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CASE REPORT Table of Contents   
Year : 2009  |  Volume : 52  |  Issue : 1  |  Page : 83-85
Secretory carcinoma arising in radial scars of the breast: A case report and review of literature


1 Department of Pathology, Tata Memorial Hospital, Parel, Mumbai-400012, India
2 Department of Radiation Oncology, Tata Memorial Hospital, Parel, Mumbai-400012, India
3 Department of Surgical Oncology, Tata Memorial Hospital, Parel, Mumbai-400012, India

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   Abstract 

Radial scars or complex sclerosing lesions are common benign lesions in the breast with characteristic radiological and pathological features. The pathological diagnosis of carcinoma arising in this setting requires careful amalgamation of clinical, radiological and morphological details. Ancillary techniques like immunohistochemistry aid in the diagnosis. We report an unusual case of a secretory carcinoma arising in the background of a radial scar.

Keywords: Breast, radial scar, secretory carcinoma

How to cite this article:
Menon S, Shet T, Munshi A, Badwe R. Secretory carcinoma arising in radial scars of the breast: A case report and review of literature. Indian J Pathol Microbiol 2009;52:83-5

How to cite this URL:
Menon S, Shet T, Munshi A, Badwe R. Secretory carcinoma arising in radial scars of the breast: A case report and review of literature. Indian J Pathol Microbiol [serial online] 2009 [cited 2014 Oct 24];52:83-5. Available from: http://www.ijpmonline.org/text.asp?2009/52/1/83/44974



   Introduction Top


Radial scars or complex sclerosing lesions are benign, well-defined pathologic and radiologic entities. The etiology is unknown but is unrelated to prior surgery or trauma. [1] Radial scars are frequently identified on screening mammography and their radiologic features may mimic carcinoma. [2] Histologically, radial scars are characterized by the presence of a fibroelastotic core with entrapped ducts and peripherally radiating ducts and lobules. The ducts and lobules emanating from radial scars can serve as the milieu for the development of lobular neoplasia, intraductal, or invasive carcinoma. Radial scars may be associated with atypical ductal hyperplasia and carcinoma in 31-50% of cases. [3] Although the management of these lesions is a matter of debate, it is now accepted that an excisional biopsy, rather than a core biopsy, should be performed when imaging findings are consistent with radial scar. [4],[5] Previous studies have shown that the patient's age and the size of the radial scar are correlated to potential neoplastic transformation.[6] Most of the malignancies arising in the background of a radial scar are low-grade carcinomas of which the most common is tubular carcinoma. [7] We report a rare case of secretory carcinoma arising in the background of a mammographically suspected and histologically confirmed radial scar.


   Case Report Top


A 40-year-old female presented to the breast clinic with a history of irregular nodularity in the right breast and serous nipple discharge since 5 months.

On examination, the right breast had vague nodularity about 1 cm in the central quadrant. The nodule was ill-defined and firm to feel. On mammography, a 0.7 cm radiolucent area with radiating spicules was noted. No microcalcifications or architectural distortion was appreciated. The patient underwent an ultrasound-guided fine needle aspiration cytology (FNAC) twice but the material was insufficient for a definitive diagnosis. A lumpectomy was performed on the patient as the mammography was suggestive of a radial scar. Grossly the lumpectomy specimen revealed a firm stellate area of about 0.6 cm. Microscopically, the lesion had a central fibroelastotic core with radiating tubules characteristic of a radial scar [Figure 1]. The tubules at the periphery were seen invading the adipose tissue. The cells lining these peripheral tubules had Grade 1 nuclei with conspicuous nucleoli and had abundant eosinophilic granular to vacuolated cytoplasm. Very occasional mitosis was noted. There was secretory material seen both intracellulary as well as extracellulary, which was found to be per-iodic acid schiff (PAS) positive and resistant to diastase digestion [Figure 2]. On immunohistochemistry, p63 and SMA confirmed the absence of a myoepithelial cell layer [Figure 3]. In addition, the malignant cells stained with S-100 protein, however, estrogen receptor (ER) and progesterone receptor (PR) were found to be negative. Following the diagnosis of secretory carcinoma, the patient underwent axillary node dissection that revealed 18 reactive lymph nodes.


   Discussion Top


Radial scars are enigmatic lesions and their pathogenesis is obscure. It is postulated that minor trauma or surgical injuries lead to fibroelastotic remodeling of stroma and retraction of surrounding breast parenchyma thus imparting a stellate configuration. [1] In recent years, the role of radial scars as a marker of neoplastic risk and as a precursor lesion in breast carcinogenesis has been debated. [4-7] The incidence of radial scars or complex sclerosing lesions have been as high as 28% in an autopsy series increasing to 42% in cases with previous diagnosis of breast carcinoma. [8],[9] Most of these lesions are detected as incidental findings during screening mammograms and a fairly accurate radiological diagnosis is possible based on criteria from Tabαr and Dean, although distinction from a carcinoma may be difficult. [2] Fine needle aspiration cytology seems to be unreliable in the diagnosis of radial scar associated malignancy (67% sensitivity and 91% specificity). Stellate lesions, therefore, should be excised to obtain a histological diagnosis regardless of cytological finding.[7] In the present case, the mammographic findings in concert with a non palpable lesion were suggestive of a radial scar and when repeated FNAC failed to sample the representative area, a lumpectomy was done.

