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Year : 2021  |  Volume : 64  |  Issue : 1  |  Page : 204-205
Pilomatricoma male breast, mimicking breast carcinoma-A rare case


Department of Pathology, Deen Dayal Upadhyay Hospital, New Delhi, India

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Date of Submission28-Feb-2020
Date of Decision15-May-2020
Date of Acceptance27-Jul-2020
Date of Web Publication8-Jan-2021
 

How to cite this article:
Sood N, Raj B. Pilomatricoma male breast, mimicking breast carcinoma-A rare case. Indian J Pathol Microbiol 2021;64:204-5

How to cite this URL:
Sood N, Raj B. Pilomatricoma male breast, mimicking breast carcinoma-A rare case. Indian J Pathol Microbiol [serial online] 2021 [cited 2021 Apr 21];64:204-5. Available from: https://www.ijpmonline.org/text.asp?2021/64/1/204/306498




A 48-year-old male patient reported with left breast lump of 2 months duration. The lump was in in lower outer quadrant measuring 5 × 3 cms. It was firm to hard, non-tender, fixed to underlying structures and adherent to skin. Fine needle aspiration smears were cellular showing tight cohesive clusters of small hyperchromatic cells with high nuclear cytoplasmic ratio, mild atypia and scanty cytoplasm. Background showed inflammatory cells and histiocytes [Figure 1]. It was reported as suspicious of neoplasm possibly of breast origin. On mammography, it was reported as BIRADS II. Core biopsy showed clusters of basaloid cells with scanty cytoplasm and mild to moderate anisonucleosis with nuclear atypia in dense fibrous stroma. The excised specimen showed an elliptical lesion measuring 5 × 3 × 2 cms with normal skin. Cut section showed central chalky white areas surrounded by firm grey white area. Sections showed central necrosis, surrounded by proliferation of small basaloid cells with abrupt transition to ghost/shadow cells, focal areas of calcification with multinucleated giant cells were noted. On immunohistochemistry, tumor cells were Pan CK and CK5 positive, thus confirming the diagnosis of Pilomatricoma [Figure 2].
Figure 1: (a) - Left breast lump in lower outer quadrant. (b) - Tight cohesive cluster of small hyperchromatic cells. (Giemsa, 40×). (c) - Small hyperchromatic cells with high nuclear cytoplasmic ratio, mild to moderate nuclear atypia and scanty cytoplasm. Background is haemorrhagic.(Giemsa, 400×). (d) - Core Biopsy-Clusters of basaloid cells, with scanty cytoplasm and mild to moderate anisonucleosis with nuclear atypia in dense fibrous stroma. (HE, 400×)

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Figure 2: (a) - Gross-Cut surface shows grey white solid mass measuring 5.5 × 4 cms with central chalky areas. (b) - Focal area of basaloid cells with adjacent ghost cells. (HE, 40×). inset showing area of calcification (Von Kossa, 400×). (c) - Multinucleated giant cells (HE, 400×). (d) - Island of anucleated (ghost) cells. (HE, 40×). (e) - Island of small basaloid cells with adjacent anucleated squames. (HE, 400×). (f) - CK5, Pan CK positive. (IHC-Biocare, 400×)

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The patient has been on follow up for last two years with no signs of recurrence.


   Discussion Top


Pilomatricoma is a benign dermal or subcutaneous tumor. It shows bimodal presentation, mainly affecting children and adolescents. However, a second smaller peak of onset is also seen in the elderly.[1] The most common sites are face and upper extremities. Breast localization is very rare (1:100000 people) with only sporadic case reports in the literature.[2],[3] Only 14 cases have been reported till date.[2] Breast localization has been reported in elderly males with an exception of a case report in a female patient.[3]

These lesions may range from 0.5 to 3 cm in size, although lesions up to 15 cm have been reported.[1] Lesions larger than 5.0 cm are considered giant pilomatricomas. The largest size reported in breast has been up to 6 cms.[2],[3] Other rare morphological variants include extruding lesions, perforating lesions, superficial cutaneous horn, and bullous Pilomatricoma.[3]

