Year : 2009 | Volume
: 5 | Issue : 4 | Page : 315--317
Pleomorphic liposarcoma of the pectoralis major muscle in an elderly man: Report of a case and review of literature
Atakan Sezer1, Nermin Tuncbilek2, Ufuk Usta3, Rusen Cosar-Alas4, Irfan Cicin5,
1 Department of General Surgery, Faculty of Medicine, Trakya University, Turkey
2 Department of Radiology, Faculty of Medicine, Trakya University, Turkey
3 Department of Pathology, Faculty of Medicine, Trakya University, Turkey
4 Department of Radiation Oncology, Faculty of Medicine, Trakya University, Turkey
5 Department of Medical Oncology, Faculty of Medicine, Trakya University, Turkey
Trakya Universitesi Hastanesi, Genel Cerrahi Anabilim Dali, -Edirne - 22030, Türkiye
Primary liposarcoma of the pectoral major muscle is extremely rare. We report a case of liposarcoma of the pectoral major muscle which was treated with surgical excision and postoperative radiotherapy. A 70-year-old man admitted with left-sided painless progressively growing breast mass. Radiological investigation revealed liposarcoma of the pectoralis major muscle. The patient was treated by surgical removal. Pathological diagnosis was pleomorphic liposarcoma. The patient had postoperative radiotherapy and free of disease for 9 months. Surgical excision and postoperative radiotherapy is the most favored treatment strategy. Careful follow-up is mandatory for detecting recurrences.
|How to cite this article:|
Sezer A, Tuncbilek N, Usta U, Cosar-Alas R, Cicin I. Pleomorphic liposarcoma of the pectoralis major muscle in an elderly man: Report of a case and review of literature.J Can Res Ther 2009;5:315-317
|How to cite this URL:|
Sezer A, Tuncbilek N, Usta U, Cosar-Alas R, Cicin I. Pleomorphic liposarcoma of the pectoralis major muscle in an elderly man: Report of a case and review of literature. J Can Res Ther [serial online] 2009 [cited 2018 Jun 18 ];5:315-317
Available from: http://www.cancerjournal.net/text.asp?2009/5/4/315/59908
Liposarcomas are the main group of soft tissue malignant tumors arising from the adipose tissue. They often present as relatively slow-growing, asymptomatic masses generally located in the thigh, gluteal region, retroperitoneum, leg, and shoulder area. Pleomorphic type is the rarest form of liposarcomas and pectoral muscle localization of the tumor is extremely rare.  To our knowledge to date, no study was performed on pleomorphic liposarcoma of the pectoral major muscle. In this paper, we reported a pleomorphic liposarcoma of the pectoral major muscle in a 70-year-old man.
A 70-year-old man admitted with painless left-sided breast mass progressively expanding for 8 months. There was no trauma, infection, or irradiation in his medical history. A physical examination revealed a soft, nontender, well-shaped, round, and mobile mass with a diameter of about 10 cm in the left upper chest wall. Posteroanterior chest radiography showed a homogeneous opacity in the left upper zone and the axillary region. On ultrasonography (USG), the mass was heterogeneously echogenic with well-defined margins. A Doppler USG examination detected an intratumoral arterial and venous flow. Craniocaudal mammography demonstrated an encapsulated high-density mass in the left pectoralis major muscle. The mass was not well visualized due to its deep submammary localization. A contrast-enhanced computed tomography (CT) scan showed a large subcutaneous tumor (6 × 8 × 10 cm) of the left pectoralis major muscle. The mass lesion was solid in density causing a smooth bulge in the anterior chest wall. No hemorrhage or calcification was noted. The mass had no significant invasion into the peripheral soft tissue or bone structures [Figure 1]. Preoperative examinations including respiratory functions, electrocardiography, biochemistry, and blood tests were normal. Under general anesthesia in a supine position, a longitudinal 10-cm incision over the mass was done. The subcutaneous fatty breast tissue was dissected laterally. The subcutaneous fatty and the breast tissue was dissected laterally. The fiber of the pectoral major muscle separated gently and a lobulated yellowish mass was seen [Figure 2]. It was well capsulated and there was no invasion into adjacent tissues and the chest wall. A complete resection of the lesion with partial pectoral major muscle resection with macroscopically clear margins was performed. In a pathological examination, the tumor was found to be microscopically composed of sheets of spindle or oval-shaped cells arranged in somewhat wavy bundles with an occasional haphazard pattern. The cells had prominent atypia with nuclear pleomorphism and hyperchromasia. Occasionally, there were lipoblasts with cytoplasmic vacuoles indenting the nuclei of the cells. The microscopic histopathologic investigation revealed clear margins of the tumor in resected specimen. Immunohistochemistry revealed a diffuse strong positive staining for vimentin and focal strong positive staining for the S100 antibody. CD34 and CD31 stained vessel walls but not the tumor cells. Immunohistochemistry was negative for alpha smooth muscle actin (alpha SMA), desmin, pankeratin, and CD68. Ki-67 showed nuclear reaction in 10-11% of the tumor cells [Figure 3]. The final histopathological diagnosis was high-grade liposarcoma. Radiotherapy was planned in the postoperative sixth week with a total dose 50 Gy in 25 fractions. Boost dose was planned with 12 MeV as total dose of 9 Gy in 4 fractions to the tumor bed. The patient was discharged at the third day of operation and the surgical wounds had healed completely. The patient was completely symptom free for 9 months after operation.
