Phyllodes tumor with a benign heterologous osseous component: a diagnostic challenge

Phyllodes tumors (PTs) are rare fibroepithelial neoplasms of the breast and constitute 0.3–1% of all primary breast tumors. They should be characterized in to a benign, borderline or malignant category based on a combination of histological features. PTs can show heterologous components, typically sarcomatous, including osteosarcomatous and chondrosarcomatous. Benign heterologous components are exceedingly rare with only one prior reported case in the English literature. This case emphasizes how difficult establishing a correct diagnosis in PTs with heterologous components can be, especially when the tumor consists mainly of a benign heterologous component. We report the case of a 65 year old woman with a recurrent breast tumor initially misdiagnosed as benign osseous metaplasia. The tumor re‐occurred as a malignant PT dominated by benign osseous and chondroid metaplasia. Multiple metastases consisting of primarily mature bone and cartilage were seen in the lungs. On microscopic revision and considering the clinical course the primary breast tumor was re‐classified as a borderline PT.     

Cholesterol granuloma of the breast with unusual ossification features (osseous metaplasia)

Cholesterol granuloma of the breast is a rare benign condition that can be mistaken for breast cancer. We present a case of a 42-year-old woman who presented with a 1-year history of asymptomatic palpable nodule in the upper external quadrant of the right breast. Mammography and ultrasonography suggested carcinoma, but excisional biopsy revealed cholesterol granuloma with unusual osseous metaplasia. Although reported to occur more frequently in the middle ear and mastoid process, we believe that better awareness of this rare benign condition is most important to avoid misdiagnosis and unnecessary surgery.     

Carcinoma of the lung with osseous stromal metaplasia

Calcification has long been a determinant in the radiologic distinction of a benign pulmonary mass. However, rare examples of calcification without ossification in pulmonary adenocarcinoma and ossification in the bronchial carcinoid have led some investigators to warn against this approach. A case of pulmonary adenocarcinoma with stromal ossification is reported herein. The literature is reviewed for neoplasms that exhibit pulmonary ossification either by primary or metastatic lesions. To our knowledge, this case represents the first report of benign osseous stromal metaplasia in the primary lesion of a pulmonary adenocarcinoma.     

Osseous metaplasia of the colon in a diversion proctocolitis

Osseous metaplasia within the gastrointestinal tract is a rare phenomenon, seen most frequently in mucinproducing left-sided colonic adenocarcinomas. It has also been documented in a variety of benign conditions, occurring in polyps and lesions associated with inflammation and ulceration. This is the first case report, to the authors' knowledge, of osseous metaplasia associated with a diversion proctocolitis. The diversion was performed following stricture formation, secondary to complicated diverticular disease with diverticular phlegmon formation. In common with other cases, in which osseous metaplasia arises within a background of inflammation, the present case demonstrated stromal fibroblastic proliferation. The underlying pathogenesis of osseous metaplasia has not yet been elucidated, but secretion of various bone morphogenic proteins (belonging to the transforming growth factor-beta superfamily) and increased alkaline phosphatase activity by both epithelial and stromal cells have been documented.     

Localized primary amyloid tumor associated with osseous metaplasia presenting as bilateral breast masses: Cytologic and radiologic features

This report details the cytologic features of primary localized amyloid tumor of the breast presenting as bilateral breast masses in a 72-yr-old woman. Clinically and radiographically, the masses simulated metastatic or multifocal carcinoma. Fine-needle aspiration revealed irregular globules of acellular amorphous material and numerous multinucleated giant cells resembling granulomatous inflammation. Histology confirmed amyloid tumors with a foreign-body giant cell reaction in response to amyloid and foci of osseous metaplasia. Subsequent clinical workup included a serum electrophoresis and immunofixation which showed a small IgG k monoclonal protein. Urine immunofixation was negative for Bence Jones protein. Bone marrow examination revealed no evidence of a plasma cell dyscrasia. To date the patient has not developed clinical or laboratory evidence of systemic amyloidosis or multiple myeloma. Amyloidosis involving the breast and specifically localized primary amyloid tumors of the breast are rare and infrequently reported entities. To our knowledge, osseous metaplasia within isolated primary amyloid tumors of the breast has not been reported. We present this unusual case to illustrate the intratumoral calcification patterns mimicking carcinoma and to characterize the cytologic features. Emphasis is placed on the inclusion of amyloidosis in the differential diagnosis of breast masses.     

