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CORRESPONDENCE
Year : 2017  |  Volume : 13  |  Issue : 3  |  Page : 593-596

Metaplastic breast carcinoma presenting as benign breast lump


1 Department of Surgery, Dr. Baba Saheb Ambedkar Medical College and Hospital, Rohini, New Delhi, India
2 Department of Surgery, University College of Medical Sciences and Guru Teg Bahadur Hospital, New Delhi, India
3 Department of Pathology, University College of Medical Sciences and Guru Teg Bahadur Hospital, New Delhi, India

Date of Web Publication31-Aug-2017

Correspondence Address:
Ashesh Jha
Department of Surgery, Dr. Baba Saheb Ambedkar Medical College and Hospital, Rohini, New Delhi - 110 085
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-1482.183221

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 > Abstract 


A 38-year-old female presented with the left breast lump for 6 months. Physical examination revealed 11 cm × 7 cm mobile lump in the left breast without any axillary or supraclavicular lymphadenopathy. Mammographically it appeared as benign breast lump (breast imaging reporting and Data System-II). Fine needle aspiration cytology and Tru-cut biopsy were not able to differentiate between benign or malignant nature of this breast lump. For better characterization of this lesion, lumpectomy was performed, which revealed malignant tumor with squamous differentiation along with areas of ductal carcinoma in situ and the inferior margin was not free. For proper locoregional control, left modified radical mastectomy was performed. Postoperative period was uneventful. Final biopsy report of the mastectomy specimen was negative for any residual tumor, and axillary lymph nodes were not involved.

Keywords: Breast lump, carcinoma breast, metaplastic carcinoma


How to cite this article:
Jha A, Agrawal V, Tanveer N, Khullar R. Metaplastic breast carcinoma presenting as benign breast lump. J Can Res Ther 2017;13:593-6

How to cite this URL:
Jha A, Agrawal V, Tanveer N, Khullar R. Metaplastic breast carcinoma presenting as benign breast lump. J Can Res Ther [serial online] 2017 [cited 2020 May 27];13:593-6. Available from: http://www.cancerjournal.net/text.asp?2017/13/3/593/183221




 > Introduction Top


Metaplastic breast cancer is a relatively uncommon subtype of breast malignancy. It represents <1% of all breast malignancies.[1],[2] Most of these patients present with the larger tumor size and without the involvement of the axillary lymph nodes. These malignancies have a higher rate of triple negativity and higher rate of both local and distant recurrences. Due to rarity of this tumor, the optimal treatment strategies are still not established. As these tumors are not very responsive to systemic therapy, surgical excision with negative margins remains the preferred option in the management of this rare neoplasm. We herein describe a case of metaplastic carcinoma in a 38-year-old female which was managed by complete surgical excision.


 > Case Report Top


A 38-year-old female presented to surgery outpatient department with a lump in the left breast for 6 months. Initially, the lump was a size of a lemon, which gradually progressed to the size of 11 cm × 7 cm occupying mainly upper and outer quadrant of the left breast. The overlying skin and nipple areola complex were normal and it was not fixed to the underlying structures. The right breast was normal and there was no ipsilateral or contralateral axillary or supraclavicular lymphadenopathy. She had no addiction and her past and family history was not significant. Clinically we had a suspicion of phyllodes tumor and as a part of routine diagnostic work-up she underwent B/L mammography and fine needle aspiration cytology (FNAC) from the left breast lump. Mammographic findings were suggestive of Breast Imaging Reporting and Data System-II (BIRADS-II) lesion [Figure 1]. FNAC yielded only a few anucleate squamous and inflammatory cells and it was suggestive of ruptured epidermal cyst [Figure 2].
Figure 1: Mammography showing Breast Imaging Reporting and Data System-II lesion

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Figure 2: Anucleate squames and degenerated cells (arrow) (May–Grünwald–Giemsa, ×40)

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Due to lack of concordance among the clinical, pathological and radiological findings Tru-cut biopsy were performed, which showed an epithelial tumor with squamous differentiation and frequent mitosis and as per pathological findings three possibilities were suggested [Figure 3]: (1) metaplastic carcinoma with squamous differentiation, (2) invasive ductal carcinoma with squamous differentiation, (3) skin adnexal tumor with squamous proliferation. Since based on these findings we were not sure about the benign or malignant nature of this lump, diagnostic lumpectomy [Figure 4] was performed, which revealed a malignant tumor with squamous differentiation along with areas of ductal carcinoma in situ (DCIS) [Figure 5]. The tumor was negative for estrogen receptor, progesterone receptor, and human epidermal growth factor receptor 2/neu [Figure 6]. The inferior margin was involved, and the superior margin was positive for DCIS. For proper locoregional control, left-sided modified radical mastectomy (MRM) was done [Figure 7] and biopsy report of the MRM specimen was negative for any residual tumor and there was no involvement of the axillary lymph nodes. Postoperative period was uneventful and during a follow-up of 1 month, she remains asymptomatic.
Figure 3: Only squamous cells with moderate pleomorphism (green arrow) and areas of necrosis (red arrow). Occasional mitosis was noted (H and E, ×40)

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Figure 4: Left breast postlumpectomy

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Figure 5: (a) The entire tumor was composed only of squamous cells with frequent mitosis (arrow) and necrosis (H and E, ×40), (b) areas of ductal carcinoma in situ seen at the periphery (arrow) (H and E, ×10)

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Figure 6: Immunohistochemistry for estrogen receptor (a), progesterone receptor (b), and human epidermal growth factor receptor 2/neu (c) was negative. Arrows show few entrapped normal ducts at the periphery of tumor acting as positive controls for estrogen and progesterone receptors (Immunohistochemistry, ×10)

