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CASE REPORT Table of Contents   
Year : 2010  |  Volume : 53  |  Issue : 2  |  Page : 356-358
Metaplastic carcinoma of the breast-A rare neoplasm with transitional cell differentiation: An exceptional feature


Department of Pathology, Government Medical College, Mysore, India

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Date of Web Publication12-Jun-2010
 

   Abstract 

Metaplastic carcinomas of the breast are malignant breast neoplasms composed of a mixture of both epithelial and mesenchymal elements. The rarity of this tumor is exemplified by the fact that it accounts for only about 0.2% of all breast carcinomas. It can present histologically with diverse differentiation and the exact histogenesis of these tumors is unknown. The present case is reported for its rarity and for the presence of transitional cell differentiation along with the other usual components of metaplastic carcinoma. Transitional cell differentiation in a metaplastic carcinoma has not been documented in the literature. Besides this, it highlights the importance of special stains and immunohistochemistry in evaluating these carcinomas and the need for early diagnosis and excision of these tumors as these carcinomas generally have a poorer prognosis as compared to breast carcinomas without metaplasia, with the tumor size having an important bearing on the outcome of this condition.

Keywords: Breast, diverse differentiation, metaplastic carcinoma

How to cite this article:
Hemalatha A L, Rao S, Nataraju G, Kumar B D, Shashidhar H B. Metaplastic carcinoma of the breast-A rare neoplasm with transitional cell differentiation: An exceptional feature. Indian J Pathol Microbiol 2010;53:356-8

How to cite this URL:
Hemalatha A L, Rao S, Nataraju G, Kumar B D, Shashidhar H B. Metaplastic carcinoma of the breast-A rare neoplasm with transitional cell differentiation: An exceptional feature. Indian J Pathol Microbiol [serial online] 2010 [cited 2019 Nov 14];53:356-8. Available from: http://www.ijpmonline.org/text.asp?2010/53/2/356/64348



   Introduction Top


Metaplastic carcinomas are rare and represent less than 0.2% of symptomatic invasive carcinomas of the breast. [1] These uncommon tumors may contain other cellular components besides the glandular component. [2] The sarcomatous elements range from cartilage, bone, myxoid changes and spindle cell component. [1] These tumors may manifest as well-circumscribed or irregular spiculated masses. [3] These carcinomas can metastasize to any part of the body. The debate regarding the classification and staging of these tumors still remains unresolved because of the small number of cases reported in the literature.

Though metaplastic carcinomas are malignant breast neoplasms composed of epithelial and mesenchymal elements, pathogenesis of such diverse elements within obviously infiltrating carcinomas has been the subject of much controversy. But since the tumors show cytokeratin positivity in both epithelial and mesenchymal elements, the term 'metaplastic carcinoma' has been designated to them. [4] It is difficult to assess the prognosis of metaplastic carcinomas because of their relative rarity, but some anecdotal evidence has suggested that they behave as highly malignant tumors with early recurrence and poor survival. [1]

This case report is presented for its diverse morphological features including different patterns of differentiation such as squamous cell, spindle cell, myxoid and transitional cell, out of which transitional cell differentiation in a metaplastic carcinoma has not been documented in the literature till date. Besides this, the present case report also highlights the importance of extensive sampling and careful scrutiny of biopsy material for multiple differentiation patterns in any clinically diagnosed breast carcinoma since metaplastic carcinomas have a more aggressive course and early diagnosis and treatment has a bearing on the final outcome.


   Case Report Top


An elderly lady aged 50 years, presented with lump in the right breast since seven months, which had ulcerated since the past two months. On examination, a hard lump measuring 10 x 8 cm was identified in the upper quadrant. An overlying ulcero-proliferative nodule measuring 4 x 3.5 cm was seen on the skin surface. Multiple enlarged mobile lymph nodes were found in the axilla. General and systemic examination of the patient including chest X-ray were normal. A clinical and cytological diagnosis of carcinoma was made following which the patient underwent simple mastectomy with axillary clearance, and the specimen was subjected for histopathological examination.

