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Original Report |
il Günhan-Bilgen1enur Memi1
1 Department of Radiology, Ege Üniversity Hospital, Bornova, 35100 Izmir,
Turkey.
2 Department of Pathology, Ege Üniversity Hospital, 35100 Izmir,
Turkey.
Received July 30, 2001;
accepted after revision December 6, 2001.
Address correspondence to I. Günhan-Bilgen.
Abstract
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CONCLUSION. Metaplastic carcinoma of the breast often manifests as a rapidly growing, palpable mass that has high density on mammography and may be microlobulated on sonography. Complex echogenicity with solid and cystic components may be seen sonographically and is related to necrosis and cystic degeneration found histopathologically. Although it is a rare breast malignancy and these features are not unique, metaplastic carcinoma should be included in the differential diagnosis for breast masses with these imaging features.
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The differential diagnosis is important for the purposes of treatment and prognosis [1, 4]. Although the pathologic and clinical aspects of these rare tumors have been described in various reports, to our knowledge, only a few reports, mostly case studies, have been published on the mammographic features [1, 8,9,10,11,12,13] and sonographic findings [10, 13].
The purpose of this study was to investigate the mammographic and sonographic findings of metaplastic carcinoma of the breast and to correlate the radiologic features with clinical and histopathologic findings.
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Mammography with two routine positions (craniocaudal and mediolateral oblique) was performed in all the patients using a Senographe Senix 600T (General Electric CGR, Issy Les Moulineaux, France) or a Mammomat 3000 (Siemens, Solna, Sweden) system. All mammograms were retrospectively reviewed by two radiologists who were specialists in breast imaging. The evaluation was performed as consensus interpretations. Mammograms were evaluated with radiologists unaware of the information from the physical examination or sonography records but aware of the histopathologic diagnosis. Each mammographic lesion was characterized according to size, mass characteristics (shape, margins, density, size, and location), presence and type of microcalcifications, associated architectural distortion, and skin changes. Parenchymal patterns were categorized as fatty, scattered fibroglandular tissue, heterogeneously dense, and extremely dense using the American College of Radiology's Breast Imaging Reporting and Data System (BI-RADS) [14].
Sonography was performed in all the patients using a 7.5-mHz transducer (SAL 70; Toshiba, Tokyo, Japan) or a broadband 5- to 11-MHz transducer (HDL 1000; Advanced Technology Laboratories, Bothell, WA). The sonographic prints and records of each patient were reviewed after the mammograms, in the same evaluation session. Sonograms were assessed for lesion shape, margin, and echogenicity.
In the retrospective study, information about preoperative needle biopsies was available in one patient. All lesions were surgically excised. Microscopic slides of samples of all patients were reviewed by two pathologists who were breast pathology specialists. Each case was reviewed by the two pathologists as a consensus evaluation. The specific metaplastic components were identified. Mammographic and sonographic findings were then correlated with histopathology. Pathologic size, predominant pathologic findings, and lymph node status were obtained from the surgical pathology reports.
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On the mammograms, in relation to the parenchymal pattern, four breasts were fatty, and four were heterogenously dense. All eight patients had masses without associated microcalcifications or architectural distortion. In three patients, the margins of the mass were partially obscured by the surrounding breast parenchyma (Fig. 1A). The margins of the masses were well circumscribed in two patients and microlobulated (Figs. 2A, 3A, and 3B) in three patients. None of the masses showed prominent spiculations. All masses were highly dense, and the shape was round in six patients and oval in two. The size varied between 1.5 and 4.5 cm (mean, 2.6 cm). Unfortunately, prior mammograms were not available in any of the patients, so the rapid growth that was noted by the patient could not be confirmed radiologically. The location of the masses were upper—outer quadrant in five patients, upper—central quadrant in one, lower—central quadrant in one, and lower—inner quadrant in one. In one patient, the neighboring skin showed focal thickening.
