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Double Feature: Carcinoma and Sarcoma Present in a Single Breast Tumor

Double Feature: Carcinoma and Sarcoma Present in a Single Breast Tumor Hindawi Publishing Corporation Case Reports in Oncological Medicine Volume 2012, Article ID 232851, 3 pages doi:10.1155/2012/232851 Case Report Double Feature: Carcinoma and Sarcoma Present in a Single Breast Tumor Catherine M. Stefaniuk and Timothy Jones Department of General Surgery and Department of Family Medicine, West Virginia School of Osteopathic Medicine, 400 North Lee Street, Lewisburg, WV 24901, USA Correspondence should be addressed to Catherine M. Stefaniuk, cstefaniuk@wvsom.edu Received 17 July 2012; Accepted 27 August 2012 Academic Editors: Y. Aoki and A. Kolacinska Copyright © 2012 C. M. Stefaniuk and T. Jones. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Introduction. Primary breast sarcomas (PBSs) are rare nonepithelial breast tumors compromised of mesenchymal mammary tissue. Although its rare nature has made the best mode of PBS treatment difficult to determine, it seems better to treat it more like a sarcoma creating clear negative margins verses breast carcinoma utilizing lumpectomy, partial mastectomy, and total mastectomy. Case. A 47-year-old obese Caucasian postmenopausal female G2P2 presents with a breast lump demonstrating a histological sample with a biphasic pattern consistent with both ductal carcinoma containing typical malignant epithelial cells and sarcomatous differentiation of carcinosarcoma. Conclusion. Carcinosarcoma is a rare breast malignancy. Sarcomas of the breast tend to be neg- ative for estrogen receptor and lack known risk factors. Current recommended treatment is to treat breast sarcomas like other soft tissue sarcomas by performing wide local excision instead of partial mastectomy. Antiestrogens and other chemotherapeutic agents typically used in breast epithelial malignancies are not recommended since these sarcomas tend to be negative with these receptors. 1. Introduction Negative surgical margins have been shown to be key for local recurrence and overall survival [2–4]. Although its rare Primary breast sarcomas (PBSs) are rare nonepithelial breast nature has made the best mode of PBS treatment difficult tumors compromised of mesenchymal mammary tissue [1]. to determine, it is better to treat it more like a sarcoma PBS was originally described in 1887 with <1,000 cases that may be found elsewhere (clear negative margins) verses referenced in the medical literature since the 19th century breast carcinoma (lumpectomy, partial mastectomy, and [1]. Currently, it is still undetermined what is the best treat- total mastectomy) [1, 3, 4]. Neoadjuvant chemotherapy ment modality for patients presenting with breast sarcoma. and radiotherapy are recommended to treat micrometastatic There are seven different groupings of PBS which include disease especially if tumor size is larger than 5 cm . PBS tends leiomyosarcoma, carcinosarcoma, angiosarcoma, epithelioid to be negative for estrogen receptor, progesterone receptor, cell sarcoma, and rhabdomyosarcoma [1]. In one retrospec- and Her2 mutations therefore making hormone therapy tive study of PBS from 1986 to 2006 [1], 13 patients were ineffective as an adjuvant [3]. In this paper, we discuss our studied. Patients underwent either partial mastectomy or findings and surgical procedure to provide more cases that total mastectomy with patients that had axillary lymph node will aid in determining an outline for how to treat patients removal showing negative pathological results. It appears with PBS in the future. that metastatic transit by axillary lymph nodes does not occur though it is debatable whether or not to do sentinel lymph node sampling [1–4]. Tumor size has been shown to 2. Case be a key variable that is significantly associated with 5-year survival rates and risk of local recurrence; tumors >5cm have A 47-year-old obese caucasian postmenopausal female G2P2 a poor prognosis while <5cm have better outcomes [1–3]. with a history of diabetes, hyperlipidemia, anemia, arthritis, 2 Case Reports in Oncological Medicine tobacco abuse, and asthma presented with a left upper medicine mapping was used to locate the sentinel node. inner-quadrant breast lump. She denied any first degree The sentinel node was identified in the midaxillary line, family medical history of cancer of any type. Family history elevated, and removed. Nuclear scanning was retested over was positive for diabetes, asthma, heart disease, chemical the area and shown to be negative. Pathologist