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OJHAS Vol. 9, Issue 4:
(Oct-Dec, 2010) |
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| Metaplastic Carcinoma of the Left Breast with Extensive
Chondroid Differentiation |
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Dhiraj B Nikumbh,
Sunil V Jagtap,
Sujata R Kanetkar,
Gaurav Jain,
Ashish Bohra
Department of Pathology, Krishna Institute of Medical Sciences, Karad, Maharashtra 415110. |
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Address For Correspondence |
Assistant Professor,
Department of Pathology,
KIMS, Karad,
District Satara,
Maharashtra, India - 415110.
E-mail:
drdhirajnikumbh@rediffmail.com |
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Nikumbh DB, Jagtap SV, Kanitkar SR, Jain G, Bohra A. Metaplastic Carcinoma of the Left Breast with Extensive
Chondroid Differentiation. Online J Health Allied Scs.
2010;9(4):30 |
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Submitted: Dec 15,
2010; Accepted Dec 31, 2010; Published: Jan 20, 2011 |
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| Abstract: |
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Metaplastic breast carcinoma is
very rare neoplasm which contains mixture of carcinomatous
(epithelial) and sarcomatous (mesenchymal) elements in variable
proportion. Metaplastic carcinoma with chondroid differentiation
is even rarer. We report a case of metaplastic carcinoma
with extensive chondroid differentiation as there is paucity
of information regarding pathological features and clinical outcomes
for these rare tumors. Tumor had characteristic definite areas
of classic infiltrating duct carcinoma with abundant chondromyxoid
matrix, focal areas of chondrosarcoma and cartilagenous
metaplasia. Tumour cells were immunoreactive for S-100, ER, and
PR. When pathologist encounter breast tumor with chondroid differentiation,
careful gross sampling, histopathology and immunoreactivity for mesenchymal and epithelial component are most useful
to differentiate metaplastic carcinoma from malignant phylloides
tumors and malignant adenomyoepithelioma.
Key Words: Metaplastic
carcinoma; Chondroid differentiation
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Metaplastic carcinomas are highly
heterogeneous group of tumours that are characterized by an admixture of adenocarcinoma with
dominant areas of spindle cells, squamous and/or mesenchymal differentiation.1,2 Heterologous mesenchymal element
ranges from areas of bland to frank sarcoma such as chondrosarcoma,
osteosarcoma, rhabdomyosarcoma, leiomyosarcoma, fibrosarcoma
along which cartilagenous and osseous metaplasia are most
commonly encountered.3 Thus metaplastic carcinoma
of breast is a rare entity with positive distinguishing features of having epithelial and mesenchymal tissue types incorporated
within one tumor.4 We report a case of metaplastic
carcinoma with extensive chondroid differentiation that is
chondrosarcoma and chondroid metaplasia along with classic infiltrating
duct carcinoma. Differential diagnosis was difficult and possible diagnosis
include malignant phylloides tumour, pure primary chondrosarcoma,
malignant adenomyoepithelioma. Immunohistochemistry for epithelial
and mesenchymal components i.e., CK and S-100 are helpful and
diagnostic. We report this case because of
its rarity.
A 33 years old female presented
in surgical oncology department of Krishna hospital, with a lump in
left breast for last 6 months. There was no history
of nipple discharge or any other breast problem. Patient
was married and had two children. There was no family history
of breast cancer. On examination a firm to hard, non tender lump measuring 5
x 3 cm was noted in the lower inner quadrant of left breast. It was
not attached to underlying structure. Skin and areola was free
from lesion. Mammography showed asymmetrical lesion that appeared to be malignant. Left axillary lymph nodes were palpable.
A clinical diagnosis of carcinoma left breast was proposed.
Chest X Ray, USG abdomen and pelvis, biochemical and hematological investigations were within normal limits.