Liposarcoma is a malignant tumor which accounts for 1% of all human malignancies and approximately 20% of all mesenchymal malignancies. It generally affects middle-aged patients and is accepted as a tumor of adults.  These tumors usually arise from the primitive mesenchymal tissue in the deep soft tissue, such as intermuscular, facial planes and similar deep-seated vascular structures. The areas where they are mostly detected are lower limbs, popliteal fossa, adductor canal, medial thigh, shoulder, and retroperitoneal, perirenal, and mesenteric regions. Intramuscular lesions of the pectoral major muscle mass are extremely rare and to the best of our knowledge, few reports on these have been published. ,,, Clinically, the symptoms of liposarcoma are nonspecific. The mostly detected areas of these tumors are lower limbs, popliteal fossa, adductor canal, medial thigh, shoulder, and retroperitoneal, perirenal, and mesenteric regions. A painful mass is in only seen in approximately 5% of the patients. A palpable mass is the most common symptom. There is no race tendency. A slight male predominance has been reported. ,, Chest radiography has limited contribution in diagnosis and may be useful for pulmonary metastases. USG is helpful in confirming the presence and the nature of the mass. CT and magnetic resonance imaging (MRI) play an important role in the preoperative evaluation and differentiating diagnosis. CT scanning is superior to MRI in detailing bone erosion and tumor mineralization. MRI is useful in describing the fatty nature of the tumor and differentiating
subtypes.  There arefive morphologic subtypes of liposarcoma: well differentiated, myxoid, round cell, dedifferentiated, and pleomorphic form. Pleomorphic type is the least common form.  The differential diagnoses must involve lipomas, angiolipoma, leiomyosarcoma, spindle cell lipomas, round cell type-Ewing's sarcoma and lymphoma. Histological type is the major factor and tumor size, localization, and the extension of surgical resection are the other factors influencing the survival rate. Lower extremity tumors have better prognosis and retroperitoneal ones are worse. Liposarcoma is a primarily surgical disease. The principle of surgery is to remove the tumor entirely and prevent recurrence. Local recurrence largely depends on the margin status at the time of surgery. Intralesional or marginal resection in which the margins run through the tumor or pseudocapsule has recurrence rates of 40-100%. Surgery with wide or radical margins is the preferred treatment option with 1-10% recurrence rates. As the rarity of the liposarcomas of the pectoral major muscle, there is not an accepted treatment modality. In this case, there was no invasion into adjacent tissues and the chest wall. According to limited data and the case en bloc, tumor and pectoral muscle and/or chest wall resection with reconstructions in the case of invasion may be the best surgical procedure. In addition, as Mankin et al.  suggested radiotherapy is often helpful in decreasing the local recurrence and metastasis postoperatively.
In conclusion, pleomorphic liposarcomas are rare neoplasms and to our knowledge, this is the first reported case of pleomorphic liposarcoma of the pectoral major muscle. Complete surgical resection and adjuvant radiotherapy appear to prolong survival and improve the quality of life in these patients with careful follow-up. The gender, a small mass of the breast and a huge mass of the tumor, and appropriate radiological investigation destine us to a proper diagnosis but physicians must be careful in patients with small, smooth, elastic masses which can be misdiagnostic in both physical and radiological examinations.
|1||Dei Tos AP. Liposarcoma: new entities and evolving concepts. Ann Diag Path 2000;4:252-66.|
|2||Gopal U, Patel MH, Wadhwa MK. Intramuscular lipoma of the pectoralis major muscle. J Postgrad Med 2002;48:330-1.|
|3||Britton CA. Subpectoral mass mimicking a malignant breast mass on mammography. AJR Am J Roentgenol 1992;159:221.|
|4||Ikeda DM, Sickles EA. Mammographic demonstration of pectoral muscle microcalcifications. AJR Am J Roentgenol 1988;151:475-6. |
|5||Pant R, Poh AC, Hwang SG. An unusual case of an intramuscular lipoma of the pectoralis major muscle simulating a malignant breast mass. Ann Acad Med Singapore 2005;34:275-6.|
|6||Greager JA, Patel MK, Briele HA, Walker MJ, Wood DK, Gupta TK. Soft tisue sarcomas of the adult thoracic wall. Cancer 1987;59:370-3.|
|7||Kransdorf MJ, Bancroft LW, Peterson JJ, Murphey MD, Foster WC, Temple HT. Imaging of fatty tumors: Distinction of lipoma and well-differentiated liposarcoma. Radiology 2002;224:99-104.|
|8||Hornick JL, Bosenberg MW, Mentzel T, McMenamin ME, Oliveira AM, Fletcher CD. Pleomorphic liposarcoma: clinicopathologic analysis of 57 cases. Am J Surg Pathol 2004;28:1257-67.|
|9||Mankin HJ, Hornicek FJ. Diagnosis, classification, and management of soft tissue sarcomas. Cancer Control 2005;12:5-21.|