Septic patients present suppressed neutrophil chemotactic responses to FMLP and leukotriene B4 stimuli compared with healthy controls. This is accompanied by increased serum concentrations of nitrate. The impairment of neutrophil chemotaxis was observed mainly in the cells obtained from nonsurvivor patients and may thus be an additional factor contributing to disease outcome.

Financial support: none suMMary Primary osteosarcoma of the breast (POB) is an extremely rare and aggressive tumor. Differential diagnosis of POB includes osteosarcoma of the chest wall and metaplastic breast carcinoma. Imaging tests that exclude the existence of a direct connection between the tumor and chest wall, as well as histopathological and immunohistochemical studies that rule out the presence of an epithelial component are required for the diagnosis of POB. We report a case of a 69-year old woman with POB. Imaging and pathological findings are presented. Therapeutic approach is discussed in the light of current knowledge, including potential complications.Keywords: breast, breast neoplasms, sarcoma, immunochemistry.A 69-year-old woman presented with a 6-month history of a palpable, painless mass in her left breast. Clinical examination revealed a hard, mobile, well-circumscribed, 10 cm mass, occupying practically the entire left breast. Contralateral breast, axilla or nipples showed no abnormalities. She denied having any history of breast trauma, radiotherapy, or breast cancer.Mammography revealed a relatively well-defined, hyperdense irregular mass without calcifications, unconnected to the underlying sternum and ribs ( Figure 1A). Ultrasound revealed a hypoechoic irregular mass with hyperechoic areas, indistinct margins, and posterior acoustic shadowing ( Figure 1B). Core needle biopsy was performed and microscopy showed a malignant poorly differentiated mesenchymal tumor.Thoracic and abdominal computed tomography showed no distant metastasis. The patient underwent simple mastectomy and sentinel lymph node biopsy. Grossly, the cut surface of the tumor was white, hard, with a stony consistency in the center and well-defined margins. The tumor measured 10x9x7 cm (Figure 2).Microscopy showed a malignant immature mesenchymal bone-forming tumor. There were foci of necrosis and cartilage, containing osteoid matrix, some of which were irregularly calcified, surrounded by atypical spindle cells and osteoclast-like multinucleated giant cells. Tumor mitotic count was 16 mitoses/10 high-power field. There was no skin and lymphovascular invasion. Sentinel lymph node was tumor-free. On immunohistochemistry, tumor cells were positive for vimentin. CD68 (KP1) and alpha-1-antitrypsin were positive in osteoclast-like giant cells. Cytokeratin (AE1/AE3), S-100, epithelial membrane antigen (EMA), p63, epidermal growth factor receptor (EGFR), CD99, estrogen and progesterone receptors, and HER2 were negative. The Ki-67 index was 5%. Extensive tumor sampling failed to identify any tumor that was biphasic or had epithelial component. A highgrade primary osteosarcoma of the breast (POB) was di-

RESUMOApresentamos um caso raro de múltiplos fibroadenomas envolvendo as mamas e a mama acessória axilar. À luz do conhecimento atual, a conduta mais adequada é discutida. Uma mulher de 37 anos foi encaminhada ao Serviço de Mastologia em função da queixa de nódulo em mama acessória axilar direita. No exame físico, não havia nódulos palpáveis nas mamas. Observou-se mama acessória axilar bilateral com nódulo à direita e sem alterações à esquerda. Mamografia e ultrassonografia demonstraram múltiplos nódulos de mama bilateral com características benignas e um nódulo suspeito de malignidade na axila direita. A paciente submeteu-se à punção aspirativa com agulha fina guiada por ultrassonografia do maior nódulo de cada mama e do nódulo na mama acessória axilar direita. Citologicamente, todos os nódulos apresentaram características benignas. Formulou-se a hipótese diagnóstica Trabalho realizado no Serviço de Mastologia, Hospital Materno Infantil -Goiânia (GO), Brasil. 70Conde DM, Morais LC, Pacheco CF, Ferreira RB, Silva EPS, Fonseca PSP, Pinto SA de fibroadenoma. Paciente submeteu-se à remoção cirúrgica do nódulo na axila direita. O exame histopatológico demonstrou fibroadenoma. Decidiu-se por uma conduta conservadora para as mamas acessórias axilares e múltiplos fibroadenomas mamários. Após 11 meses de seguimento, não houve recidiva do nódulo na axila direita nem alterações dos fibroadenomas. A conduta conservadora na mama acessória axilar é possível, porém o tecido mamário acessório pode ser afetado por neoplasia. Nos casos suspeitos de malignidade, a investigação deve ser conduzida com os mesmos recursos propedêuticos utilizados nas mamas normalmente posicionadas. Na presença de múltiplos fibroadenomas nas mamas, a conduta conservadora pode ser adotada com segurança.

We present a case of a 72-year-old woman referred to the breast disorder service due to abnormalities on mammography and breast ultrasound. The patient reported using different hormone therapy (HT) formulations during 25 years and had stopped taking HT for 4 years. Physical examination showed no alterations in the breasts or axilla. Mammography from 2012 detected asymmetry at the 3 o'clock position in the anterior right breast. Ultrasound revealed an irregular, hypoechoic mass with indistinct margins, and posterior acoustic shadowing. A retrospective analysis of mammographies from 2007, 2009 and 2010 showed that a very subtle asymmetry had existed since 2007. Follow-up imaging demonstrated no change in asymmetry during 4.5 years. The patient underwent breast-conserving therapy and sentinel lymph node biopsy. Histopathologic examination demonstrated classic invasive lobular carcinoma. There were no sentinel node metastases. The patient received radiotherapy and endrocrine therapy. This case demonstrates that breast cancer may remain stable and not grow for many years. This aspect should be kept in mind by all professionals dealing with women's healthcare, in particular HT users who may develop breast cancer with a less aggressive behavior. Any suspicious finding on mammography, despite being unchanged for a number of years, must be investigated. Gynecol EndocrinolDownloaded from informahealthcare.com by The University of Manchester on 11/02/14 For personal use only. 304 D. M. Conde et al. Gynecol Endocrinol, 2013; 29(4): 301-304 Gynecol Endocrinol Downloaded from informahealthcare.com by The University of Manchester on 11/02/14 For personal use only.

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