Wo m e n s I m a g i n g O r i g i n a l R e s e a r c h

Smith et al. Imaging of Primary Breast Sarcoma Womens Imaging Original Research

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Imaging Features of Primary Breast Sarcoma

Taletha B. Smith1 Michael Z. Gilcrease 2 Lumarie Santiago1 Kelly K. Hunt 3 Wei T. Yang1
Smith TB, Gilcrease MZ, Santiago L, Hunt KK, Yang WT

OBJECTIVE. This purpose of this study is to describe the imaging ndings in patients who presented with a diagnosis of primary breast sarcoma. MATERIALS AND METHODS. A search was performed of the pathology database at a single institution for patients with a histopathologic diagnosis of primary breast sarcoma or pure sarcomatoid carcinoma and who underwent preoperative mammography, sonography, or MRI. Patients with malignant phyllodes tumors were excluded. The imaging studies were retrospectively reviewed using the American College of Radiology BI-RADS lexicon. We documented clinical presentation, histopathologic characteristics, axillary nodal status, and the presence of distant metastases. RESULTS. Twenty-four women were included in the study; their mean age was 56 years (range, 2186 years), and the mean tumor size was 6.1 cm (range, 0.915 cm). Only one tumor was identied in each patient. The predominant mammographic nding was a noncalcied oval mass with indistinct (9/14 [64%]) margins. Sonography most commonly revealed an oval (19/22 [86%]) solid mass with indistinct margins (17/22 [77%]). The masses were frequently hypoechoic (18/21 [86%]) and hypervascular (17/20 [85%]) and had posterior acoustic enhancement (13/21 [62%]). MRI showed a round or oval T2-hyperintense mass with irregular margins in four of ve (80%) patients, and inhomogeneous enhancement was most common (3/4 [75%]). CONCLUSION. Primary breast sarcoma has imaging features that are not typically seen in inltrating ductal carcinoma. A large oval hypervascular mass with indistinct margins should raise the suspicion for a primary breast sarcoma and prompt biopsy. reast sarcoma is a rare but aggressive entity that accounts for less than 1% of all breast cancers in the United States, with an incidence of 44.8 cases per 10 million women per year [1, 2]. Specic types of breast sarcoma include angiosarcoma, liposarcoma, brosarcoma, leiomyosarcoma, sarcomas with bone and cartilage, and malignant brous histiocytoma [3]. Breast sarcomas can grow very large, but most studies report a mean tumor size of 3 cm and a median tumor size of 4 cm [3]. Tumor size is an important prognostic factor, with sarcomas measuring less than 5 cm associated with a better outcome. As in other breast tumors, margin status of resected tumors is a major factor in recurrence [4]. Currently, mastectomy without axillary lymph node dissection is considered the standard treatment for women with breast sarcoma because lymphatic spread is uncommon in this type of malignancy [4].

Keywords: mammography, MRI, primary breast sarcoma, ultrasound DOI:10.2214/AJR.11.7341 Received June 8, 2011; accepted after revision September 1, 2011.
1 Department of Diagnostic Radiology, The University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1350, Houston, TX 77030. Address correspondence to W. T. Yang (wyang@mdanderson.org). 2 Department of Pathology, The University of Texas M. D. Anderson Cancer Center, Houston, TX. 3 Department of Surgical Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, TX.