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Figure 7: Left-sided modified radical mastectomy being performed

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 > Discussion Top


Breast cancer remains the most common malignancy in women worldwide, and histologically most of these tumors are either invasive ductal or invasive lobular carcinoma. Metaplastic breast carcinoma is a rare form of breast malignancy and this term was first proposed by Huvos et al. in 1973.[3] This was not recognized as a distinct entity for a long period, and various authors have proposed different nomenclature and classifications for this rare malignancy. In the year 2000, the WHO recognized this malignancy as a distinct entity and proposed a classification of metaplastic breast carcinoma into epithelial type and mixed type.[4] Classification of metaplastic carcinoma was proposed by the World Health Organization in 2003[5] as (1) squamous cell carcinoma, (2) adenocarcinoma with spindle cell proliferation, (3) adenosquamous, including mucoepidermoid, and (4) mixed epithelial and mesenchymal. Subtypes of mixed epithelial and mesenchymal carcinoma include (a) carcinoma with chondroid metaplasia, (b) carcinoma with osseous metaplasia, and (c) carcinosarcoma.

Even clinical presentation and radiological features of this carcinoma have several differences from the other common types of breast malignancies. Most of these patients present with a history of a rapidly enlarging breast lump and at the time of presentation, they usually have larger tumor size, which generally more than 2 cm in size.[2],[6],[7] Mostly, it is not fixed to the skin or underlying structures; however, Kaufman et al. showed fixity to skin or to the underlying structures in 20% of cases.[6] The rate of axillary lymph node involvement is relatively low, and the reported incidence varies between 6% and 26%.[8],[9],[10] Mammographically it may present as a high-density lesion with obscured, irregular, and/or spiculated margins or it may have more benign appearance with oval or rounded lesion with circumscribed margins.[11] Most of these lesions are not calcified. Sonographically, it appears as hypoechoic solid or mixed cystic or solid mass with posterior acoustic enhancement. In our case, mammographically it appeared as a benign lesion (BIRADS-II).

There are no standard treatment guidelines which can be applied uniformly to all patients with metaplastic breast cancer. Despite having larger tumor size at presentation, breast conservation therapy may be considered in appropriate patients as there is no difference in overall or disease-free survival between patients undergoing MRM or breast conservation therapy.[12],[13] In our case, we went for completion mastectomy as we were not able to excise the lump with negative margins. These tumors are generally resistant to chemotherapeutic and hormonal agents and they even do not respond to radiotherapy. Therefore, complete surgical excision with negative margins remains the mainstay of treatment.


 > Conclusion Top


Metaplastic breast carcinoma is a rare subtype of breast malignancy; it usually present with a larger tumor size and without the involvement of the axillary lymph nodes. Complete surgical excision remains the preferred option in the management of these tumors.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 > References Top

1.
Luini A, Aguilar M, Gatti G, Fasani R, Botteri E, Brito JA, et al. Metaplastic carcinoma of the breast, an unusual disease with worse prognosis: The experience of the European institute of oncology and review of the literature. Breast Cancer Res Treat 2007;101:349-53.  Back to cited text no. 1
    
2.
Tavassoli FA. Classification of metaplastic carcinomas of the breast. Pathol Annu 1992;27(Pt 2):89-119.  Back to cited text no. 2
    
3.
Huvos AG, Lucas JC Jr., Foote FW Jr. Metaplastic breast carcinoma. Rare form of mammary cancer. N Y State J Med 1973;73:1078-82.  Back to cited text no. 3
    
4.
Fritz A, Percy C, Jack A, Solin LH. In: International Classification of Diseases of Oncology. 3rd ed. Geneva: World Health Organization; 2000.  Back to cited text no. 4
    
5.
Tavassoli FA, Devilee P. World Health Organization Classification of Tumours. Pathology and Genetics of Tumours of the Breast and Female Genital Organs. Lyon, France: IARC Press; 2003. p. 37-41.  Back to cited text no. 5
    
6.
Kaufman MW, Marti JR, Gallager HS, Hoehn JL. Carcinoma of the breast with pseudosarcomatous metaplasia. Cancer 1984;53:1908-17.  Back to cited text no. 6
    
7.
Chao TC, Wang CS, Chen SC, Chen MF. Metaplastic carcinomas of the breast. J Surg Oncol 1999;71:220-5.  Back to cited text no. 7
    
8.
Rayson D, Adjei AA, Suman VJ, Wold LE, Ingle JN. Metaplastic breast cancer: Prognosis and response to systemic therapy. Ann Oncol 1999;10:413-9.  Back to cited text no. 8
    
9.
Wargotz ES, Norris HJ. Metaplastic carcinomas of the breast. I. Matrix-producing carcinoma. Hum Pathol 1989;20:628-35.  Back to cited text no. 9
    
10.
Wargotz ES, Norris HJ. Metaplastic carcinomas of the breast. III. Carcinosarcoma. Cancer 1989;64:1490-9.  Back to cited text no. 10
    
11.
Yang WT, Hennessy B, Broglio K, Mills C, Sneige N, Davis WG, et al. Imaging differences in metaplastic and invasive ductal carcinomas of the breast. AJR Am J Roentgenol 2007;189:1288-93.  Back to cited text no. 11
    
12.
Tseng WH, Martinez SR. Metaplastic breast cancer: To radiate or not to radiate? Ann Surg Oncol 2011;18:94-103.  Back to cited text no. 12
    
13.
Dave G, Cosmatos H, Do T, Lodin K, Varshney D. Metaplastic carcinoma of the breast: A retrospective review. Int J Radiat Oncol Biol Phys 2006;64:771-5.  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]



 

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