INTERNATIONAL JOURNAL OF MEDICAL AND APPLIED SCIENCES CASE REPORT CARCINOSARCOMA OF BREAST: A RARE...

INTERNATIONAL JOURNAL OF MEDICAL AND APPLIED SCIENCES ISSN:2320‐3137

155 www.earthjournals.org Volume 2 Issue 3 2013

CASE REPORT

CARCINOSARCOMA OF BREAST: A RARE CASE

JAISWAL RIDDHI1*, AGARWAL AKANKSHA2

1 ASSISTANT PROFESSOR, KING GEORGE’S MEDICAL UNIVERSITY

LUCKNOW 2 THIRD YEAR RESIDENT, KING GEORGE’S MEDICAL UNIVERSITY

LUCKNOW

ABSTRACT Carcinosarcoma of the breast, also called as metaplastic carcinoma, is a rare and aggressive tumour with two distinct cell lines comprising of epithelial and mesenchymal components, with few cases reported, incidence being 0.1% of all the breast tumours [1].. The prognosis of carcinosarcoma breast is poor compared to more common types of breast cancers such as infiltrating ductal or lobular carcinomas. These tumours are a diagnostic and therapeutic challenge to both the clinician and pathologist. A case of carcinosarcoma breast in a 40 -years woman is presented here.

KEY WORDS: Carcinoma,case report, breast , tumours

INTRODUCTION Carcinosarcoma have been observed in various organs including the ovary and uterus. The true definition of metaplastic carcinoma of the breast is a tumour of malignant epithelial tissue (carcinoma) mixed with malignant cells of mesenchymal origin (sarcoma) without an apparent intermediate zone, with apparent histological and cytological features present on light microscopy and

Immunohistochemical testing [2]. Recent studies indicate it to be a malignant mammary neoplasm probably with multipotential myoepithelial cell origin [3]. ‘Monophasic sarcomatoid carcinoma” term is used in presence of identifiable epithelial component. The term for biphasic tumours like’ biphasic sarcomatoid carcinoma’ or carcinosarcoma’ may be used. Rescent evidences suggest these tumours to originate



from malignant myofibroblasts or from metaplastic differentiation of malignant epithelial cells into myofibroblasts [4]. The differential diagnoses include spindle cell sarcoma, malignant phyllodes tumour and stromal sarcomas [8]. Here we present a case of 40- years female who was diagnosed with carcinosarcoma breast on the basis of histological picture and supported by immunohistochemistry.

CASE:

a 40 -years female underwent modified radical mastectomy for malignant breast lump and the specimen was submitted in our department for Histopathological examination. Patient had a history of left breast lump since 7 months, gradually increasing in size and associated with pain. There was no significant obstetric or family history. Patient had breastfed all her children. Mammography revealed a high density cystic mass with irregular margins and foci of calcification. Fine needle aspiration cytology of the lesion, done at a private institute diagnosed the lesion as infiltrating ductal carcinoma and biopsy was advised for further confirmation.

Gross examination showed a 18X15X6 cm sized MRM specimen was received with attached skin flap measuring 17X14

cm.NAC was retracted and a nodule 5X5 cm was identified underlying the skin, which on cutting showed solid white areas. On serial sectioning a solid growth measuring 11X9X6 cm was identified. The growth cut soft to firm and on cutting a cystic cavity was identified. 5 lymph nodes were also identified in the axillary tail.

Microscopic examination of the tumour consisted of both the malignant epithelial and mesenchymal components disposed as sheets and lobules along with focal areas of necrosis and chondroid differentiation. Epithelial component was pleomorphic, round to oval cells, with high nucleo Cytoplasmic ratio, hyperchromatic to vesicular nuclei, inconspicuous to prominent nucleoli, surrounded by scant to abundant eosinophilic cytoplasm. Spindled mesenchymal cells had hyperchromatic, fusiform nuclei and moderate bipolar cytoplasm. Fair number of mitotic figures was also seen. All the lymph nodes were free from tumour cell invasion.

Immunohistochemistry showed Positivity for CK 7, Pan CK, Vimentin, Ki67, S100 but was Negative for desmin and SMA.

Further evaluation of hormonal receptor assay was ‘triple negative’ i.e. ER, PR, HER2Neu were negative.



FIGURE 1: GROSS PICTURE OF BREAST SPECIMEN SHOWING RETRACTED NIPPLES ALONG WITH A NODULAR GROWTH ON THE SURFACE.