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On sonographic examination, two masses had discrete well-circumscribed oval contours, whereas six masses showed microlobulation (Figs. 2B and 3C). In one patient, the mass showed heterogenous echogenicity. The mass had both solid and cystic areas (Fig. 1B). In another patient, the mass was round, homogeneous, and solid with smooth margins. Although the mammographic and sonographic features were consistent with a benign mass, such as fibroadenoma, because of the patient's age (44 years) and family history (her sister died of breast cancer at 46 years), histopathologic examination, which disclosed carcinosarcoma, was strongly recommended.
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Breast-conserving surgery (lumpectomy with axillary node dissection) was performed in one patient who showed axillary lymph node involvement. Two years after surgery, she developed local recurrence, contralateral breast masses, supraclavicular lymphadenopathy, and pulmonary nodules consistent with metastasis, although metastatic disease was not proven histopathologically. The other seven patients were treated with modified radical mastectomy, with the axilla showing no metastatic involvement.
Fine-needle aspiration cytology of the lesion that was available in one patient was diagnosed as malignant epithelial tumor. At histopathologic examination, the metaplastic components of the lesions were squamous cell type in three patients (Figs. 2C and 2D), matrix-producing type in two, carcinosarcomatoid in two (Figs. 3D and 3E), and a mixture of spindle cell and matrix-producing type in one. In the complex mass, which showed heterogenous echogenicity with solid and cystic components on sonography, necrosis and cystic degeneration were found at histopathology. All eight patients underwent axillary lymph node dissection, and involvement was positive in only one.
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Wargotz and Norris [3, 5, 15] and Wargotz et al. [4] suggested four variants of metaplastic carcinoma, including matrix-producing carcinoma, spindle cell carcinoma, squamous cell carcinoma, and carcinosarcoma. Oberman [6] suggested that all such tumors be categorized as metaplastic carcinoma of the breast, deemphasizing whether the metaplastic component is of mesenchymal or epithelial origin. Although these rare tumors show pathologic features of both carcinoma and sarcoma, because metaplastic carcinoma with a sarcomatous component is a different entity from primary breast sarcoma, we believe differentiation is significant to characterize them as distinct entities for purposes of diagnosis, treatment, and prognosis.
Metaplastic carcinomas are usually seen in women who are more than 50 years old [2, 3, 5, 6, 9]. The ages of our patients were between 44 and 63 years old; only two patients were less than 50 years old. The presenting symptom is usually a palpable mass, and axillary lymph node metastasis is infrequent [2,3,4,5]. All our patients had palpable masses, and only one (12.5%) had axillary lymph node involvement. The number of our patients is too few to accurately determine the frequency of lymph node involvement in a larger patient population.
The mammographic appearance of metaplastic breast carcinoma has been described in case reports or in small series [1, 8,9,10,11,12,13]. To our knowledge, only four reports have been published that correlate mammographic and pathologic features of this rare tumor [1, 8, 10, 12]. Brenner et al. [1], in their study of three patients, described the mass as well circumscribed, irregular, or spiculated, whereas Patterson et al. [8], in their series on nine patients, reported a predominantly circumscribed, noncalcified mass with a spiculated portion. Samuels et al. [13] described the margins of five masses, which were oval, as indistinct and partially well circumscribed; in three of them, the tumor margin was also partly spiculated. Park et al. [10], in their study of 16 patients, described the characteristic appearance as an ill-defined or obscured round mass with associated architectural distortion. As for the presence of microcalcifications, Evans et al. [12], in their case report of osseous metaplasia, described a predominantly circumscribed mass with a densely calcified center and an osteoid matrix. Brenner et al. reported a 2-cm smooth mass with macrocalcifications, and Park et al. reported one patient with clustered microcalcifications without an associated mass.