Pre–operative FNAC was done
in our hospital reported as positive for malignant cells suggestive
of duct carcinoma. A wide excision of left breast lump
with axillary clearance was done. Specimen measured 7 x 5 x 3
cm, partially covered with skin measuring 5 x 2 cm and on cut section
showed a grey white, glistening tumor measuring 4 x 3 x 2 cm. [Figure
1]
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Figure
1: Gross photograph of cut specimen
of carcinoma breast with grey white glistening appearance |
On histopathological examination,
the tumour composed of cells arranged in glandular, tubular, whorls
and nests (50% area of infiltrating duct carcinoma). Individual
cells were round to oval with moderately pleomorphic to vesicular
nuclei with occasional prominent nucleoli and moderate amount
of eosinophilic cytoplasm. Admixed with this tumor, there was
malignant cartilage forming tumor composed of variable size nodular
masses on basophilic cartilaginous matrix. Nodules composed
of immature chondroblasts arranged in lacunae with moderately
pleomorphic nuclei with uni or multiloculated cytoplasm [Figure
2,3].
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Figure
2, 3: Photomicrograph of tumor
showing infiltrating duct carcinoma and metaplastic carcinoma with extensive
chondroid differentiation that is chondrosarcoma focus. (Hematoxylin & Eosin Staining at 40 X magnification) |
Sheets of cartilaginous matrix
and chondroid metaplasia were seen with desmoplasia. Frequent mitotic
figures and occasional necrosis were noted. Section from axillary
dissection showed 3 lymph nodes, which were free from tumor.
Overlying skin was free from tumor.
Final diagnosis of metaplastic
carcinoma with extensive chondroid differentiation was made. Postoperative
radiotherapy was given and the patient is on regular follow
up with a further treatment plan consisting of chemotherapy.
Metaplastic carcinoma of the breast
is a rare type of breast cancer accounting for 0.2 to 1%
of breast malignancy.1,4-6 The term metaplastic carcinoma
first introduced by Huvos et al.7,8
In fewer than 5 % of all mammary adenocarcinoma, part
of all carcinomatous epithelium is transformed to nonglandular
growth pattern by a process referred to as metaplasia.1
There are four variants of metaplastic carcinoma:
matrix producing carcinoma, carcinosarcoma, squamous cell carcinoma
and spindle cell carcinoma.4 Metaplastic carcinoma
with chondroid differentiation (MCCD), a matrix producing
carcinoma is distinctive form of metaplastic carcinoma consisting
of overt carcinoma with transition to an abundant cartilaginous,
osseous or both cartilaginous or osseous stromal matrix
in the absence of intervening spindle cell component.5
Metaplastic
carcinoma of breast comprise of a heterogeneous group
of neoplasms that are regarded as ductal carcinoma that undergo
metaplasia into non-glandular growth patterns.9-11
The mixed cell origin is corroborated with IHC staining for mesenchymal cells (Vimentin),
epithelial cells (Cytokeratin) and myoepithelial cells (S-100 protein).
In most of metaplastic carcinoma, the foci of transition
between invasive ductal carcinoma and metaplastic elements are
detected and for this reason extensive sampling should be
performed12, as demonstrated in present case.
Metaplastic carcinoma with chondroid differentiation is a
distinctive form of metaplastic carcinoma with a relatively favorable
prognosis than other subtypes of metaplastic carcinomas.1
Differential diagnosis for metaplastic
carcinoma with chondroid differentiation are malignant phylloides
tumour, primary chondrosacoma and malignant adenomyoepithelioma
mainly.1
Malignant phylloides tumor with
heterologous sarcomatous component of chondrosarcoma is very rare
and differentiated from metaplastic carcinoma with chondroid differentiation
by moderate to marked stromal atypia, high mitotic (>10/10 hpf) count, cellular overgrowth and infiltrative
border.1,13,14 Primary chondrosarcoma of breast is
differentiated from metaplastic carcinoma with chondroid differentiation
by absence of direct transition between carcinomatous and mesenchymal
components in the former and IHC is helpful of both mesenchymal
and epithelial masses to differentiate between the two.13
Malignant adenomyoepithelioma are rarely encountered. Tumors with
only myoepithelial characteristic have been described. Adenomyoepithelioma
is characterized by two components, glandular lined
by epithelial cells with apocrine features surrounded by myoepithelial
cells. Myoepithelial cells are in nests with clear cytoplasm.