confirmed dependency, hypertension, and kidney disease. Patient had lymphocytes in the node and did not note metastasis. If the an abnormal mammogram which illustrated a mass in the sentinel node was located substernally, it would have been left left breast at the 11 o’clock position in the upper inner in place and targeted for radiation therapy. If sentinel node quadrant that has an abnormal asymmetric density rounded along midaxillary line was positive, a partial mastectomy with microlobulated margin. Her previous mammogram of the whole breast with axillary lymph nodes would have was 5 years prior. been removed. Since the sentinel node was negative, a She was referred to general surgery for evaluation. Upon partial mastectomy/quadrantectomy was performed without breast exam, it was noted that the left breast was larger removal of any further lymph nodes. than the right with patient supine. Right breast was slightly Preceding surgery, the palpable mass was marked in the more nodular than left without any dominant mass or upper medial quadrant of the left breast via ultrasound with lesion appearing normodense for her age. Her left breast generous margins drawn with pen. The mass was removed revealed an increased dense area that was about 2 cm × using a paddle of ellipsed skin at approximately 7 cm × 4cm 2 cm in upper inner quadrant approximately 10 cm from widening down to the pectoralis fascia with subtraction of the areola in the 11 o’clock position. Margins were vaguely fascia as well. A bovie was used set at 20 degrees to remove palpable. Mobile nonenlarged lymph node was noted in the the breast mass and cauterize perforating vessels. Clips were left axilla. All other findings on physical examination were placed along the area where the removed fascia was to tag noncontributory. We pursued her condition by performing previous location of the tumor. Incision was closed using an ultrasound-guided biopsy of the irregular-shaped mass vicryl for deep dermis and monocryl for skin. Dermabond located in the 11 o’clock position. Several specimens were was spread along the closure site. Patient has well tolerated taken using SenoRx EnCor system, and specimens were the procedure, and positive cosmetic results were noted. No sent to pathology. Pathology results indicated malignant drain was inserted, and the patient had one post-op day in carcinosarcoma and invasive ductal carcinoma. the hospital. Final pathology of the left axillary sentinel lymph node showed sinus histiocytosis with lymphoid hyperplasia 3. Cytologic Microscopic Description without histologic evidence of malignancy. Anterior breast tissue showed adipose tissue with focal septal fibrosis Specimen preparation included 2 Pap stains and 2 Wright- lacking histologic malignancy. The lumpectomy illustrated Giemsa stains. On analysis, individual malignant cells were poorly differentiated invasive ductal carcinoma with sarco- visualized with significant nuclear pleomorphism enlarged matous features. The Nottingham histologic grade: nuclear irregular granular nuclei, and minimal cytoplasm with pleomorphism of 3, tubule formation of 3, and mitotic occasional mitotic figures. Sample demonstrated a biphasic count of 3 (22/10HPF) made the combined Nottingham pattern consistent with both ductal carcinoma with more score 9. The breast lumpectomy size was 10.1 × 6.0 × typical malignant epithelial cells and sarcomatous differen- 7.2 cm with irregular tumor mass measuring 2.3 × 2.0 × tiation consistent with carcinosarcoma. There were portions 1.8 cm at its greatest dimension. Tumor had no identified of the tumor showing significant pleomorphic nuclei with microcalcifications, lymphatic/vascular invasion, nor skin numerous multinucleated cells with prominent eosinophilic involvement. Venous vascular invasion was suspicious in nucleoi with fluffy and spindle-shaped nuclei and atypical one section on analysis. Surgical resection margins were mitoses. free of tumor; tumor was approximately 1.5 cm of inferior Immunoperoxidase stains were performed producing resection margin, 3.0 cm on superior resection margin, positive results for actin consistent with sarcomatous com- 3.4 cm from peripheral resection margin, and 4.2 cm from ponent and negative for both estrogen and progesterone medial resection margin. Pathologic state is IIA and TNM receptor. On biopsy, no definitive evidence of lymphovas- grading of pT2pN0pMX. Immunoperoxidase stains were cular invasion, carcinoma in situ, or microcalcifications was performed and revealed a population of sarcomatous appear- identified. HER2 : chromosome 17 (D17Z1) ratio analysis