Grossly, radial scars have a stellate configuration with central pale area of fibrosis and peripheral elastic streaks. Microscopically, there is a central fibroelastotic core with a corona of radiating tubules and lobules. These epithelial structures may show varying degrees of hyperplasia and atypia merging imperceptibly with areas of in-situ carcinoma and invasive malignancy. The rate of atypical hyperplasia and malignancy varies from 30% to as high as 50%. [3],[7] In a study of 126 lesions of radial scars, Sloane, et al. found that the significant risk factors for development of carcinoma in radial scars were age >40 years old and the size of the lesion >7mm. [6] However, in a recent study, age > 50 years old was found to be significantly associated with progression to carcinoma in radial scars whereas size was not a factor. [5] In comparison, our patient was young (40 years old) and the size of the radial scar was 0.6 cm.

Most of the carcinomas arising in the background of radial scars are of low grade with tubular and low-grade ductal carcinoma being the most common entities. Only one case of a secretory carcinoma in a radial scar is documented in English literature.[7] The presence of PAS-positive and diastase-resistant secretory material in our case along with the absence of myoepithelial cells (absent p63 and SMA positive cells) confirmed the diagnosis of secretory carcinoma. ER and PR were found to be negative in our case. ER and PR are known to be negative in a majority of secretory carcinomas even though they are of a low grade. A novel fusion gene ETV6-NTRK3 is characteristically expressed in secretory carcinomas. [10] This fusion transcript was not studied in the present case due to the non availability of the primers at our institution. Axillary node metastasis is rare in secretory carcinoma. Recent data supports a conservative surgery with sentinel node biopsy followed by accurate follow-up. [11] In our case, an axillary dissection was performed as a second stage procedure and the patient is on regular follow-up.

In conclusion, our case highlights the importance of recognizing radial scars on mammography. As shown in our case, FNAC may be unreliable in such situations and an excisional biopsy/lumpectomy is therefore advisable. The excisional biopsy will avoid sampling errors associated with needle biopsy techniques and will also rule out a malignant focus.

 
   References Top

1.Kennedy M, Masterson AV, Kerin M, Flanagan F. Pathology and clinical relevance of radial scars: A review. J Clin Pathol 2003;56:721-4.  Back to cited text no. 1  [PUBMED]  [FULLTEXT]
2.Tabar L, Dean PB. Stellate lesions. In: Tabαr L, Dean PB, eds. Teaching atlas of mammography, Second revised edition. New York: George Thieme Verlag; 1985. p. 87-136.  Back to cited text no. 2    
3.Frouge C, Trisant H, Guinegretiθre JM, Meunier M, Contesso G, Paola RD, et al . Mammographic lesions suggestive of radial scars: Microscopic findings in 40 cases. Radiology 1995;195:623-5.  Back to cited text no. 3    
4.Doyle EM, Banville N, Quinn CM, Flanagan F, O'Doherty A, Hill AD, et al . Radial scars/complex sclerosing lesions and malignancy in a screening programme: Incidence and histological features revisited. Histopathology 2007;50:607-14.   Back to cited text no. 4  [PUBMED]  [FULLTEXT]
5.Manfrin E, Remo A, Falsirollo F, Reghellin D, Bonnetti F. Risk of neoplastic transformation in asymptomatic radial scar: Analysis of 117 cases. Breast Cancer Res Treat 2008;107:371-7.  Back to cited text no. 5    
6.Sloane JP, Mayers MM. Carcinoma and atypical hyperplasia in radial scars and complex sclerosing lesions: Importance of lesion size and patient age. Histopathology 1993;23:225-31.  Back to cited text no. 6  [PUBMED]  
7.Mokbel K, Price RK, Mostafa A, Williams N, Wells CA, Perry N, et al . Radial scar and carcinoma of the breast: Microscopic findings in 32 cases. Breast 1999;8:339-42.  Back to cited text no. 7  [PUBMED]  [FULLTEXT]
8.Nielsen M, Jensen J andersen JA. An autopsy study of radial scar in the female breast. Histopathology 1985;9:287-95.  Back to cited text no. 8    
9.Nielsen M, Christensen L andersen J. Radial scars in women with breast cancer. Cancer 1987;59:1019-25.  Back to cited text no. 9    
10.Diallo R, Schaefer KL, Bankfalvi A, Decker T, Ruhnke M, Wülfing P, et al . Secretory carcinoma of the breast: a distinct variant of invasive ductal carcinoma assessed by comparative genomic hybridization and immunohistochemistry. Human Pathol 2003;34:1299-305.  Back to cited text no. 10    
11.Vieni S, Cabibi D, Cipolla C, Fricano S, Graceffa G, Latteri MA. Secretory breast carcinoma with metastatic sentinel lymph node. World J Surg Oncol 2006;4:88.  Back to cited text no. 11  [PUBMED]  [FULLTEXT]

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Correspondence Address:
Santosh Menon
Department of Pathology, Tata Memorial Hospital, Parel, Mumbai - 400 012
India
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DOI: 10.4103/0377-4929.44974

PMID: 19136791

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  [Figure 1], [Figure 2], [Figure 3]



 

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