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CORRESPONDENCE
Year : 2019  |  Volume : 15  |  Issue : 5  |  Page : 1186-1188

Synchronous occurrence of lobular breast carcinoma and granulosa cell tumor of ovary mimicking metastatic lobular breast carcinoma


1 Department of Pathology, KGMU, Lucknow, Uttar Pradesh, India
2 MCH, Department of Surgical Oncology, KGMU, Lucknow, Uttar Pradesh, India

Date of Web Publication4-Oct-2019

Correspondence Address:
Sumaira Qayoom
Department of Pathology, KGMU, Lucknow - 226 003, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcrt.JCRT_2_18

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 > Abstract 


Breast cancer is one of the main sources of ovarian metastasis. Diffuse sheet of lobular carcinoma cells can strongly mimic granulosa cell tumor (GCT) which itself is a rare ovarian neoplasm constituting <5% of all the ovarian neoplasms. A 55-year-old female presented with a painful lump in the right breast associated with nipple discharge for 4 months, which on radiological and cytological findings was suspicious of an epithelial malignancy. During routine work-up, a solid-cystic lesion in the left ovarian adnexa was identified. The patient underwent right modified radical mastectomy along with left salpingo-oophorectomy. Histopathological and immunohistochemical features confirmed the diagnosis of a synchronous lobular carcinoma breast with GCT ovary. Simultaneous occurrence of Lobular carcinoma breast (LCB) and GCT ovary is extremely rare. Morphologically, these can look similar, raising a suspicion of LCB metastasis to ovary. This is important to differentiate the two for a proper patient management and prognosis.

Keywords: Granulosa cell tumor ovary, immunohistochemistry, lobular carcinoma breast


How to cite this article:
Qayoom S, Kumari M, Gupta S, Goel M. Synchronous occurrence of lobular breast carcinoma and granulosa cell tumor of ovary mimicking metastatic lobular breast carcinoma. J Can Res Ther 2019;15:1186-8

How to cite this URL:
Qayoom S, Kumari M, Gupta S, Goel M. Synchronous occurrence of lobular breast carcinoma and granulosa cell tumor of ovary mimicking metastatic lobular breast carcinoma. J Can Res Ther [serial online] 2019 [cited 2019 Nov 15];15:1186-8. Available from: http://www.cancerjournal.net/text.asp?2019/15/5/1186/244442




 > Introduction Top


Secondary ovarian tumors comprise approximately 7%–24% of all ovarian malignant tumors, and breast cancer is one of the main sources of ovarian metastasis constituting 24%–40% of cases.[1],[2] Depending on the histological pattern, these metastatic cancers can resemble any of the primary ovarian neoplasms. Diffuse sheet and solid nests of lobular carcinoma cells can strongly mimic granulosa cell tumor (GCT)[1],[3] which itself is a rare ovarian neoplasm constituting <5% of all the ovarian neoplasms.[4] The simultaneous occurrence of a primary breast carcinoma and GCT is quite uncommon.


 > Case Report Top


A 55-year-old female presented with a painful lump in the right breast associated with nipple discharge for 4 months. There were no menstrual complaints. On mammography, small hypoechoic lesion measuring 9 mm × 10 mm with irregular margins was seen in the upper outer quadrant of the breast along with few enlarged right-side axillary lymph nodes, the largest measuring 20 mm × 11 mm. Fine-needle aspiration smears revealed atypical cells suspicious of an epithelial malignancy. During routine work-up, solid-cystic lesion measuring 93 mm × 83 mm × 64 mm was identified in the left adnexa. The patient underwent right modified radical mastectomy along with left salpingo-oophorectomy. Gross examination revealed a 6 cm × 6 cm × 3 cm breast mass in the upper outer quadrant. Thirteen lymph nodes were dissected, the largest measuring 1.5 cm × 1.0 cm. Left oophorectomy specimen showed solid cystic lesion with well-defined solid nodule measuring 1.5 cm × 1.0 cm. Ovarian capsule did not show any surface deposits. Microscopic examination from the breast lesion showed malignant tumor cells disposed in Indian file pattern; individual tumor cells were round to oval with high N:C ratio, fine chromatin, inconspicuous nucleoli, and scant amount of cytoplasm. Margins were free from invasion. Three lymph nodes showed metastatic deposit without perinodal extension. Microscopic examination of the ovarian lesion showed tumor cells disposed in sheet and cords. Individual tumor cells were round to oval, medium-sized, and mildly pleomorphic with high N:C ratio, fine chromatin, inconspicuous nucleoli, occasional nuclear groove, and scant cytoplasm. With this histomorphology, three differential diagnoses were considered as follows: (1) lobular breast carcinoma (LBC) metastasizing to ovary, (2) GCT of ovary metastasizing to the breast, and (3) synchronous LBC and GCT ovary. For further differentiation, immunohistochemistry (IHC) was applied. Breast tumor was positive for estrogen receptor (ER), progesterone receptor (PR), GCDFP, CK7, and epithelial membrane antigen (EMA), while being negative for E-cadherin, inhibin, and Her-2-neu. The ovarian lesion was positive for E-cadherin and inhibin, and focally for calretinin, while being negative for ER, GCDFP, CK7, and EMA [Figure 1]. Based on the above features, a final diagnosis of “synchronous infiltrating LBC with GCT – ovary” was made. The patient was treated using adjuvant chemotherapy using 5 fluorouracil, epidoxorubicin, and cyclophosphamide followed by taxane. The patient is doing fine for almost a year.
Figure 1: A comparative morphology on H and E stain and immunophenotypic features of breast tumor and ovarian lesion of the present case