ing cells with the tumor to be positive for actin; stains was then performed which showed negative HER2 gene for estrogen and progesterone receptors were uniformly amplification with an HER2 : D17Z1 equal to 1.17. negative. Overlying skin and dermis was free of malignancy. After surgery patient was referred to oncologist for followup. One year out from surgery patient is well with no 4. Surgical Procedure signs of recurrence of sarcoma of the breast. In accordance with current evidence based guidelines [4–6], we performed a partial mastectomy/quadrantectomy. Prior to surgery, patient was prepped by radiology for a sentinel 5. Commentary lymph node biopsy with frozen section analysis approx- imately two hours before her operation with radioactive Carcinosarcoma is a rare breast malignancy. Sarcomas of the tracer. Isobars were marked on the axillary area and nuclear breast tend to be negative for estrogen receptor and lack Case Reports in Oncological Medicine 3 known risk factors [3]. Current recommended treatment is to treatbreastsarcomasasothersofttissuesarcomasby performing wide local excision instead of partial mastectomy [3–5]. Anti-estrogens and other chemotherapeutic agents typically used in breast epithelial malignancies are not recommended due to the lack of efficacy since these sarcomas tend to be negative with these receptors [3]. In our patient, we performed a sentinel lymph node dissection to ensure that no metastasis to the draining lymph nodes had occurred due to the carcinomatous features of the breast. Since carcinosarcomas of the breast tend to follow a sarcomatous path [4]; we proceed with tumor removal with sizeable resection of the tumor margins. In addition to wide excision, it is also recommended to provide adjuvant radiotherapy to improve overall local control [4]. Adjuvant chemotherapy has been used with some success, but since response rates are limited, it is hard to recommend [4]. Current chemotherapeutics that have been used/recommended are doxorubicin alone or in combination with ifosfamide due to their use in other soft tissue sarcomas [3]. To ensure that no metastasis is present, a full metastatic work-up can be performed including but not limited to a chest X-ray and/or bone scan. We recommend to any surgeon presented with a similar patient that a thorough surgical plan is to be mapped out, and all options are to be considered. This way, both you and patient will be prepared for possibly different surgical procedures and know potential outcomes. References [1] R. C. Fields, R. L. Aft, W. E. Gillanders, T. J. Eberlein, and J. A. Margenthaler, “Treatment and outcomes of patients with primary breast sarcoma,” American Journal of Surgery, vol. 196, no. 4, pp. 559–561, 2008. [2] S. Al-Benna, K. Poggemann, H. U. Steinau, and L. Ste- instraesser, “Diagnosis and management of primary breast sarcoma,” Breast Cancer Research and Treatment, vol. 122, no. 3, pp. 619–626, 2010. [3] Y. W. Lum and L. Jacobs, “Primary breast sarcoma,” Surgical Clinics of North America, vol. 88, no. 3, pp. 559–570, 2008. [4] S. A. Vorburger, Y. Xing, K. K. Hunt et al., “Angiosarcoma of the breast,” Cancer, vol. 104, no. 12, pp. 2682–2688, 2005. [5] NCCN Guidelines Breast Cancer Version 2, National Compre- hensive Cancer Network, 2011, http://www.nccn.org/profes- sionals/physician gls/f guidelines.asp. [6] NCCN Guidelines Soft Tissue Sarcoma Version 1, National Comprehensive Cancer Network, 2011, http://www.nccn.org/ professionals/physician gls/f guidelines.asp. MEDIATORS of INFLAMMATION The Scientific Gastroenterology Journal of World Journal Research and Practice Diabetes Research Disease Markers Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 International Journal of Journal of Immunology Research Endocrinology Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 Submit your manuscripts at http://www.hindawi.com BioMed PPAR Research Research International Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 Journal of Obesity Evidence-Based Journal of Journal of Stem Cells Complementary and Ophthalmology International Alternative Medicine Oncology Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 Parkinson’s Disease Computational and Behavioural Mathematical Methods AIDS Oxidative Medicine and in Medicine Research and Treatment Cellular Longevity Neurology Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Case Reports in Oncological Medicine Hindawi Publishing Corporation

Double Feature: Carcinoma and Sarcoma Present in a Single Breast Tumor

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Hindawi Publishing Corporation
