AJR 2005; 184:1799-1801
© American Roentgen Ray Society
Lobular Carcinoma In Situ of the Breast Presenting as a Mass
Lauren F. Stein1,
Gilat Zisman1,
Jocelyn A. Rapelyea1,
Arnold M. Schwartz2,
Bruce Abell3 and
Rachel F. Brem1
1 Department of Radiology, The George Washington University Medical Center, 2150
Pennsylvania Ave., Washington, D.C. 20037.
2 Department of Pathology, The George Washington University Medical Center,
Washington, D.C. 20037.
3 Department of Surgery, The George Washington University Medical Center,
Washington, D.C. 20037.
Received July 8, 2004;
accepted after revision August 25, 2004.
Address correspondence to R. F. Brem
(rbrem{at}mfa.gwu.edu).
Introduction
Foote and Stewart [1]
described lobular carcinoma in situ (LCIS) as a distinct pathologic entity in
1941. Historically, it has been considered an incidental finding in breast
tissue, often adjacent to the area of abnormality that prompts biopsy. It was
previously thought to lack any corollary signs of mass or calcification on
mammogram [2,
3]. Recent studies indicate
that LCIS foci may contain specific microcalcifications
[3,
4], but to our knowledge, there
is no report of LCIS forming a solid mass. We report a case of LCIS that
presented as a focal mass.
Case Report
The patient was a 50-year-old nulliparous, diabetic hypertensive woman
whose previous screening mammograms showed multiple, bilateral, and stable
subcentimeter nodules without dominant mass or suspicious microcalcifications.
Just before diagnosis, mammograms performed at an outside institution showed a
dominant mass in the outer portion of the right breast (Figs.
1A and
1B). Evaluation at our
institution with sonography showed a 9-mm hypoechoic, microlobulated mass
(Fig. 1C). The patient was
offered but refused minimally invasive biopsy and chose to have surgical
excisional biopsy. The patient underwent preoperative needle localization with
sonographic guidance. A specimen radiograph showed a poorly defined mass
(Fig. 1D). Pathologic
evaluation of the surgical excisional biopsy specimen was interpreted as LCIS
(Fig. 1E). As a result of the
clinical and radiologic presentation, which strongly suggested an invasive
carcinoma, the entire specimen was resected and evaluated pathologically, with
confirmation of the diagnosis of LCIS. As a result of the
radiologic-pathologic discordance, additional sections of the lesion were
sectioned and immunohistochemically analyzed for E-cadherin reactivity.
Membranebound immunohistochemical reactivity was identified in more ductal
appearing components indicative of a mixed lesion composed of low-grade ductal
carcinoma in situ (DCIS) and LCIS. Immunohistochemical reactivity was
diffusely positive for estrogen receptor and progesterone receptor and absent
for expression of HER-2 (Fig.
1F).
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Fig. 1C. —50-year-old woman with new mammographically detected mass.
High-resolution, real-time sonogram of right breast at 9-o'clock position
shows indeterminate, hypoechoic, and microlobulated 6.5 x 6.6-mm
nodule.
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Fig. 1E. —50-year-old woman with new mammographically detected mass.
Pathologic image of area of lobular carcinoma in situ (LCIS) with intralobular
fibrosis shows uniformity of receptor cells and expression of lobular units.
(x200)
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Fig. 1F. —50-year-old woman with new mammographically detected mass.
Pathologic image of immunoreactivity of LCIS for estrogen receptors reveals
positive nuclear staining indicative of estrogen receptor expression.
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Discussion
The natural history of LCIS is difficult to define, as it generally has no
specific clinical or mammographic findings
[2,
3,
5]. It is usually incidentally
identified histologically in breast tissue biopsied for other reasons.
Preoperative detection of LCIS is not possible, since no specific mammographic
features of this entity are generally recognized
[3]. Therefore, its reported
incidence depends on the frequency of biopsy, and is consequently
underestimated [2,
4,
6]. LCIS occurs predominantly
in women with a mean age of 45 years old, approximately 10 to 15 years younger
than the mean age when invasive breast carcinoma occurs
[1].
LCIS is a high-risk marker for the future development of invasive carcinoma
[2-5].
