Contributed by Kate McFadden, MD and Malathy Kapali, MD
Published on line in April 2003
The patient was a female in her 40s with microcalcifications at the 11 o'clock position of the right breast found on routine mammogram. She had no family history of breast or ovarian carcinoma or menstrual/reproductive irregularities conferring higher risk of breast carcinoma. There was a remote history of oral contraceptive use. Her past medical history was significant for asthma and a sebaceous cyst of the right breast that was drained two years earlier. The patient underwent her first mammogram at the age of 35, which was normal. A second mammogram at the age of 40 revealed a cluster of calcifications in the right breast. One group of calcifications changed significantly on a 6 month follow up mammogram and the patient subsequently underwent stereotactic biopsy at this site. The pathology was read as ductal carcinoma in-situ, solid type, with high nuclear grade, focal necrosis and apocrine features. The tumor was present in all three core biopsies. The patient elected to undergo segmental mastectomy with radiation and chemotherapy.
The specimen consisted of a portion of fibroadipose tissue measuring 10.0 x 6.0 x 3.0 centimeters with two localization wires inserted in the anterior aspect of the specimen. The accompanying radiograph demonstrated the wires terminating near a clip and some microcalcifications in the superior/central aspect of the specimen. On sectioning, the previous biopsy site was visualized in the anterior/superior portion of the specimen. No other focal lesions were evident.
As per the original biopsy, histologic sections revealed substantial, solid ductal carcinoma in situ with apocrine features and comedonecrosis. The cells were large with abundant, eosinophilic, granular cytoplasm and pleomorphic vesicular nuclei with prominent nucleoli (Figures 1 and 2). Some ducts exhibited a paler cells with foamy cytoplasm and similar nuclei. Adjacent to this was an infiltrating tumor (1.0 cm measured on the slide) composed of cells with abundant eosinophilic, granular cytoplasm and low grade nuclei arranged in cords between strands of hyalinized stroma (Figure 3).
Histologic differential diagnosis includes a number of eosinophilic and granular cell tumors of the breast e.g. acinic-like carcinoma, oncocytic carcinoma, and granular cell tumor (5). The immunologic features below can help differentiate among these when morphologic criteria are not definitive.
|Apocrine carcinoma:||cytokeratin positive, GCDFP-15 positive, CEA positive, c-erbB-2 oncoprotein positive, vimentin negative, S100 negative, estrogen and progesterone receptor negative.|
|Acinic-like carcinoma:||S100 positive, alpha-1-antichymotrypsin positive, EMA positive.|
|Granular cell tumor:||S100 positive, vimentin positive, neuron specific enolase positive, cytokeratin negative.|
|Oncocytic carcinoma:||anti-mitochondrial antibody positive, GCDFP-15 negative.|
Immunohistochemistry on both the in-situ and invasive components of this case revealed positive staining for cytokeratin AE 1/3 (Figure 4), e-cadherin (Figures 5 and 6), gross cystic disease fluid protein 15 (GCDFP-15) (Figures 7 and 8), and c-erbB-2 oncoprotein (her-2/neu) (figures 9 and 10) and negative staining for estrogen and progesterone receptors, S-100 and vimentin.