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Copyright © 2012 Catherine M. Stefaniuk and Timothy Jones. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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Abstract

Hindawi Publishing Corporation Case Reports in Oncological Medicine Volume 2012, Article ID 232851, 3 pages doi:10.1155/2012/232851 Case Report Double Feature: Carcinoma and Sarcoma Present in a Single Breast Tumor Catherine M. Stefaniuk and Timothy Jones Department of General Surgery and Department of Family Medicine, West Virginia School of Osteopathic Medicine, 400 North Lee Street, Lewisburg, WV 24901, USA Correspondence should be addressed to Catherine M. Stefaniuk, cstefaniuk@wvsom.edu Received 17 July 2012; Accepted 27 August 2012 Academic Editors: Y. Aoki and A. Kolacinska Copyright © 2012 C. M. Stefaniuk and T. Jones. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Introduction. Primary breast sarcomas (PBSs) are rare nonepithelial breast tumors compromised of mesenchymal mammary tissue. Although its rare nature has made the best mode of PBS treatment difficult to determine, it seems better to treat it more like a sarcoma creating clear negative margins verses breast carcinoma utilizing lumpectomy, partial mastectomy, and total mastectomy. Case. A 47-year-old obese Caucasian postmenopausal female G2P2 presents with a breast lump demonstrating a histological sample with a biphasic pattern consistent with both ductal carcinoma containing typical malignant epithelial cells and sarcomatous differentiation of carcinosarcoma. Conclusion. Carcinosarcoma is a rare breast malignancy. Sarcomas of the breast tend to be neg- ative for estrogen receptor and lack known risk factors. Current recommended treatment is to treat breast sarcomas like other soft tissue sarcomas by performing wide local excision instead of partial mastectomy. Antiestrogens and other chemotherapeutic agents typically used in breast epithelial malignancies are not recommended since these sarcomas tend to be negative with these receptors. 1. Introduction Negative surgical margins have been shown to be key for local recurrence and overall survival [2–4]. Although its rare Primary breast sarcomas (PBSs) are rare nonepithelial breast nature has made the best mode of PBS treatment difficult tumors compromised of mesenchymal mammary tissue [1]. to determine, it is better to treat it more like a sarcoma PBS was originally described in 1887 with <1,000 cases that may be found elsewhere (clear negative margins) verses referenced in the medical literature since the 19th century breast carcinoma (lumpectomy, partial mastectomy, and [1]. Currently, it is still undetermined what is the best treat- total mastectomy) [1, 3, 4]. Neoadjuvant chemotherapy ment modality for patients presenting with breast sarcoma. and radiotherapy are recommended to treat micrometastatic There are seven different groupings of PBS which include disease especially if tumor size is larger than 5 cm . PBS tends leiomyosarcoma, carcinosarcoma, angiosarcoma, epithelioid to be negative for estrogen receptor, progesterone receptor, cell sarcoma, and rhabdomyosarcoma [1]. In one retrospec- and Her2 mutations therefore making hormone therapy tive study of PBS from 1986 to 2006 [1], 13 patients were ineffective as an adjuvant [3]. In this paper, we discuss our studied. Patients underwent either partial mastectomy or findings and surgical procedure to provide more cases that total mastectomy with patients that had axillary lymph node will aid in determining an outline for how to treat patients removal showing negative pathological results. It appears with PBS in the future. that metastatic transit by axillary lymph nodes does not occur though it is debatable whether or not to do sentinel lymph node sampling [1–4]. Tumor size has been shown to 2. Case be a key variable that is significantly associated with 5-year survival rates and risk of local recurrence; tumors >5cm have A 47-year-old obese caucasian postmenopausal female G2P2 a poor prognosis while <5cm have better outcomes [1–3]. with a history of diabetes, hyperlipidemia, anemia, arthritis, 2 Case Reports in Oncological Medicine tobacco abuse, and asthma presented with a left upper medicine mapping was used to locate the sentinel node. inner-quadrant breast lump. She denied any first degree The sentinel node was identified in the midaxillary line, family medical history of cancer of any type. Family history elevated, and removed. Nuclear scanning was retested over was positive for diabetes, asthma, heart disease, chemical the area and shown to be