Histopathologically it is different from metaplastic carcinoma
with chondroid differentiation.5,14 The average 5 year
survival with metaplastic carcinoma with chondroid differentiation is reported to be 68 %, which is relatively more favorable
than previously reported for metaplastic carcinoma.9,14
To conclude, when pathologist encountered a malignant breast
tumors with chondroid elements, metaplastic carcinoma with
chondroid differentiation (MCCD) should be considered,
even though epithelial component may be present, due to
its rarity, different prognosis and paucity of literature.
We sincerely acknowledge the support of Dr. SJ Bhosale and Dr. PG Chougule, Professors of
Surgical Oncology, KIMS, Karad.
- Rosen PP. Carcinoma with metaplasia.In :Rosen PP,editor.Rosens Breast Pathology.
2nd edition. Philadelphia: Lippincott Williams and Wilkins. 2001. pp 425-452
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Tavassoli FA. Papillary lesions.In :Tavassoli FA,editor.Pathology of Breast.
2nd edition. Stanford (CT): Appleton and Lange. 1999. 481-504
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Dunne B, Lee AH, Pinder
SE et al. An immunohitochemical study of metaplastic spindle cell carcinoma,
phyllodes tumour and fibromatosis of breast. Hum Pathology 2003;34:1009–1015
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Pollock JM, Green A, Donnell C, Dyess DL, Tucker JA. Metaplastic Breast Carcinoma with Osseous Differentiation: A Case Report
Southern Medical Journal February 2006;99(2):168-170. Available at
http://journals.lww.com/smajournalonline/fulltext/2006/02000/metaplastic_breast_carcinoma_with_osseous.19.aspx#
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Ellios ID, Corneli ssc CJ,
Schnitt SJ et al. Tumour of breast. Invasive Breast Carcinoma. In: Tavassoli
FA, Devileep, editors. Pathology and Genetics of tumours of breast and
female genital organs. Lyon; IARC Press. 2003. pp 37-41
-
Tavassoli FA. Classification
of Metaplastic Carcinoma of breast. Pathol Annu 1992;27:89-119.
-
Havos AG, Lucas JC, Forte
FW. Metaplastic breast carcinoma: Rare form of mammary cancer.
NY State J Med 1973;73:1078-1082.
-
Al Sayed AD, Elweshi
AM, Tulba AM et al. Metaplastic carcinoma of the breast clinical
presentation treatment result and prognostic factors. Acta Onchologica.
2006;45:188-195
-
Wargotz ES, Norris HJ. Metaplastic
carcinoma of the breast. I. Matrix producing carcinoma. Hum Pathol 1989;20:628-635
-
Park JM, Hum BK, Moon WK,
et al. Metaplastic Carcinoma of the breast : Mammographic and sonographic
findings. J clinical Ultrasound 2000;28:179-186.
-
Gunhan BI, Memis A, Ustam
EE et al. Metaplastic carcinoma of breast: Clinical, mammographic and
sonographic findings with histological correlation. AJR 2002;178:1421-1425.
-
Patterson SK, Tworek JA,
Ranbidoux MA et al. Metaplastic carcinoma of the breast; Mammographic
appearance with pathological correlation. AJR 1997;169:709-712
-
Gupta S, Gupta V, Aggarwal
PN et al. Primary chondrosarcoma of the breast: A case report. Indian
Journal of Cancer 2003;40:77-79
-
Hee JS, Hak HK, Sun MK,
et al. Imaging features of metaplastic carcinoma with chondroid differentiation
of the breast. AJR 2007;188:691-696
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