WEB This is a Web exclusive article. AJR 2012; 198:W386W393 0361803X/12/1984W386 American Roentgen Ray Society

At present, various imaging modalities, such as mammography, sonography, and MRI, are used to evaluate primary breast sarcoma. However, because breast sarcomas occur infrequently, analysis of their imaging characteristics has been limited. Previous studies have consisted mainly of case reports and a few retrospective studies. Knowledge of the imaging features is important to ensure prompt diagnosis and treatment, particularly considering the aggressiveness of these sarcomas. In this retrospective review, we describe and compare the histopathologic ndings and mammographic, sonographic, and MRI characteristics in patients who presented with primary breast sarcomas. Materials and Methods Patient Selection
We searched the pathology database at The University of Texas M. D. Anderson Cancer Center to identify patients who had received a histologic diagnosis

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of primary breast sarcoma between January 2001 and February 2011. Only patients who had available preoperative mammography, sonography, or MRI examinations between January 2006 and February 2011 were included in our study. Because pure sarcomatoid carcinoma of the breast may be indistinguishable microscopically from primary breast sarcoma, we included for comparison those patients with a histopathologic diagnosis of metaplastic carcinoma if more than 95% of sarcomatoid features were present and excluded patients with malignant phyllodes tumors. Clinical notes, pathology records, and imaging studies were reviewed to document data on patient age and clinical ndings (palpable nding, nipple inversion or retraction, nipple discharge, and skin changes) at presentation, imaging features, breast tumor histopathology, axillary node status, and the presence of local or distant metastases. For this study, our institutional review board approved the retrospective data collection and analysis. calcication, shape, margin type, and the presence of skin thickening or axillary adenopathy.

Sonography Mammography
Mammograms of the study-eligible patients that had been acquired both from M. D. Anderson Cancer Center and from outside institutions were reviewed. On-site mammograms had been obtained with a mammography unit (Lorad M-III, Hologic) and included at least two standard views (craniocaudal and mediolateral oblique). For the current study, the images were retrospectively reviewed by two radiologists with 3 and 16 years of experience, respectively, using the American College of Radiology (ACR) BI-RADS Atlas lexicon [5]. We recorded data, including the presence of a mass or We reviewed real-time gray-scale and color Doppler sonograms acquired both on site and from outside institutions. Sonography at our institution had been performed by both a sonographer certied by the American Registry for Diagnostic Medical Sonography in breast sonography and by one of 13 radiologists who specialize in breast imaging. Sonograms were performed on an ultrasound system (ACOUSON Antares, Siemens Healthcare) using 135-MHz linear array transducers. Lesion characteristics, such as shape, margin, lesion boundary, echo pattern, posterior acoustic features, the presence of calcications, vascularity, and surrounding tissue features, were documented by the same two radiologists using the ACR BI-RADS lexicon [6]. The presence of regional adenopathy was also noted.

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TABLE 1: Mammographic Characteristics of 16 Patients With Primary BreastSarcoma

Mammographic Characteristics General ndings Mass Yes No Skin thickening Yes No Breast density Heterogeneously dense Scattered broglandular densities Abnormal ipsilateral lymph nodes Yes No Characteristics of the mass (n = 14) Mass shape Oval Lobular Round Mass margin Circumscribed Indistinct Microlobulated Mass density High density Equal density Presence of calcication Yes No
NoteThe data include four patients with pure sarcomatoid carcinoma.

No. (%) of Patients

MRI
14 (88) 2 (13) 2 (13) 14 (88) 10 (63) 6 (38) 0 (0) 16 (100) MRI examinations that were acquired from both outside facilities and from our institution were evaluated. For MRI examinations performed at our institution, a 1.5-T or 3-T MRI system (Signa HDe and Signa HDxt, both from GE Healthcare) was used to acquire unenhanced and contrast-enhanced images using an eight-channel coil. Sequences included unenhanced axial T1-weighted, sagittal fat-suppressed T2-weighted, and axial diffusion-weighted sequences, as well as contrast-enhanced sagittal dynamic T1-weighted and axial delayed fat-suppressed T1weighted images. Subtraction-generated images were also reviewed, and DynaCad (Invivo) was used to evaluate kinetics. Images were reviewed by the same two radiologists, and data were recorded using the ACR BI-RADS lexicon [7]. Recorded characteristics included mass versus nonmasslike character, shape, margin, enhancement pattern, kinetics, and the presence of skin, nipple, or pectoralis muscle involvement. The presence of regional adenopathy was also documented.