negative. Pathologist confirmed dependency, hypertension, and kidney disease. Patient had lymphocytes in the node and did not note metastasis. If the an abnormal mammogram which illustrated a mass in the sentinel node was located substernally, it would have been left left breast at the 11 o’clock position in the upper inner in place and targeted for radiation therapy. If sentinel node quadrant that has an abnormal asymmetric density rounded along midaxillary line was positive, a partial mastectomy with microlobulated margin. Her previous mammogram of the whole breast with axillary lymph nodes would have was 5 years prior. been removed. Since the sentinel node was negative, a She was referred to general surgery for evaluation. Upon partial mastectomy/quadrantectomy was performed without breast exam, it was noted that the left breast was larger removal of any further lymph nodes. than the right with patient supine. Right breast was slightly Preceding surgery, the palpable mass was marked in the more nodular than left without any dominant mass or upper medial quadrant of the left breast via ultrasound with lesion appearing normodense for her age. Her left breast generous margins drawn with pen. The mass was removed revealed an increased dense area that was about 2 cm × using a paddle of ellipsed skin at approximately 7 cm × 4cm 2 cm in upper inner quadrant approximately 10 cm from widening down to the pectoralis fascia with subtraction of the areola in the 11 o’clock position. Margins were vaguely fascia as well. A bovie was used set at 20 degrees to remove palpable. Mobile nonenlarged lymph node was noted in the the breast mass and cauterize perforating vessels. Clips were left axilla. All other findings on physical examination were placed along the area where the removed fascia was to tag noncontributory. We pursued her condition by performing previous location of the tumor. Incision was closed using an ultrasound-guided biopsy of the irregular-shaped mass vicryl for deep dermis and monocryl for skin. Dermabond located in the 11 o’clock position. Several specimens were was spread along the closure site. Patient has well tolerated taken using SenoRx EnCor system, and specimens were the procedure, and positive cosmetic results were noted. No sent to pathology. Pathology results indicated malignant drain was inserted, and the patient had one post-op day in carcinosarcoma and invasive ductal carcinoma. the hospital. Final pathology of the left axillary sentinel lymph node showed sinus histiocytosis with lymphoid hyperplasia 3. Cytologic Microscopic Description without histologic evidence of malignancy. Anterior breast tissue showed adipose tissue with focal septal fibrosis Specimen preparation included 2 Pap stains and 2 Wright- lacking histologic malignancy. The lumpectomy illustrated Giemsa stains. On analysis, individual malignant cells were poorly differentiated invasive ductal carcinoma with sarco- visualized with significant nuclear pleomorphism enlarged matous features. The Nottingham histologic grade: nuclear irregular granular nuclei, and minimal cytoplasm with pleomorphism of 3, tubule formation of 3, and mitotic occasional mitotic figures. Sample demonstrated a biphasic count of 3 (22/10HPF) made the combined Nottingham pattern consistent with both ductal carcinoma with more score 9. The breast lumpectomy size was 10.1 × 6.0 × typical malignant epithelial cells and sarcomatous differen- 7.2 cm with irregular tumor mass measuring 2.3 × 2.0 × tiation consistent with carcinosarcoma. There were portions 1.8 cm at its greatest dimension. Tumor had no identified of the tumor showing significant pleomorphic nuclei with microcalcifications, lymphatic/vascular invasion, nor skin numerous multinucleated cells with prominent eosinophilic involvement. Venous vascular invasion was suspicious in nucleoi with fluffy and spindle-shaped nuclei and atypical one section on analysis. Surgical resection margins were mitoses. free of tumor; tumor was approximately 1.5 cm of inferior Immunoperoxidase stains were performed producing resection margin, 3.0 cm on superior resection margin, positive results for actin consistent with sarcomatous com- 3.4 cm from peripheral resection margin, and 4.2 cm from ponent and negative for both estrogen and progesterone medial resection margin. Pathologic state is IIA and TNM receptor. On biopsy, no definitive evidence of lymphovas- grading of pT2pN0pMX. Immunoperoxidase stains were cular invasion, carcinoma in situ, or microcalcifications was performed and revealed a population of sarcomatous appear- identified. HER2 : chromosome 