Multiple lesions have been reported in 2-10% of cases. These lesions can be sporadic or associated to syndromes such as Gardner syndrome and myotonic dystrophy. The exact etiology is still unclear. Forbis and Helwig considered Pilomatricoma as hamartomas.[4] It is also postulated that repeated skin traumas can induce an inflammatory response leading to an overgrowth of hair matrix. It possibly originates from the peri-areolar piliferous bulbs in the breast region.[2],[4] Mammography is often deceptive and shows dense breast tissue with nodules containing clusters of pleomorphic irregular microcalcifications. It is usually diagnosed as BI-RADS III to IV. It may even mimic inclusion cysts, fibrocystic changes, lobular neoplasias, papillomas, calcified fibroadenomas and invasive ductal carcinoma radiologically.[5] Hence role of breast mammography is debatable, given the broad differentials of the lesion.[5]

Characteristics cytology of shadow cells, primitive-appearing basaloid cells with a high nuclear/cytoplasmic ratio and foreign body giant cells are helpful in making a precise preoperative diagnosis, which are absent in 40% of cases as in our case.[2] Ieni et al. reported diagnostic accuracy of only 20% on cytological examination.[6] Scarcity of material further leads to misdiagnosis.[5] The presence of numerous keratinized squamous cells and paucity of basaloid cells can be misinterpreted as EIC and benign cystic lesions, although not seen in this case. On the contrary high cellular yield of small primitive basaloid cells having high nuclear cytoplasmic ratio, nuclear molding and mild atypia has been misdiagnosed as carcinoma.[6] Cellular components and diagnostic trap arising commonly due to predominance of one component over the others should always be considered while examining FNA smears to avoid incorrect diagnosis on cytology.[6]

Histopathological features are characteristically two populations of cells in islands with enucleated shadow cells in the center and nucleated basophilic cells on the periphery. The basaloid cells have deep basophilic nuclei with scant cytoplasm that lack distinct cell borders. These cells are surrounded by foreign body-type giant cells and calcification are confirmatory of diagnosis.[1] In breast localization a core-needle biopsy has proven to be an effective technique for diagnosing Pilomatricoma nodule.[4] However in this case even the trucut biopsy was non-representative.

Malignant Pilomatricomas are rare, seen in elderly and may metastasize to the lung, bone, brain, abdominal organs, skin and lymph nodes.[1] So far only 80 cases have been reported in the literature.[5] Surgical excision is the treatment of choice as these tumors do not regress and recurrence is rare.[5]

Pilomatricoma is is a great mimicker of breast malignancy clinically as well as on radiology and cytology. We need to consider this possibility in clinically suspicious breast lesions. This case is being presented for its unusual presentation and diagnostic dilemma on cytology.

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.
Julian CG, Bowers PW. A clinical review of 209 pilomatricomas. J Am Acad Dermatol 1998;39:191-5.  Back to cited text no. 1
    
2.
Kapoor A, Narayanan R, Tandon A, Santosh AK. Pilomatricoma: An unusual cause of lump in a male breast. J Clin Ultrasound 2018;46:209-11.  Back to cited text no. 2
    
3.
Prasanna MR, Calton N. Perforating pilomatricoma mimicking breast carcinoma in an adult male. Choice 2014;5:8.  Back to cited text no. 3
    
4.
Nori J, Abdulcadir D, Giannotti E, Calabrese M. Pilomatrixoma of the breast, a rare lesion simulating breast cancer: A case report. J Radiol Case Rep2013;7:43-50.  Back to cited text no. 4
    
5.
Borders MH, Fitzpatrick KA, McClenathan JH. Benign pilomatricoma of the breast. Appl Radiol 2015;44:24.  Back to cited text no. 5
    
6.
Ieni A, Todaro P, Bonanno AM, Catalano F, Catalano A, Tuccari G. Limits of fine-needle aspiration cytology in diagnosing pilomatrixoma: A series of 25 cases with clinico-pathologic correlations. Indian J Dermatol 2012;57:152.  Back to cited text no. 6
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Correspondence Address:
Bal Raj
Department of Pathology, Deen Dayal Upadhyay Hospital, New Delhi - 110 064
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJPM.IJPM_194_20

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