12 (86) 1 (7) 1 (7) 4 (29) 9 (64) 1 (7) 12 (86) 2 (14) 3 (21) 11 (79)

Histopathologic Characteristics
Specimens obtained from outside facilities and our institution were reviewed by a dedicated breast pathologist (with 15 years of experience). Patients with malignant phyllodes tumors were excluded. Slides from patients with a diagnosis of metaplastic sarcomatoid carcinoma were retrospectively reviewed to identify those with pure (> 95%) sarcomatoid morphology, and only pure sarcomatoid carcinomas were included in this study. In addition, we reviewed the nal histopathologic results for ipsilateral lymph nodes obtained by axillary lymph node dissection or by needle biopsy.

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Smith et al.
Fig. 1 40-year-old woman with palpable left breast mass. Final histopathologic analysis at segmental mastectomy (after core needle biopsy) revealed highgrade sarcoma. A, Mediolateral oblique left mammogram shows oval high-density mass (arrow ) with indistinct margins. B, Longitudinal power Doppler sonogram of left breast shows solid oval hypoechoic hypervascular mass with circumscribed margins (arrow ) and posterior acoustic enhancement.

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Results Patient Selection We identied 24 women who met our inclusion criteria. Each woman had a single tumor in one breast. The mean patient age at presentation was 56 years (range, 2186 years; median, 53 years). Ninety-two percent (22/24) of the patients with primary breast sarcoma presented with a palpable nding. The two patients without a palpable abnormality had new skin thickening and discoloration on examination and were found to have radiation-associated angiosarcoma of the breast. Skin ndings were documented in 21 patients, and the presence or absence of nipple retraction and discharge was recorded in 22 patients. Twenty-four percent (5/21) of patients had skin changes, four of which were diagnosed as radiation-associated angiosarcoma. Five percent (1/22) of patients had nipple retraction, and none (0/22) had nipple discharge on presentation. The mean tumor size was 6.1 cm (range, 0.915 cm; median, 5.0 cm).

A
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Fig. 2 65-year-old woman presented with palpable left breast mass. Final histopathologic analysis revealed high-grade sarcoma, not further classied. A, Mediolateral oblique mammogram of left breast shows oval high-density mass with circumscribed margin (arrow ). Asterisks are CAD marks indicating mass. No associated skin thickening or ipsilateral axillary adenopathy is present. B, Extended-FOV sonogram (ACOUSON Antares, Siemens Healthcare) of central left breast shows large complex mixed cystic and solid mass (arrows ) with indistinct margins. C, Sagittal T1-weighted subtraction image with parametric color coding shows large complex mass with peripheral enhancement (arrow ), likely reecting internal necrosis. Kinetic evaluation of peripheral areas of enhancement showed rapid initial enhancement and delayed washout (data not shown).

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Fig. 3 53-year-old woman who presented with palpable left breast mass. Histopathologic analysis revealed high-grade sarcoma with features of osteosarcoma. A, Lateromedial spot magnication mammogram of left breast reveals high-density mass (short arrow ) with indistinct margins and osteoid calcication (long arrow ). B, Longitudinal sonogram of left breast shows prominent shadowing (arrow ) secondary to calcication within mass. C, Photomicrograph of high-grade sarcoma with chondroid and osseous differentiation. Photomicrograph shows mainly atypical chondrocytes within tumor (thick arrow ) with focal osteoid production (long thin arrow ) and moderately circumscribed tumor border focally (short thin arrow ).