17 (D17Z1) ratio analysis ing cells with the tumor to be positive for actin; stains was then performed which showed negative HER2 gene for estrogen and progesterone receptors were uniformly amplification with an HER2 : D17Z1 equal to 1.17. negative. Overlying skin and dermis was free of malignancy. After surgery patient was referred to oncologist for followup. One year out from surgery patient is well with no 4. Surgical Procedure signs of recurrence of sarcoma of the breast. In accordance with current evidence based guidelines [4–6], we performed a partial mastectomy/quadrantectomy. Prior to surgery, patient was prepped by radiology for a sentinel 5. Commentary lymph node biopsy with frozen section analysis approx- imately two hours before her operation with radioactive Carcinosarcoma is a rare breast malignancy. Sarcomas of the tracer. Isobars were marked on the axillary area and nuclear breast tend to be negative for estrogen receptor and lack Case Reports in Oncological Medicine 3 known risk factors [3]. Current recommended treatment is to treatbreastsarcomasasothersofttissuesarcomasby performing wide local excision instead of partial mastectomy [3–5]. Anti-estrogens and other chemotherapeutic agents typically used in breast epithelial malignancies are not recommended due to the lack of efficacy since these sarcomas tend to be negative with these receptors [3]. In our patient, we performed a sentinel lymph node dissection to ensure that no metastasis to the draining lymph nodes had occurred due to the carcinomatous features of the breast. Since carcinosarcomas of the breast tend to follow a sarcomatous path [4]; we proceed with tumor removal with sizeable resection of the tumor margins. In addition to wide excision, it is also recommended to provide adjuvant radiotherapy to improve overall local control [4]. Adjuvant chemotherapy has been used with some success, but since response rates are limited, it is hard to recommend [4]. Current chemotherapeutics that have been used/recommended are doxorubicin alone or in combination with ifosfamide due to their use in other soft tissue sarcomas [3]. To ensure that no metastasis is present, a full metastatic work-up can be performed including but not limited to a chest X-ray and/or bone scan. We recommend to any surgeon presented with a similar patient that a thorough surgical plan is to be mapped out, and all options are to be considered. This way, both you and patient will be prepared for possibly different surgical procedures and know potential outcomes. References [1] R. C. Fields, R. L. Aft, W. E. Gillanders, T. J. Eberlein, and J. A. Margenthaler, “Treatment and outcomes of patients with primary breast sarcoma,” American Journal of Surgery, vol. 196, no. 4, pp. 559–561, 2008. [2] S. Al-Benna, K. Poggemann, H. U. Steinau, and L. Ste- instraesser, “Diagnosis and management of primary breast sarcoma,” Breast Cancer Research and Treatment, vol. 122, no. 3, pp. 619–626, 2010. [3] Y. W. Lum and L. Jacobs, “Primary breast sarcoma,” Surgical Clinics of North America, vol. 88, no. 3, pp. 559–570, 2008. [4] S. A. Vorburger, Y. Xing, K. K. Hunt et al., “Angiosarcoma of the breast,” Cancer, vol. 104, no. 12, pp. 2682–2688, 2005. [5] NCCN Guidelines Breast Cancer Version 2, National Compre- hensive Cancer Network, 2011, http://www.nccn.org/profes- sionals/physician gls/f guidelines.asp. [6] NCCN Guidelines Soft Tissue Sarcoma Version 1, National Comprehensive Cancer Network, 2011, http://www.nccn.org/ professionals/physician gls/f guidelines.asp. MEDIATORS of INFLAMMATION The Scientific Gastroenterology Journal of World Journal Research and Practice Diabetes Research Disease Markers Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 International Journal of Journal of Immunology Research Endocrinology Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 Submit your manuscripts at http://www.hindawi.com BioMed PPAR Research Research International Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 Journal of Obesity Evidence-Based Journal of Journal of Stem Cells Complementary and Ophthalmology International Alternative Medicine Oncology Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 Parkinson’s Disease Computational and Behavioural Mathematical Methods AIDS Oxidative Medicine and in Medicine Research and Treatment Cellular Longevity Neurology Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014

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Case Reports in Oncological Medicine – Hindawi Publishing Corporation

Published: Nov 5, 2012

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