same patient maybe located in different organs with the breast[7]. Mammography and ultrasonographyshowed nonspecific features of IMT’s of thebreast. IMT can see as hypo-hyperechoic,smooth or irregularly circumscribed lesionson ultrasonographic images [5, 8, 9,10]. It hasalso been reported to co-occur in patients withbreast cancer [6]. In our case, it was describeda multilobulated heterogenous hypoechoiclesion in ultrasonography.IMTs of the breast are lack typical clinical andradiological characteristics. It was diagnosedat pathological examination after resection ofthe mass. IMTs are diagnosed based on theirpathological appearance and, breast IMTshave the same morphological features arisingin other sites. Breast IMT should bedifferentiated from other spindle cell lesionsof the breast ranging from reactive tumor-likelesions to high-grade malignant tumors. Thedistinction may be challenging in smallbiopsies. Histomorphological features andwww.actaoncologicaturcica.comimmunohistochemistry facilitate the correctdiagnosis of an excised specimen. Diagnosticfeatures are α-smooth muscle actin positivespindle cells admixed with inflammatory cellscomposed of plasma cells and lymphocytesand ALK expression by immunohistochemistryor ALK gene rearrangement.Nevertheless, approximately 50% of IMTpatients have ALK gene rearrangement. Thereis a good correlation between ALK immunohistochemistryand the ALK gene rearrangementby FISH analysis [4,6]. In ourcase, ALK was negative.Previous studies have indicated that ALKnegativeIMTs are more diagnosed at a higherage, associated with metastases andhistological differences from ALK-positiveIMTs. There s a higher degree of nuclearpleomorphism, atypical atypia mitosesdetected in ALK-negative IMTs [4,11]. IMTis more commonly seen in children and youngadults, but a broad age range has beendocumented [4]. Our case was 64 years old.Nuclear atypia and atypical mitoses were notidentified.IMTs recurrence rate is 2% for pulmonarytumors and 25% for extrapulmonary lesions[11]. The recurrence rate depends on illdefinedmorphology, tumor size, multifocality,the success of the surgical resection[11]. Also, a high degree of atypia, thepresence of ganglion-like cells, increasedmitotic figures, high Ki-67 proliferativeindex, the absence of ALK reactivity, oncogeneticprotein overexpression (p53) isassociated with potential aggressive growing,recurrence and malignancy [11,12]. For thisreason, complete surgical resection of IMTs ismandatory. [3] Distant metastasis of IMTs is5% of the cases [1, 13]. The metastatic IMTscases are characterized by a broad range ofage and primary sites, metastases typicallydeveloped in the lungs, brain, liver and bone[12]. In addition to this, metastasis to thelymph nodes or the mediastinum weredetected only two cases [13].Copyright©Ankara Onkoloji Hastanesi
Acta Oncologica Turcica 2022; 55: 180-185184IMTs of the breast are unusual conditions andcan be confused with malignancy [9].Malignant course, recurrence and metastasisof IMTs are also rare [8]. Until today a fewcases of IMT has been reported in the malebreast [4]. Surgical margin negative wideexcision is sufficient. Cases that developedrecurrence despite negative surgical marginshave been reported [12]. Wide excision withnegative margins or simple mastectomy isrecommended for a patient with IMT of thebreast [6, 8]. In this case, excision was madewith a negative surgical margin. Incompleteresection is associated with a high risk forrecurrence of IMT. IMT recurrence rate wasdetected at 25% in the other anatomicallocation [12]. In this case, recurrence was notdetected in the eight month follow up periods.Axillary lymph node management is unclearin the cases of breast IMT. If axillary lymphnode metastasis suspicion exists, wide localexcision with sentinel lymph node biopsy ormodified radical mastectomy should beperformed [6]. However, some researchsuggests that routine SNLB is unnecessarybecause of lymphatic spread of the lesion isunusual [8]. A case of breast inflammatorymyofibroblastic tumor with internal lymphnode and supraclavicular lymph nodemetastasis has been reported [14]. Othertreatment options for IMTs of the breasts inthe literature are corticosteroids, chemotherapy,radiotherapy and immunomodulation.Some reports show that corticosteroidsare helpful with treatment [15]. There aresporadic cases treated with chemotherapy andanti-inflammatory agents in two studies [10].Although this results, more investigation isneeded for treatment strategy for IMTs of thebreasts.ConclusionIMTs of the breast is a rare and intermediate(rarely metastasizing) malignant potentialtumor. Due to recurrence and metastasis risk,complete excision with negative margins andregular follow up plays a critical role intreating IMTs.REFERENCESwww.actaoncologicaturcica.com1. Coffin CM, Fletcher JA. Inflammatory myofibroblastictumor. In CDM Fletcher, JA Bridge, PCWHogendoorn, F Mertens (Eds) WHO classification oftumors of soft tissue and bone, 4th ed, pp: 83-84, Lyon,WHO press.2. Magro G., Salvatorelli L. Inflammatory MyofibroblasticTumor of the Breast. In: van Krieken J. (eds)Encyclopedia of Pathology. Encyclopedia of Pathology.2018, Pp: 185-191, Springer, Cham.3. Coffin CM, Watterson J, Priest JR, Dehner LP.Extrapulmonary inflammatory myofibroblastic tumor(inflammatory pseudotumor) a clinicopathologic andimmunohistochemical study of 84 cases. Am J SurgPathol. 1995; 19(8): 859-872.4. Coffin CM, Hornick JL, Fletcher CD.Inflammatory myofibroblastic tumor: comparison ofclinicopathologic, histologic, and immunohistochemicalfeatures including ALK expression in atypicaland aggressive cases. Am J Surg Pathol. 2007; 31(4):509-520.5. Choi EJ, Jin GY, Chung MJ, Moon WS, Youn HJ.Primary inflammatory myofibroblastic tumors of thebreast with metastasis: radiographic andhistopathologic predictive factors. J Breast Cancer.2015; 18(2): 200-205.6. Li J, Yun W, Qin J, Zhao J, Liu X, Wu J, et alInflammatory myofibroblastic tumor of the breastcoexisting with breast cancer: a case report. BreastCare (Basel). 2013; 8(4): 290-292.7. Lv X, Ye J, Jiang G, Wang Y, Lv J, Wang Y.Simultaneous multiple primary cancers withconcomitant inflammatory myofibroblastic tumor: acase report. Int J Clin Exp Pathol. 2020; 13 (5): 1212-1215.8. Markopoulos C, Charalampoudis P,Karagiannis E, Antonopoulou Z, Mantas D. Inflam-Copyright©Ankara Onkoloji Hastanesi
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