Ossifying adult xanthogranuloma

Although a xanthogranuloma is a relatively common benign cutaneous condition and ossification has been observed within many cutaneous lesions, the association between ossification and xanthogranuloma has not, to our knowledge, been reported previously. We believe we describe for the first time the case of a xanthogranuloma with marked osseous metaplasia on the trunk of a 41-year-old woman. Microscopically, the lesion showed typical features of a xanthogranuloma, with the exceptional feature of exuberant bone formation. The presence of bone within this lesion is likely secondary to a metaplastic process.     

Peutz-Jeghers syndrome with osseous metaplasia of the intestinal polyps

A cam of Peutz-Jeghers syndrome (PJS) with osseous metaplasia In three of 15 hamartomatous polyps of the small Intestine Is reported. At 35 years of age, the patient was diagnosed as having PJS by cutaneous pigmentation around the mouth and polyposis of the stomach, duodenum and Intestine. Fifty-two polyps of the large intestine were resected, which were Characteristic of those of PJS. Three of them showed adenomatous and carcinomatous changes, but there was no osseous metaplasia in any of the resected polyps. At age 40, he had surgery under the diagnosis of Intestinal obstruction. There were 15 polyps in the resected jejunum. These polyps were also characteristic of those of PJS. Additionally, three of these polyps were accompanied by osseous metaplasia. Histologically, mature bone formation and Calcification were found close to the hyperplastic glands In the submucosa or in the propriate muscle. Malignant transformation was not observed. Osseous metaplasia is extremely rare in benign potyps, and it has not been reported in hamartomatous polyps of PJS to date. The knowledge of this association may be helpful in the clinical diagnosis of this benign lesion in PJS.     

Primary amyloid tumour of the breast: a case report

A case of primary amyloid tumour of the breast is reported with a brief review of the literature. The tumour was mammographically suspicious of carcinoma. Fine needle aspiration cytology yielded clumps of amorphous material surrounded by giant cells and lymphocytes. Subsequent histology showed nodular amyloid associated with osseous metaplasia and giant cell reaction. There are 13 cases of amyloid tumour of the breast reported in the literature and in four of these fine needle aspiration had been undertaken.     

Lung osteoma—a new benign lung lesion

Extraskeletal osteomas have not been described in the lung. Tumors with osseous elements can be found, such as hamartoma and amyloid tumor, and reactive lesions such as osseous metaplasia. A 39-year-old male patient was treated for multiple myeloma and got a bone marrow transplantation 2 years and a few months before he presented with a solitary well-circumscribed tumor in the right middle lobe. The patient underwent surgical resection. The tumor presented with a fibrous capsule and consisted of mature bone trabecules. Within the tumor, fatty tissue was seen. There were small bone spicules interpreted as areas of new bone formation and appositional growth. No amyloid deposition, no immature epithelial tubules as in hamartomas, and no normal lung structure as in osseous metaplasia were seen. Within the osseous elements, a positive reaction was seen with antibodies for osteonectin, whereas the reaction for calcitonin was negative. To the best of our knowledge, this is the first case of an osteoma being reported in the lung looking like any other extraskeletal osteoma. This tumor might have been induced by circulating stem cells; however, due to autologous bona marrow transplantation, this cannot be proven.     

Adenocarcinoma arising in a traditional serrated adenoma of the rectosigmoid colon with osseous metaplasia

Within the gastrointestinal tract, osseous metaplasia is an extremely rare phenomenon. It has only recently been described within a traditional serrated adenoma. Serrated colorectal carcinoma is the end point of the serrated neoplasia pathway. Left sided lesions typically arise from traditional serrated adenomas and represent only 8% of colorectal carcinomas. Herein reported is a case of colorectal adenocarcinoma arising from a traditional serrated adenoma with the rare occurrence of osseous metaplasia within the adenoma. The significance of the finding is discussed.     