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 > Discussion Top


Breast cancer is one of the main sources of ovarian metastasis, constituting 24%–40% of cases.[1] The incidence of lobular carcinoma metastasizing into gastrointestinal tract ovary, uterus, and retroperitoneum is higher than other breast cancer subtypes.[3] Secondary ovarian tumors are not so rare, with the incidence ranging from 6% to 28% of all the malignant ovarian tumors.[5],[6] However, metastasis is usually not suspected on clinical examinations and is recognized by microscopic examination.[7] Regardless of the site of primary tumor, the presence of metastasis to the female genital tract is a poor prognostic factor, which makes it important to make the correct diagnosis of metastasis.[8] However, depending on the infiltration pattern, and the cell type, these metastatic lesions can simulate various primary ovarian neoplasms and vice versa. Primary GCT of ovary can masquerade the metastasis from the LBC, as was seen in the present case. The fact that patients diagnosed with GCT ovary have increased the risk of breast cancer [9] makes the concomitant presence of breast cancer and GCT ovary a possibility but a very rare phenomenon. Hammer et al. found only one case of invasive lobular carcinoma breast in patient of GCT ovary; however, time relation is not mentioned in his study.[4] Differentiating the two lesions demands very high suspicion due to its rarity but is important as metastasis in ovary will upstage the LBC to stage 4, while primary GCT of ovary is associated with good prognosis and is regarded as low-grade malignant tumor.[10] On morphology, differentiating GCT from LBC becomes difficult in the absence of classical call Exner bodies as in the present case. Hence, the role of IHC is indispensable in these difficult situations. GCTs are classically positive for inhibin and calretinin and negative for EMA and CK7.[11],[12] These are usually positive for hormone receptors, but some may be negative as was the present case.[13] On the other hand, lobular carcinoma breast is usually positive for hormone receptors, EMA, CK7, and GCDFP and negative for inhibin and calretinin. However, only 43% of the metastatic breast cancers are positive for GCDFP-15, while approximately 33% of breast cancer cases are positive for inhibin.[3],[14] Therefore, when in doubt, it is advisable to put a complete panel of marker, to avoid the overlap in the immunophenotypic features of these tumors.

To conclude, we present here one of the extremely unusual cases of synchronous LBC and GCT of ovary. Metastatic LBC to ovary can mimic a GCT ovary and should be differentiated by the use of panel of IHC markers as it changes the prognosis and management of the patient.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 > References Top

1.
Gagnon Y, Têtu B. Ovarian metastases of breast carcinoma. A clinicopathologic study of 59 cases. Cancer 1989;64:892-8.  Back to cited text no. 1
    
2.
Jones C, Tong AW, Mir M, Coyle Y. Lobular carcinoma of the breast with gastrointestinal metastasis. Proc (Bayl Univ Med Cent) 2015;28:50-3.  Back to cited text no. 2
    
3.
Young RH. From krukenberg to today: The ever present problems posed by metastatic tumors in the ovary. Part II. Adv Anat Pathol 2007;14:149-77.  Back to cited text no. 3
    
4.
Hammer A, Lauszus FF, Petersen AC. Ovarian granulosa cell tumor and increased risk of breast cancer. Acta Obstet Gynecol Scand 2013;92:1422-5.  Back to cited text no. 4
    
5.
Webb MJ, Decker DG, Mussey E. Cancer metastatic to the ovary: Factors influencing survival. Obstet Gynecol 1975;45:391-6.  Back to cited text no. 5
    
6.
Demopoulos RI, Touger L, Dubin N. Secondary ovarian carcinoma: A clinical and pathological evaluation. Int J Gynecol Pathol 1987;6:166-75.  Back to cited text no. 6
    
7.
Young RH, Scully RE. Metastatic tumors of the ovary. In: Kurman RJ, editor. Blaustein's Pathology of the Female Genital Tract. 3rd ed. New York: Springer-Verlag; 1987. p. 742-68.  Back to cited text no. 7
    
8.
Mazur MT, Hsueh S, Gersell DJ. Metastases to the female genital tract. Analysis of 325 cases. Cancer 1984;53:1978-84.  Back to cited text no. 8
    
9.
Ohel G, Kaneti H, Schenker JG. Granulosa cell tumors in Israel: A study of 172 cases. Gynecol Oncol 1983;15:278-86.  Back to cited text no. 9
    
10.
Evans AT 3rd, Gaffey TA, Malkasian GD Jr., Annegers JF. Clinicopathologic review of 118 granulosa and 82 theca cell tumors. Obstet Gynecol 1980;55:231-8.  Back to cited text no. 10
    
11.
Yao DX, Soslow RA, Hedvat CV, Leitao M, Baergen RN. Melan-A (A103) and inhibin expression in ovarian neoplasms. Appl Immunohistochem Mol Morphol 2003;11:244-9.  Back to cited text no. 11
    
12.
Costa MJ, DeRose PB, Roth LM, Brescia RJ, Zaloudek CJ, Cohen C, et al. Immunohistochemical phenotype of ovarian granulosa cell tumors: Absence of epithelial membrane antigen has diagnostic value. Hum Pathol 1994;25:60-6.  Back to cited text no. 12
    
13.
Farinola MA, Gown AM, Judson K, Ronnett BM, Barry TS, Movahedi-Lankarani S, et al. Estrogen receptor alpha and progesterone receptor expression in ovarian adult granulosa cell tumors and sertoli-leydig cell tumors. Int J Gynecol Pathol 2007;26:375-82.  Back to cited text no. 13
    
14.
Chang E, Lee E, Oh SJ, Kim JS, Kang C. The immunoexpressions and prognostic significance of inhibin alpha and beta human chorionic gonadotrophins (HCG) in breast carcinomas. Cancer Res Treat 2005;37:241-6.  Back to cited text no. 14
    


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