Gross and Microscopic Findings

Gross examination of the mastectomy specimen showed two ulcero-proliferative nodules. The specimen measured 18 x 11 x 6 cm and the largest ulcero-proliferative nodule measured 4 x 3.5 cm. Cut section revealed an ill-defined grey white mass measuring 7 x 6 cm with areas of hemorrhage and necrosis. Specimen from the axillary clearance measured 8 x 6 x 2 cm, cut section of which revealed eight lymph nodes. On light microscopy, multiple sections studied from breast mass showed a pleomorphic malignant tumor composed of ductal epithelial cells which showed large areas of squamous differentiation [Figure 1], mucin secretion, spindle cell change and prominent transitional cell differentiation [Figure 2]. The tumor cells were seen infiltrating into the overlying skin. A histopathological diagnosis of metaplastic carcinoma of breast was offered. All the eight lymph nodes identified showed features of metastatic deposits. Special stain for mucin (PAS) showed focal positivity. Immunohistochemistry for cytokeratin showed positivity in both epithelial and mesenchymal elements.


   Discussion Top


Metaplastic carcinoma of the breast is a rare entity, accounting for only about 0.2% of all breast carcinomas. [1] The diagnosis can be difficult to establish both on clinical and histopathological basis and the behavior seems to be more aggressive than that of the ordinary invasive ductal carcinoma. [3] The median age of presentation of metaplastic carcinoma of the breast in a series of 19 patients was 48 years and 50.5 years in another series of 14 cases. [5] In the present case, the patient was aged 50 years.

Most of these tumors present as large, firm, nodular tumors, often measuring up to 5 cm in diameter. Fixation to skin or deep fascia is not uncommon. [1] In the present case, the patient presented with an ulcero-proliferative mass, highlighting the fact that there is increased need for creating awareness in the patients in developing countries regarding breast malignancy. Though metaplastic carcinomas are malignant breast neoplasms composed of epithelial and mesenchymal elements, pathogenesis of such diverse elements with obviously infiltrating carcinomas .

The most common differential diagnosis to be considered in a case of metaplastic carcinoma with squamous cell differentiation is primary squamous cell carcinoma of the breast, which was ruled out in the present case owing to the presence of areas of invasive ductal carcinoma along with the other metaplastic elements. However, squamous cell carcinoma of breast is in itself considered to be a special type of metaplastic carcinoma. [6]

In a case of metaplastic carcinoma with spindle cell differentiation the possibility of a phylloides tumor has to be ruled out which was done in this case considering the presence of malignant glandular elements.

The exceptional finding in the present case besides the usual microscopic patterns described in a metaplastic carcinoma was the presence of transitional cell differentiation. This finding could not be traced in the documented literature.

Metaplastic carcinoma of the breast is an aggressive form of breast cancer associated with poor outcome, high incidence of local recurrence and pulmonary metastasis. [5] The present case had no evidence of pulmonary or any other distant metastasis. The tumor size has an important impact on outcome. In a series of 19 female patients studied, the median tumor size was 9 cm, with the three-year event-free survival of 15%. [5] In the present case, the size of the tumor was 7 cm and the patient has been advised a regular follow-up.

In conclusion, metaplastic carcinomas of the breast, although rare, have to be diagnosed and excised at the earliest as these tumors have a poor outcome.

 
   References Top

1.Fletcher CD. Diagnostic Histopathology of Tumours. 2 nd ed, vol 1. Churchill Livingstone; 2000. p. 900.  Back to cited text no. 1      
2.Agarwal K, Kaur M, Bajaj P, Agarwal C, Pathania OP. Metaplastic carcinomas of the breast (light microscopic and immunohistochemical features). Indian J Cancer 2001;38:80-84.  Back to cited text no. 2      
3.Kiran A, Veena M, Hasan H, Ghazala M. An usual case of metaplastic breast carcinoma (sarcomatoid variant). Indian J Surg 2003;65:377-8.  Back to cited text no. 3      
4.Saxena S, Bansal A, Mohil RS, Bhatnagar D. Metaplastic carcinoma of the breast: A rare breast tumour. Indian J Pathol Microbiol 2004;47:217-20.  Back to cited text no. 4      
5.Al Sayed AD, El Weshi AN, Tulbah AM, Rahal MM, Ezzat AA. Metaplastic carcinoma of the breast clinical presentation, treatment results and prognostic factors. Acta Oncol 2006;45:188-95.  Back to cited text no. 5  [PUBMED]  [FULLTEXT]  
6.Rosai J. Rosai and Ackerman's Surgical Pathology, 9 th ed, Vol 2. New Delhi: Thomson Press (India) Ltd; 2004. p. 1811-2.  Back to cited text no. 6      

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Correspondence Address:
A L Hemalatha
Department of Pathology, No. 156, 12th cross, 2nd Main, Jayanagar, Mysore-570 014, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0377-4929.64348

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    Figures

  [Figure 1], [Figure 2]

This article has been cited by
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[Pubmed]



 

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    Abstract
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