Mammography Of the 24 patients, 16 had undergone a preoperative mammogram (Table 1). Of those 16 patients, 14 had tumors that presented as a single mass on mammography (the two sarcomas that did not present as a mass were radiation-associated angiosarcomas that presented as mammographically visible skin thickening). Eighty-six percent (12/14) of the sarcomas presented as an oval mass, 7% (1/14) as a lobular mass, and 7% (1/14) as a round mass. Sixty-four percent (9/14) of the masses had indistinct margins, 29% (4/14) were circumscribed, and 7% were microlobulated (Figs. 1A, 2A, and 3A). Most of the masses were of high density, and calcication was present within the mass in 21% (3/14) of cases (Figs. 4A and 5A). The three cases with mass and calcication on mammography included a sarcomatoid metaplastic tumor, an osteosarcoma, and a high-grade sarcoma not otherwise classied. Breast tissue was heterogeneously dense in 63% of patients; 38% had scattered broglandular densities. Sonography Both gray-scale and power Doppler sonography were performed on 20 patients with breast sarcoma, and gray-scale sonography alone performed on two patients (Table 2). All 22 patients with breast sonography had a single mass, three of which were located in the dermis (Figs. 5A and 5B). The three patients with breast sarcoma who presented with a dermal mass and skin thickening were found to have radiation-associated angiosarcoma. The masses observed on sonography

A
Fig. 4 82-year-old woman who presented with palpable left breast mass. Final histopathologic analysis revealed sarcomatoid carcinoma composed mainly of high-grade spindle cell component with focal areas of osteoid production. A, Lateromedial magnication mammogram of left breast shows high-density mass (arrow ) with indistinct margins and associated osteoid calcication. B, Longitudinal gray-scale sonogram of left breast shows solid oval hypoechoic mass (long arrows ) with indistinct margins and internal calcications (short arrows ).

were oval in 86% (19/22) and round in 14% (3/22) of cases (Figs. 1B, 2B, and 3B). Margin analysis revealed that 77% (17/22) were indistinct, 14% (3/22) were microlobulated, and 9% (2/22) were circumscribed. The masses were hypoechoic in 82% of cases, and had posterior acoustic enhancement in 59% of cases. Echotexture could not be adequately assessed in one case because of dense calcication within the mass, and posterior acoustic features could not be determined in one case because of the large size of the mass. Seventy-seven percent of masses had vascularity, 71% with internal and 29% marginal vascu-

larity. Calcications were identied in 9% of the masses (Figs. 4B, 5B, and 5C). MRI Five of the 24 patients with primary breast sarcoma underwent breast MRI. One of those ve patients had a local recurrence (Table 3). Four patients presented with a single mass with variable enhancement, and one patient presented only with enhancing skin thickening. (The latter patient had radiation-associated angiosarcoma.) Of the four tumors with a breast mass, three had an oval mass and one had a round mass (Fig. 2C). Margins for

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B
Fig. 572-year-old woman who underwent left segmental mastectomy and radiation therapy for invasive ductal carcinoma 10 years before who presented with new skin nodule and erythema. Final histopathologic analysis revealed cutaneous angiosarcoma. A, Longitudinal gray-scale sonogram of lower-outer quadrant left breast shows solid isoechoic dermal mass with indistinct margins (calipers ) and posterior acoustic enhancement (arrow ) corresponding to palpable nding. B, Longitudinal power Doppler sonogram shows internal hypervascularity within mass (arrow ). C, Photomicrograph shows main part of tumor (long arrow ) is composed of atypical spindled cells with intervening cleft formation. Smaller vessels formed by atypical cells (short arrow ) permeate surrounding tissue.

