Cytologic diagnosis of undifferentiated high grade pleomorphic sarcoma of breast presenting with brain metastasis
A 60-year-old postmenopausal woman presented to the outpatient department with symptoms of headache and occasional dizziness for the last 2 months with one episode of generalized tonic clonic seizure 2 days back. The patient was of poor health status with mild pallor. The patient, on enquiry, also complained about a lump in her left breast for the last six months. There was no history of nipple discharge. On examination, a firm 6 × 4 cm swelling was palpated in the upper outer quadrant of the left breast. The swelling was non-tender and mobile with fixity to the overlying skin but not with the chest wall. There was no axillary lymphadenopathy; and the other breast was found normal on clinical examination. Clinical examination and history did not reveal any other abnormality. The patient underwent laboratory and imaging studies with fine needle aspiration of the breast lump. CT scan showed a heterogeneously enhancing hypodense infratentorial lesion measuring 6.3 × 5.7 cm in left cerebellar hemisphere and vermis compressing and displacing the fourth ventricle []. Laboratory tests showed hemoglobin of 9.8 gm/dl with microcytic, hypochromic anemia. The chest X-ray was normal. During FNAC, two passes were made. The smears were stained with Papanicolaou and May-Grunwald-Giemsa (MGG) stain and showed a dispersed population of malignant pleomorphic, sometimes bizarre, spindle cells and few multinucleated tumor giant cells. There was no epithelial component in the prepared smears. The background was hemorrhagic []. A cytologic diagnosis of malignant sarcomatoid spindle cell tumor was made. The differential diagnoses suggested were undifferentiated high grade pleomorphic sarcoma, malignant phyllodes tumor and metaplastic carcinoma (spindle/sarcomatoid variant). The patient underwent wide excision of the tumor. No axillary dissection was done. The histopathologic examination showed a high grade sarcoma composed of pleomorphic spindle cells arranged in fascicles and vague storiform pattern. There were bizarre and multinucleated tumor giant cells. The mitotic count was 15/10 HPF with atypical forms. There were foci of dystrophic calcification []. Immunohistochemistry for Cytokeratin (CK), Epithelial Membrane Antigen (EMA), Smooth Muscle Actin (SMA), desmin and S-100 protein were performed with adequate controls and showed no immunoreactivity indicating a lack of differentiation. A stereotactic biopsy from the cerebellar lesion showed similar histological and immunohistochemical pattern. A diagnosis of primary high grade undifferentiated pleomorphic sarcoma of breast with cerebellar metastasis was made. The patient in the post-operative period deteriorated quickly and developed progressive ataxia and headache. The patient died 3 weeks later.