However, some investigators have speculated that individual foci of LCIS
progress to invasive disease
[3]. Regardless of the
mechanisms involved, a woman with LCIS has approximately a 15% chance of
developing an infiltrating ductal or lobular carcinoma in the breast in which
the LCIS is discovered, but also has a similar risk (15%) for contralateral
development of cancer over the next 30 years
[5]. Recent evidence also shows
that 18-25% of the cases diagnosed with LCIS at core needle biopsy were
upgraded to more invasive cancer pathologies at surgical excision
[7,
8].
Microscopically, LCIS consists of numerous cells of uniform appearance with
round nuclei and relatively clear cytoplasm. The malignant cells fill the
lobular acini, leaving the basement membrane intact
[5]. Nonspecific
microcalcifications are often the impetus for biopsy in the cases when LCIS is
discovered. However, a substantial percentage of women with LCIS have no
abnormalities on mammography
[3]. Identification of
mammographic features of LCIS has been attempted in several studies with only
minimal success [9]. Recently,
however, several studies have determined that calcifications could be a
specific finding of LCIS and not just an indirectly associated regional
abnormality [3,
4]. These studies describe two
types of calcifications associated with LCIS: classic nonnecrotic
calcifications and pleomorphic necrotic calcifications. Classic calcifications
are described as smaller and morphologically identical to calcifications in
surrounding breast tissue. Pleomorphic calcifications are identified by their
association with central necrosis in the LCIS focus and their location amid
pleomorphic cells. These calcifications are likened to comedocarcinoma
calcifications found in DCIS
[4]. Because of this finding,
cases that were previously considered DCIS because of necrotic features are
being redefined as LCIS. The similarity between LCIS and DCIS may lead to
difficulty in distinguishing between these two pathologic entities.
DCIS is generally clinically silent and is often discovered incidentally.
However, it can manifest clinically as a palpable mass, nipple discharge, or
Paget's disease [10]. On
mammography, 62-98% of DCIS lesions are detected by the presence of
characteristic microcalcifications, with only 2-23% manifesting solely as a
mass or asymmetric density
[10]. Although the majority of
DCIS cases are detected mammographically, 6-23% of DCIS lesions are not
visible mammographically and manifest with clinical symptoms such as nipple
discharge or a palpable mass. Detection of DCIS as calcifications on
mammography becomes more likely with high-grade lesions
[10]. In the rare instance
that DCIS presents as a mass, it is associated with a higher nuclear grade.
This is a case of a mass consisting primarily of LCIS with foci of low-grade
DCIS. The manifestation of a mass is previously unreported for LCIS and rare
for low-grade DCIS.
LCIS can be pathologically differentiated from DCIS by loss of cellular
cohesion, intracytoplasmic vacuoles, and pagetoid ductal involvement.
Likewise, microacini are present in DCIS and absent in LCIS
[4]. In reality, however, these
histologic distinctions are not always clear. Frykberg
[2] delineates several factors
that may generate some difficulty in the pathologic diagnosis of LCIS. He
states that the cells of LCIS may proliferate outside the lobules into the
major lactiferous ducts, that ductal forms of breast carcinoma may extend into
the breast lobules, and that LCIS may resemble low-grade forms of DCIS. This
latter point is significant, especially in light of the fact that these two
entities may closely coexist
[2]. This case exemplifies the
overlap that can be found between these two types of lesions.
The stain for E-cadherin, a recent development in pathology, has made the
differentiation of LCIS and DCIS more precise. E-cadherin is a transmembrane
glycoprotein responsible for calcium-dependent cell-to-cell adhesion; it is
lost in lobular but not ductal carcinomas. This case underscores the
importance of E-cadherin in elucidating the variable histologic components of
a lesion that predominantly appears to be LCIS. Considering the potential
coexistence of LCIS and DCIS and their similarities in pathology, this stain
may be beneficial in improving our understanding of specific radiologic
features of LCIS and its pathogenesis.
This report describes the detection of LCIS as a mass by mammography and
sonogram. It was only after E-cadherin staining that ductal in situ components
were identified in the same lesion. To our knowledge, LCIS has never been
reported to manifest as a discrete mass
[2-6,
10,
11]. Thus, a mass identified
with mammography and/or sonography can be concordant with LCIS.
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Introduction
Case Report