C all masses were irregular or spiculated. Two of four tumors showed T1 hypointensity, and two showed mixed T1 signal, likely secondary to internal necrosis. All four masses showed T2 and STIR hyperintensity on unenhanced images. Enhancement was variable, with one smaller mass (2 cm) showing homogeneous enhancement and the remaining larger masses (6.515 cm) showing heterogeneous, mainly peripheral enhancement, likely secondary to central necrosis. Kinetics could only be evaluated in two tumors both of which showed early rapid uptake with delayed washout. Histopathologic Characteristics The histologic characteristics of the 24 unifocal primary breast sarcomas are as follows: four were metaplastic carcinomas with pure (> 95%) sarcomatoid features, four were nonradiation-associated angiosarcomas, four were radiation-associated angiosarcomas, two were osteosarcomas, one was malignant brous histiocytoma, and one was liposarcoma (Table 4). Eight patients had primary breast sarcoma not otherwise classied. Fourteen of the 24 patients (58%) underwent histologic evaluation of the ipsilateral axillary lymph nodes, by either surgical lymph node sampling or needle biopsy. Two of the 14 (14%) patients had ipsilateral axillary lymph node metastasis. At histologic examination, their primary tumors were high-grade breast sarcoma not otherwise classied in one patient and pure sarcomatoid carcinoma in the second patient; the tumor size was larger than 5.0 cm in both patients. Distant metastatic disease was found in 29% (7/24) of patients; 13% (3/24) had evidence of local recurrence. All recurrences happened within 4 years of initial surgical treatment. The seven patients with distant metastases had the following tumor subtypes: primary breast sarcoma not otherwise classied (n = 3), osteosarcoma (n = 2), radiation-associated angiosarcoma (n = 1), and metaplastic (pure sarcomatoid) carcinoma (n = 1). The average tumor size for the seven patients with distant metastasis was 8.0 cm (range, 3.013 cm; median, 8.0 cm). Sites of distant metastases included the lungs (n = 7), liver (n = 2), bone (n = 2), and supercial soft tissues (n = 1). Discussion The ndings in this retrospective analysis indicate that primary breast sarcomas and pure sarcomatoid carcinomas of the breast present with mammographic and sonographic imaging features that differ from those of typical inltrating ductal carcinoma. Because breast sarcoma is rare, analysis of its imaging characteristics has been limited [810]. A recent retrospective review of 21 primary breast sarcomas described a breast mass in 68% and architectural distortion in 32% of tumors [8]. Although small in number, the majority (67%, [4/6]) of tumors with mammographically visible architectural distortion were angiosarcomas [8]. Another retrospective review of 26 primary breast angiosarcomas described the most frequent mammography nding (seen in 50% of cases [8/16]) as oval circumscribed noncalcied masses and focal asymmetry (seen in 31% of cases [5/16]) [9]. In our study, the majority of sarcomas presented as noncalcied oval masses with indistinct or circumscribed margins at mammography, similar to the study by Yang et al. [9]. However, unlike previous reports, we noted unique coarse osteoid calcications in 21% of the breast sarcomas, highlighting the different morphology of calcications in breast sarcomas when compared to the typical microcalcications of ductal carcinomas. To our knowl-

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Imaging of Primary Breast Sarcoma TABLE 2: Sonographic Characteristics of 22 Patients With Primary BreastSarcoma
Sonographic Characteristics General ndings Mass Downloaded from www.ajronline.org by 114.79.29.226 on 12/13/13 from IP address 114.79.29.226. Copyright ARRS. For personal use only; all rights reserved Yesa No Skin thickening Yesb No Abnormal ipsilateral lymph nodes Yes No Mass characteristics Shape Oval Round Margin Circumscribed Indistinct Microlobulated Echogenicity Hypoechoic Hyperechoic Complex NA Posterior acoustic features Enhancement Neutral Shadowing NA Vascularity Yes No NA Region of vascularity (n = 17) Internal Margin Presence of calcicationc Yes No 2 (9) 20 (91) 12 (71) 5 (29) 17 (77) 3 (14) 2 (9) 13 (59) 7 (32) 1 (5) 1 (5) 18 (82) 2 (9) 1 (5) 1 (5) 2 (9) 17 (77) 3 (14) 19 (86) 3 (14) 0 (0) 22 (100) 3 (14) 19 (86) 22 (100) 0 (0) No. (%) of Patients

