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Year : 2016  |  Volume : 59  |  Issue : 1  |  Page : 126-127
Pregnancy-like hyperplasia and cystic hypersecretory changes adjacent to metaplastic carcinoma of the breast


1 Department of Pathology, Istanbul Research and Training Hospital, Istanbul, Turkey
2 Department of General Surgery, Istanbul Research and Training Hospital, Istanbul, Turkey
3 Department of Radiology, Istanbul Research and Training Hospital, Istanbul, Turkey

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Date of Web Publication9-Mar-2016
 

How to cite this article:
Kelten C, Boyaci C, Leblebici C, Trabulus DC, Nazli MA. Pregnancy-like hyperplasia and cystic hypersecretory changes adjacent to metaplastic carcinoma of the breast. Indian J Pathol Microbiol 2016;59:126-7

How to cite this URL:
Kelten C, Boyaci C, Leblebici C, Trabulus DC, Nazli MA. Pregnancy-like hyperplasia and cystic hypersecretory changes adjacent to metaplastic carcinoma of the breast. Indian J Pathol Microbiol [serial online] 2016 [cited 2019 Nov 12];59:126-7. Available from: http://www.ijpmonline.org/text.asp?2016/59/1/126/178238


A 49-year-old Caucasian woman was admitted to our hospital because of mass in her right breast. The patient was nulligravida nulliparous. No history was obtained for drug uses such as antihypertensive, antipsychotic, or exogenous estrogen intake. She had no family history of breast cancer. Physical examination revealed a relatively well-circumscribed, nodular, and firm mass in the upper quadrant of her right breast. Radiologically, hypoechoic mass with ill-defined borders and 35 mm in largest dimension was determined. Core needle biopsy revealed invasive breast carcinoma. The patient underwent modified radical mastectomy. Macroscopically, an ill-defined ( 3. 5 cm × 3 cm × 2 cm in size) solid tumor, gray-white in color with common hemorrhagic areas, was identified. Microscopically, the tumor composed of both malignant epithelial and mesenchymal components [Figure 1]a. The epithelial part showed irregular solid proliferations of tumor cells including common necrotic areas as well as lumen formation [Figure 1]b. Squamous eddies were noted focally [Figure 1]c. Tumor cells showed large eosinophilic cytoplasm in the form of epithelioid, polygonal, and spindle-shaped and large pleomorphic nucleus with vesicular chromatin distribution and prominent nucleoli. These groups of tumor cells intermingled with a mesenchymal component demonstrating myxoid/myxochondroid features [Figure 1]d. Osteoid formation was noticed focally [Figure 1]e. Interestingly, varying degrees of cystic hypersecretory lesions (CHL) as well as pregnancy-like hyperplasia (PLH) were determined concomitantly adjacent to invasive tumor [Figure 1]f and g. CHL were identified as cystic hypersecretory hyperplasia (CHH) with or without atypia and an alteration through high-grade ductal carcinoma in situ (DCIS) with patterns of flat, micropapillary, papillary, or cribriform was noted [Figure 1]h, i, and k. Similarly, PLH was observed in a spectrum as PLH without atypia, PLH with atypia, and adjacent to them as DCIS [Figure 1]l and m. Some of the terminal ductal lobular units showed both features of PLH and CHL, concomitantly. Microcalcification associated with these lesions was not detected. The tissues sampled away from the tumor showed only fibrocystic changes such as stromal fibrosis, adenosis, dilated ducts, and apocrine metaplasia. The invasive tumor showed positive immunostaining, both for pancytokeratin and vimentin [Figure 2]a and b; negative staining for estrogen and progesterone hormone receptors and CerbB2 (triple negative). No lymphovascular and perineural invasion was determined. Axillary lymph nodes were free of tumor. The tumor stage was T2N0M0. Chemotherapy was planned for the treatment. After four cycles of cyclophosphamide and doxorubicin, pleural tumor metastasis was detected. Therefore, cisplatin and gemcitabine were added. However, the patient died 23 months after her initial operation due to brain metastasis.
Figure 1: (a) Metaplastic carcinoma with carcinomatous and sarcomatous components. Epithelial part of the tumor (b) forms glands, (c) squamous eddies and stromal part features (d) myxochondroid, (e) osteoid areas. (f) Intermingled cystic hypersecretory lesions and pregnancy-like changes neighboring invasive tumor. (g) Terminal ductal lobular unit captured and enlarged by cystic hypersecretory lesions. (h) Cystic hypersecretory hyperplasia associated with high-grade in situ ductal carcinoma with (i) papillary, (k) micropapillary and cribriform patterns. (l) pregnancy-like changes with and (m) without atypia in expanded terminal ductal lobular units