Fine-needle aspiration of a metaplastic breast carcinoma with extensive melanocytic differentiation: a case report

Metaplastic carcinomas of the breast are uncommon breast tumors with aberrant cellular differentiation, most commonly showing ductal, squamous, and mesenchymal components. A breast carcinoma composed of both epithelial and melanocytic differentiation is rare, with only four previously reported cases in the literature. We present the fifth reported case, where the diagnosis was suggested by fine-needle aspiration (FNA) and later confirmed after the surgical specimen was excised. Histologically, this neoplasm revealed multidirectional differentiation, consisting primarily of squamous and melanocytic cell types, with focal glandular and osseous metaplasia. Based on the morphologic, immunohistochemical, and ultrastructural findings, we conclude that such tumors fall within the spectrum of metaplastic carcinomas of the breast. We believe that this case will further contribute to the understanding of this enigmatic tumor.     

Endometrial tubal metaplasia in a young puerperal woman after breast cancer

Introduction: Tamoxifen is the usual endocrine (anti-estrogen) therapy for hormone receptor-positive breast cancer in pre and post-menopausal women. Previous studies have suggested an increased prevalence of endometrial diseases after treatment with tamoxifen. Case presentation: The authors report a case of 38-year-old woman with diagnosis of endometrial polyp and tubal metaplasia, during puerperium and after micropapillary ductal breast cancer surgery, 5 years of tamoxifen treatment, spontaneous pregnancy without complications and full-term vaginal delivery. Conclusion: Tamoxifen is a safe and reliable treatment of breast cancer, but data suggest an association with endometrial polyps, hyperplasia, metaplasia and carcinoma. One of the most common types of endometrial metaplasia is ciliated tubal metaplasia. It is generally known that endometrial tubal metaplasia is a benign disease. However studies propose endometrial tubal metaplasia to be a potential premalignant endometrial lesion and its association with endometrial hyperplasia and well-differentiated endometrioid carcinoma. We propose close monitoring of patients taking tamoxifen and prompt evaluation of any uterine bleeding or pelvic complaint or abnormal TVUS images.     

Basaloid squamous carcinoma with a spindle cell component and osseous metaplasia presenting as a polyp of the hypopharynx

We report a case of basaloid squamous carcinoma with a spindle cell component of the hypopharynx, in a 61-years-old-man. An excisional biopsy of a pedonculated and polypoid tumour was performed by endoscopy. The histologic examination revealed a biphasic tumour with both a basaloid carcinomatous and a spindle cell component. Focally, osseous metaplasia was seen. The spindle cell component demonstrated immunoreactivity with the p63 epithelial marker. The patient was treated with chemotherapy followed by radiotherapy. The patient has been free of disease for one year. It's the ninth case reported in the literature of a biphasic carcinoma with both a basaloid squamous and a spindle cell component and the first case with osseous metaplasia.     

Synovial metaplasia,a specialized form of repair

Synovial metaplasia is a change seen most frequently in the tissues surrounding silicone breast prostheses and in healing tissue adjacent to joint prostheses. It has also been described in skin and soft tissues, most frequently in healing or healed traumatic or surgical wounds. We report a case of synovial metaplasia occurring in a hitherto unreported location, namely, adjacent to a silicone low-pressure voice prosthesis. A review of cases of synovial metaplasia reported in the literature revealed that in most cases, spaces that form adjacent to foreign material (most commonly silicone breast prostheses) and the smooth gliding surfaces of the foreign material that resist penetration by fibroblast processes are frequent associated findings that precede the occurrence of synovial metaplasia. Thus, synovial metaplasia might represent a specialized form of healing in cases that have this combination of physical features.     

A case of epithelioid hemangioma of the spine

Epithelioid hemangioma is a rare and benign vascular tumor, most often occurring in the skin. Numerous other localizations, including bones, have been reported. The overall favorable clinical outcome of cutaneous epithelioid hemangioma is now well documented, but it still remains debated in osseous localization, as local recurrences and metastases have been described. We report a case of epithelioid hemangioma of the spine occurring in a 25-year-old male, and discuss main differential diagnoses. Recent studies tend to demonstrate that osseous epithelioid hemangioma, as cutaneous epithelioid hemangioma, should be considered as a benign tumor. Histologically, epithelioid hemangioma consists of a vascular proliferation with diffuse or lobular pattern and features vascular spaces lined by epitheliod endothelial cells with numerous lymphocytes and eosinophils. The main differential diagnosis is represented by epithelioid hemangioendothelioma, the surgical treatment of which must be more aggressive. Precise histological diagnosis is essential for accurate clinical management and to avoid overtreatment.     