NoteThe data include four patients with pure sarcomatoid carcinoma. NA = not available. aThree of the masses were located in the dermis. bAll cases of breast sarcoma with skin thickening were radiation-associated angiosarcomas. cAll cases of breast sarcoma with calcication had osteoid-type calcication.

edge, this feature has not been emphasized in previous reports on breast sarcomas. At sonography, the primary breast sarcomas in our study were oval solid hypoecho-

ic masses with indistinct margins, posterior acoustic enhancement, and internal hypervascularity, ndings similar to those reported by Surov et al. [8]. Such imaging features, though

nonspecic, are similar to those associated with phyllodes tumors [11]. Recognition of these similarities will help avoid misdiagnosis of an aggressive sarcoma as a benign phyllodes tumor during examination of a breast mass. Distinguishing phyllodes tumors from primary breast sarcomas and benign broepithelial lesions is difcult on mammography and ultrasound. A retrospective review of phyllodes tumors [12] described a lobulated mass with circumscribed or indistinct margins as the most common presentation of both malignant and benign lesions, whereas Tan et al. [13] reported that an irregular shape on sonography is more common in malignant and borderline phyllodes tumors. Although not specically evaluated in our study, the MRI appearance may aid in distinguishing sarcomas from phyllodes tumors. Both tumor types can present as lobulated masses with smooth margins and cystic areas on MRI [13]. However, internal septations and hyperintense slitlike uid-lled spaces described on T2-weighted images are features reported in phyllodes tumors that we did not nd at MRI in breast sarcomas [13]. The MRI appearance of brosarcomas has been reported as well-dened multilobulated masses with internal septa and homogeneous high T2 signal intensity, secondary to the abundant intercellular myxoid stroma [14]. Primary breast sarcomas are a heterogeneous group of malignant neoplasms that arise from the interlobular mesenchymal elements, which comprise the supporting mammary stroma [15]. The most common form of breast sarcoma is angiosarcoma; other distinct breast sarcomas include liposarcoma, brosarcoma, leiomyosarcoma, sarcomas with bone and cartilage, and malignant brous histiocytoma. Primary breast sarcomas have variable sizes, ranging from 1 to 30 cm, with a mean and median size of 3 and 4 cm, respectively. The growth pattern of most primary breast sarcomas is that of a rapidly expanding mass with a pushing border, causing the mass to appear well circumscribed grossly, even though the border may show histologic invasion. This may explain the circumscribed or indistinct margins of oval masses seen in our study, and is in contrast to most invasive breast carcinomas, which typically have stellate or illdened borders macroscopically and widely inltrative borders at the microscopic level. Angiosarcomas of the breast are not as circumscribed as other breast sarcomas and grow as ill-dened hemorrhagic mass lesions,

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Smith et al. TABLE 3: MRI Characteristics of Five Patients With Primary Breast Sarcoma
MRI Characteristics General ndings Breast lesion Downloaded from www.ajronline.org by 114.79.29.226 on 12/13/13 from IP address 114.79.29.226. Copyright ARRS. For personal use only; all rights reserved Mass Nonmasslike Neithera Skin thickening Yesa No Abnormal ipsilateral lymph nodes Yes No Mass characteristics (n = 4)a Shape Oval Round Margin Irregular or spiculated Smooth T1 signal Hypointense Isointense Hyperintense Mixed T2 or STIR signal Hypointense Isointense Hyperintense Mixed Enhancement Heterogeneous Homogeneous Kinetics (n = 2)b: rapid early uptake with delayed washout
radiation-associated angiosarcoma.

No. (%) of Patients

4 (80) 0 (0) 1 (20) 1 (20) 4 (80) 0 (0) 5 (100)

3 (75) 1 (25) 4 (100) 0 (0) 2 (50) 0 (0) 0 (0) 2 (50) 0 (0) 0 (0) 4 (100) 0 (0) 3 (75) 1 (25) 2 (100)

aSkin thickening and enhancement without an intraparenchymal breast mass was present in a patient with bKinetic information was only available for two cases.