In our series, the margins of the tumors were either obscured (37.5%), microlobulated (37.5%), or well circumscribed (25%). All the masses had high density without spiculations or associated microcalcifications on mammography. In contrast to the study of Park et al. [10], associated architectural distortion was not noted in our patients. When we compare and combine the mammographic findings of the masses in all the previously reported series and in this study, we could probably conclude that no specific or distinctive descriptor for mass margin is characteristic of metaplastic carcinoma. However, a high-density mass without associated microcalcifications might be useful in suggesting the diagnosis.
Although seen rarely and possibly not a characteristic finding, metaplastic carcinoma could be included in the differential diagnosis of predominantly circumscribed, noncalcified masses seen on mammography. Metaplastic carcinomas are likely to have circumscribed margins, especially when the tumor is composed solely of spindle cells [8]. In one of our patients, the mass was so well circumscribed that it mimicked a fibroadenoma. However, histopathologic examination disclosed carcinosarcoma. One important feature that may be helpful in distinguishing metaplastic carcinomas from predominantly circumscribed noncalcified masses is the concurrence of a circumscribed portion with a spiculated portion, which is seen in carcinomas with a mixture of growth patterns of metaplastic and invasive carcinoma not otherwise specified [8].
One sonographic examination, one of the masses showed complex internal echogenicity with solid and cystic components, which was consistent with necrosis and cystic degeneration at pathologic examination. The sonographic features of metaplastic carcinoma have been previously reported [10, 13]. Samuels et al. [13], in their study of five patients, of whom four had sonographic examinations, showed both cystic and solid components in two of the masses. The histopathologic diagnosis of these tumors was predominantly squamous cell carcinoma. Park et al. [10], in their study of 16 patients, of whom 11 had sonograms, observed complex internal echogenicity with solid and cystic components in six lesions. Four of these six lesions also had hemorrhagic or cystic necrosis at pathologic examination. We believe that metaplastic carcinoma, although a rare tumor, should be considered in the differential diagnosis of breast masses with solid and cystic components.
In most metaplastic carcinomas, foci of transition between invasive ductal carcinoma and the metaplastic element are detected, sometimes only after extensive sampling. In tumors in which the metaplastic spindle component constitutes almost the entire tumor, the distinction from a sarcoma may be difficult. In some of these cases, ductal carcinoma in situ adjacent to the tumor often suggests that the spindle cells were of epithelial origin [8]. The diagnosis of metaplastic breast carcinoma may be made with aspiration cytology or core biopsy, but excisional biopsy is preferred because diagnostic errors resulting from inadequate samples are avoided, especially in cases of associated necrosis or hemorrhage [8, 12, 16].
Patterson et al. [8] have stated that the distinction between metaplastic breast cancer and sarcoma is clinically important because the surgical treatment, chemotherapy regimens, and metastatic pathways are different. Typically, axillary lymph node involvement is rare in breast sarcoma even when the disease is diffusely disseminated, whereas lymph node metastases are reported in 25-30% of cases with metaplastic carcinomas [1, 8]. All eight patients in our series underwent axillary lymph node dissection, and metastasis was detected in only one patient (12.5%); at histopathologic examination, the metaplastic component of the tumor was carcinosarcomatoid type. However, the number of our cases is too few to accurately determine the frequency of lymph node involvement in a larger patient population. Although no series has been sufficiently large to determine overall prognosis, survival most likely depends on tumor size, histologic type, grade, lymph node status, and perhaps most directly on the type and grade of the mesenchymal component. The overall 5-year survival rate is approximately 40% [1]. Chemotherapy is usually directed toward the sarcomatous component of the disease on the basis of the patterns of metastases [1].
In conclusion, metaplastic carcinoma of the breast manifests as a rapidly growing, palpable mass that has high density on mammography and may be microlobulated on sonography. Complex echogenicity with solid and cystic components may be seen sonographically and is related to necrosis and cystic degeneration found histopathologically. Although metaplastic carcinoma is a rare breast malignancy, and these features are not unique, metaplastic carcinoma should be included in the differential diagnosis.
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