Choroid plexus papilloma with osseous and adipose metaplasia

Rare cases of osseous and chondroid metaplasia in choroid plexus papillomas have been described. We report a case of left lateral ventricular choroid plexus papilloma presenting in a 25-year-old man. The tumor demonstrates prominent calcification with associated osseous metaplasia and a region of adipose metaplasia, which has not been previously described in these tumors. There is no evidence of mucin in the papilloma on mucicarmine and alcian blue stains. A MIB-1 labeling index (marker of cell proliferation) of 0.1% was noted. P53 immunoreactivity was not observed in the papilloma. Ann Diagn Pathol 5:43-47, 2001.     

Extensive squamous metaplasia in gynecomastia

Extensive squamous metaplasia is described in a case of gynecomastia. Numerous ducts in all sections of breast tissue revealed multiple foci of squamous metaplasia, many of which included large, papillary excrescences of keratinizing squamous cells into duct lumens, with foci of dyskeratosis. Review of four years of gynecomastia cases from our surgical pathology files revealed a total incidence of squamous metaplasia equaling six of 40 cases of gynecomastia, including the case reported here. The other five cases included only one or two small foci of squamous metaplasia. These findings demonstrate that squamous metaplasia in gynecomastia is not rare, but is usually very limited. However, an unusual case, such as that reported here, may show extensive, florid squamous metaplasia, without associated inflammation or neoplasm.     

Primary intermediate-grade cardiac myxofibrosarcoma with osseous metaplasia: an extremely rare occurrence with a previously unreported feature

Primary cardiac myxofibrosarcoma (MFS) is a very rare cardiac tumor with no more than 22 cases reported in the literature, including our case. We report an MFS arising in the left atrium in a 65-year-old woman who presented with pneumonia and cardiac failure. The 9.5-cm mass was diagnosed by echocardiogram. Histopathology examination showed an intermediate-grade MFS with osseous metaplasia, a feature that has not been reported before.     

Atypical apocrine metaplasia in sclerosing lesions of the breast: a study of 51 patients

Sclerosing breast lesions with cytologically atypical apocrine metaplasia present a difficult diagnostic problem. The clinical significance of these lesions has not been established although, historically, apocrine metaplasia and sclerosing adenosis have been regarded as totally benign. To further assess these lesions, we studied 51 patients with atypical apocrine metaplasia in sclerosing lesions of the breast, obtaining an average follow-up of 35 mo (12 to 76 mo). For convenience, these have been grouped together as atypical apocrine sclerosing lesions (AASL). The average age at diagnosis was 58 yr. The lesions tended to be small (67% less than 1.0 cm) and usually were detected by mammography (78%). Four patients had an ipsilateral mastectomy following a biopsy of AASL that was interpreted as carcinoma or "precancerous" by the referring pathologist. Two patients had nonapocrine intraductal and infiltrating duct carcinoma in previous contralateral mastectomy specimens. None of the 47 women with an intact breast developed breast carcinoma during the follow-up period. Immediate treatment with surgery and/or radiation is not indicated. The long-term clinical implication of these lesions is yet to be determined; therefore, continued clinical observation of AASL patients is advisable.     

Intestinal metaplasia in stilboestrol-induced vaginal adenosis

We present an unusual case of vaginal adenosis with progressive intestinal metaplasia, previously undescribed, in a female patient exposed to stilboestrol in utero. Argentaffin cells were present within these areas, a feature not previously reported in benign vaginal adenosis. The development of the intestinal metaplasia coincided with the onset of a vaginal discharge so severe that, after 7 years, a vaginal resection was performed. Intestinal-type glands have been described in the cervix and ovary, almost invariably associated with malignancy. The possible role of intestinal metaplasia in the development of enteric-type neoplasms of the vagina is discussed.