TABLE 4: Histopathologic Findings of 24 Patients With Primary BreastSarcoma

Sarcoma Type Other primary sarcoma, not further classied Angiosarcoma Radiation-associated angiosarcoma Metaplastic, predominantly sarcomatoid, tumor Osteosarcoma Liposarcoma Malignant brous histiocytoma No. (%) of Patients 8 (33) 4 (17) 4 (17) 4 (17) 2 (8) 1 (4) 1 (4)

with less cellular components widely dispersed around the main portion of the tumor. This may explain the ndings of architectural distortion described by Surov et al. [8]. A diagnosis of primary breast sarcoma should be made only after metaplastic carcinoma has been excluded. Immunohistochemical studies for epithelial and myoepithelial markers allow conrmation of epithelial origin or inconspicuous foci of epithelial cells in a carcinoma that has undergone virtually complete conversion into a spindle cell neoplasm [15]. The distinction is important for treatment as well as for prognosis. The imaging features of metaplastic carcinomas have been described as round or lobular masses with indistinct margins on mammography and hypervascular solid masses on sonography [16], ndings similar to those for primary breast sarcomas. However, metaplastic carcinoma frequently involves the axillary lymph nodes (34%) [16, 17], which is unusual for primary breast sarcomas. Axillary adenopathy was not identied by mammography, sonography, or MRI in any of the 24 patients in our study. Axillary nodal metastasis was less common than distant metastasis in our study. The most common site of distant metastasis was the lungs and pleura, followed by liver, bone, and supercial soft tissues. Primary breast sarcomas occur over a wide age range, but most (except for angiosarcomas) occur in women in their fth or sixth decade of life [18]. Angiosarcomas of the breast generally occur at a younger age (mean age, 35 years), except for patients with postradiation angiosarcoma [19]. Primary breast sarcomas are locally aggressive tumors, as evidenced by the high rate of local recurrence when excisional surgery is performed. A high rate of distant relapse is consistent with the aggressive biology of primary breast sarcomas, with a 5-year overall survival ranging from 49% to 67% [18]. High-grade tumors and large tumors (> 5 cm) generally have a worse prognosis. Of the various histologic subtypes, angiosarcoma is the most aggressive. A contemporary multidisciplinary approach to therapy including surgery, radiation, and chemotherapy is advocated. Local therapy should be aggressive, with either wide excision or total mastectomy [1, 18, 20]. Because the axillary lymph nodes are seldom involved, axillary dissection should be avoided unless there are clinically positive nodes. Adjuvant radiotherapy has been recommended, especially for large or high-grade tumors [1, 21].

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Imaging of Primary Breast Sarcoma The role of chemotherapy, however, is unclear. To date, response rates have been limited, but some have advocated the use of neoadjuvant chemotherapy to help shrink large tumors to obtain negative margins, with additional adjuvant chemotherapy for chemosensitive tumors. Although multimodal approaches including radiation and chemotherapy may reduce the frequency of local and systemic recurrence in sarcomas, the results to date are inconclusive in patients with primary breast sarcoma [20]. The limitations in our study include the small number of patients who were retrospectively reviewed from a single institution. However, this is an inherent problem when evaluating a rare disease. Another limitation was that all patients did not undergo imaging with all three modalities (mammography, sonography, and MRI). In summary, our ndings indicate that primary breast sarcomas present with mammographic features of noncalcied oval masses that are distinct from inltrating ductal carcinomas. At sonography, most primary breast sarcomas are oval solid hypoechoic masses with posterior acoustic enhancement that may mimic phyllodes tumors. Recognition of this overlap in imaging features should alert breast radiologists to perform a biopsy in the appropriate clinical context. For patients with a history of prior breast radiation, new skin thickening or other skin changes should prompt physicians to perform a biopsy to exclude radiation-associated angiosarcoma. References
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