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Figure 2: Tumor shows positive immunostaining both with (a) pancytokeratin and (b) vimentin

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CHL are special type of breast lesions which are characterized by multiple cystic glandular structures including eosinophilic colloid-like material in their lumens. Therefore, the appearance of lesion reminds thyroid parenchyma on low power field. This group of lesions are termed gradually due to the presence of cytonuclear atypia on the cells lining the cystic glands and whether structural pattern accompanying. According to this, the cystic glandular ducts lining by single row epithelium with ordinary nuclear features are termed as "CHH." If nuclear atypia (nuclear enlargement, vesiculation, prominent nucleoli) accompanies CHH, it is then termed as "CHH with atypia." If there is an increased row of lining cells or complex structural growing patterns such as micropapillary, papillary, or cribriform appearance, it is considered "carcinoma in situ." In this case, CHL are neighboring to the metaplastic tumor. Moreover, the transition from CHH to CHH with atypia and DCIS was observed even in a single duct. In addition, isolated benign dilated glands embedded in invasive tumor were noticed.

The histologic relationship of PLH and CHL has been reported previously. [1] DCIS arising from pregnancy-like changes and/or CHL has been demonstrated in a small number of cases. [2] However, few cases of invasive carcinoma of the breast have been reported in this setting. [2],[3] Shin and Rosen reported 4 mm focus of well-differentiated invasive breast carcinoma with intermediate nuclear grade adjacent to areas of cystic hypersecretory DCIS and CHH with atypia. They indicated areas with atypical PLH in a separate sample of same biopsy material. Takeuchi et al., reported classic type invasive lobular carcinoma arising from preexisting PLH/CHH. However, they mentioned that they observed no continuous transition from PLH/CHH to lobular neoplasm. Another case with invasive lobular carcinoma including cystic hypersecretory carcinoma was reported by Rosen. [4] To the best of our knowledge, this is the first report of metaplastic breast carcinoma, which is a high-grade tumor in the setting of PLH/CHL in English literature.

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Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Shin SJ, Rosen PP. Pregnancy-like (pseudolactational) hyperplasia: A primary diagnosis in mammographically detected lesions of the breast and its relationship to cystic hypersecretory hyperplasia. Am J Surg Pathol 2000;24:1670-4.  Back to cited text no. 1
    
2.
Shin SJ, Rosen PP. Carcinoma arising from preexisting pregnancy-like and cystic hypersecretory hyperplasia lesions of the breast: A clinicopathologic study of 9 patients. Am J Surg Pathol 2004;28:789-93.  Back to cited text no. 2
    
3.
Takeuchi T, Tsuzuki H, Numoto S, Furihata M. Coexistence of pregnancy-like and cystic hypersecretory hyperplasia with invasive lobular carcinoma. Onkologie 2011;34:448-50.  Back to cited text no. 3
    
4.
Rosen PP, editors. Cystic hypersecretory carcinoma and cystic hypersecretory hyperplasia. In: Rosen's Breast Pathology. Philadelphia, PA: Lippincott Williams and Wilkins; 2001. p. 527-34.  Back to cited text no. 4
    

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Correspondence Address:
Canan Kelten
Department of Pathology, Istanbul Research and Training Hospital, Istanbul
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0377-4929.178238

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