FIGURE 2: GROSS PICTURE SHOWING CUT SURFACE OF THE TUMOUR. A FLESHY TUMOUR MASS WITH VARIEGATED APPEARANCE.



FIGURE 3: LOW MAGNIFICATION PHOTOMICTOGRAPH SHOWING BOTH THE EPITHELIAL AND STROMAL COMPONENTS. THE STROMAL COMPONENT SHOWS SPINDEL CELLS ARRANGED IN LOBULAR PATTERN SURROUNDED BY EPITHELIAL CELLS.

FIGURE 4: PHOTOMICROGRAPH SHOWING HIGH MAGNIFICATION VIEW OF THE TUMOUR CELLS. PLEOMORPHIC SPINDLE CELLS ARE PRESENT IN ISLANDS, SURROUNDED BY LAYER OF MALIGNANT EPITHELIAL CELL LAYER.



FIGURE 5: IHC STAINING FOR CYTOKERATIN MARKER SHOW POSITIVITY IN THE EPITHELIAL COMPONENT

DISCUSSION

Carcinosarcoma of the breast (metaplastic, biphasic metaplastic, metaplastic sarcomatoid carcinoma, sarcomatoid carcinoma) is an aggressive, rare neoplasm. The true definition of metaplastic carcinoma of the breast is a tumour of malignant epithelial tissue (carcinoma) mixed with malignant cells of mesenchymal origin (sarcoma) with apparent histologic and cytologic features present on light microscopy and Immunohistochemical testing [3]. Indeed, this tumour type is often referred to as metaplastic breast cancer, characterized as an unusual and uncommon neoplasm that is comprised by an admixture of two or more components [7] The tumour components may be homogeneously adenosquamous, or heterogeneously epithelial (adenocarcinoma) and mesenchymal (matrix, spindle cell and sarcomatous) in origin [7]. However, it seems more appropriate to term all breast

carcinomas with obvious carcinomatous and sarcomatous features as biphasic metaplastic sarcomatoid carcinoma (MSC)

Regardless of the name given to this entity, most metaplastic tumours of the breast are poorly differentiated, high grade, highly cellular, with mitotically active pleomorphic spindle cells. The majority are estrogen and progesterone receptor negative, and HER2-neu negative by immunohistochemistry [9]. The clinical and pathologic features of metaplastic breast carcinomas are important to distinguish from other types of uncommon breast malignancies such as spindle cell carcinoma, matrix producing carcinoma, fibrosarcoma, osteosarcoma, malignant fibrous histiocytoma, phylloides tumor and stromal sarcoma as their behavior, response to treatment and survival rates differ greatly. Clinical features of metaplastic breast cancer are similar to those patients with invasive ductal carcinoma. Recurrence can be rapid as the primary tumour is aggressive, thus mandating close interval follow-up after resection. Pulmonary metastasis is more common than



brain, skeletal or hepatic metastasis, and the prognosis for these patients is poor [3]. Outcomes for local recurrences are somewhat improved when surgical resection is achievable. In general, the recommended treatment options have followed the established NCCN guidelines for patients with invasive breast cancer. In the majority of the reported cases, mastectomy with or without axillary node dissection was performed, followed by post-operative chemotherapy and radiation therapy in various combinations.

Adjuvant hormonal therapy and chemotherapy is based upon the receptor status of the primary tumor and is an important tool in treatment recommendations. The HER1/EGFR receptor is reported to be over-expressed in the majority of metaplastic sarcomatoid carcinomas of the breast and should be included in the initial evaluation of the various tumors which are described under this classification. The results may then be utilized to tailor the adjuvant therapy based upon these findings. New treatment opportunities may exist with the development of agents targeting the EGFR receptor such as gefitinib (ZD1839, Iressa) and cetuximab (Erbitux)[11,12]

CONCLUSION

Appropriate diagnosis of carcinosarcoma requires a calculated approach on the part of clinician and pathologist. Histopathology, supplemented by immunohistochemistry and hormonal status are mandatory for proper treatment planning.

REFERENCES:

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11. Leibl S, Moinfar F. Metaplastic breast carcinomas are negative for Her-2 but frequently express EGFR (Her-1): potential relevance to adjuvant treatment with EGFR tyrosine kinase inhibitors? J Clin Pathol. 2005;58:700–704. doi: 10.1136/jcp.2004.025

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INTERNATIONAL JOURNAL OF MEDICAL AND APPLIED SCIENCES CASE REPORT CARCINOSARCOMA OF BREAST: A RARE...

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