DOI:10.2214/AJR.05.0368
AJR 2005; 185:1593-1594
© American Roentgen Ray Society
Radiologic-Pathologic Conference of The University of Ankara Medical
School |
Radiologic-Pathologic Conference of The University of Ankara Medical School
Metaplastic Breast Carcinoma with Osteochondrosarcomatous Differentiation
Basak Erguvan-Dogan1,
Cisel Yazgan2,
Cetin Atasoy2,
Serpil Dizbay Sak3,
Selma Tukel2,
Koray Ceyhan4,
Savas Kocak5 and
Y. Serdar Akyar2
1 Department of Diagnostic Radiology, Breast Imaging, The University of Texas M.
D. Anderson Cancer Center, 1515 Holcombe Blvd., Unit 1350, Houston, TX
77230.
2 Department of Radiology, Ankara University Medical School, Ankara,
Turkey.
3 Department of Pathology, Ankara University Medical School, Ankara,
Turkey.
4 Department of Pathology, Clinical Cytology Section, Ankara University Medical
School, Ankara, Turkey.
5 Department of Surgery, Ankara University Medical School, Ankara, Turkey.
Received March 2, 2005;
accepted after revision May 29, 2005.
Address correspondence to B. Erguvan-Dogan
(basak.dogan{at}di.mdacc.tmc.edu).
A 75-year-old woman presented with a 6-month history of painless
palpable mass in her right breast. Mammography revealed a 4-cm oval calcified
mass in the upper outer right breast (Figs.
1A and
1B). A second 1-cm lobulated
mass was detected in the 12-o'clock region. The patient underwent incisional
biopsy of the palpable mass, which revealed invasive ductal cancer with
osteochondrosarcomatous differentiation
(Fig. 1C). Chest radiography
and a bone scan were negative for distant metastasis. The patient underwent a
right mastectomy. Histopathologic evaluation revealed a second 1.5-cm focus of
osteochondrosarcomatous metaplastic cancer in the 12-o'clock position in
addition to residual metaplastic cancer at the site of prior surgery,
consistent with multicentric malignancy.
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Fig. 1A —75-year-old woman with palpable abnormality in upper right
breast. Mammograms revealed 4 x 2 cm circumscribed, virtually completely
calcified ovoid mass at 10-o'clock position in right breast. Although mass was
largely circumscribed, calcifications took irregular form at medial and
lateral margins of mass (arrows). At 12-o'clock region, smaller mass
lesion with irregular, microlobulated margins and associated architectural
distortion is seen (thin arrow) in background of nodular breast
tissue. Incisional biopsy of larger mass revealed metaplastic carcinoma with
osteochondrosarcomatous differentiation.
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Fig. 1B —75-year-old woman with palpable abnormality in upper right
breast. Mammograms revealed 4 x 2 cm circumscribed, virtually completely
calcified ovoid mass at 10-o'clock position in right breast. Although mass was
largely circumscribed, calcifications took irregular form at medial and
lateral margins of mass (arrows). At 12-o'clock region, smaller mass
lesion with irregular, microlobulated margins and associated architectural
distortion is seen (thin arrow) in background of nodular breast
tissue. Incisional biopsy of larger mass revealed metaplastic carcinoma with
osteochondrosarcomatous differentiation.
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Fig. 1C —75-year-old woman with palpable abnormality in upper right
breast. Mastectomy specimen showed multicentric metaplastic carcinoma with
osteosarcomatous component and small area of ductal epithelial differentiation
(arrowhead). Osteosarcomatous component of metaplastic tumor
corresponded to densely calcified regions of tumor (arrow) shown on
mammography, which represent bone formation. (H and E, x100)
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Fig. 1D —75-year-old woman with palpable abnormality in upper right
breast. Six months later, patient presented with pulmonary complaints. CT of
chest revealed left diffuse pleural thickening, pleural effusion, multiple
bilateral calcified lung nodules (arrows), and parenchymal
masses.
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Six months later, after coronary angioplasty, the patient presented with
the chief complaints of chest pain and difficulty breathing. Chest radiography
showed multiple bilateral pulmonary nodules. CT revealed left diffuse pleural
thickening, minimal pleural effusion, and new bilateral calcified and
noncalcified lung nodules and masses (Fig.
1D). Fine-needle aspiration biopsy of the lung nodules was not
diagnostic because of the densely calcified nature of the lesions. Despite
vigorous chemotherapy, the patient died due to widespread metastatic disease 1
year after the diagnosis.
Metaplastic carcinomas of the breast are uncommon tumors that constitute
less than 5% of all breast carcinomas
[1]. These tumors are ductal
carcinomas that show metaplastic change including squamous cell, spindle cell,
and heterologous mesenchymal elements that produce a cartilaginous or osseous
matrix.
Virtually all metaplastic tumors present as fast-growing palpable masses.
On mammography, metaplastic cancers are frequently circumscribed, noncalcified
tumors that have a low suspicion index for malignancy
[2-4].
Tumors with ill-defined, spiculated margins or microlobulation are less common
mammographic appearances of metaplastic tumors. When present, calcification
represents the bone formation in the osteosarcomatous metaplastic component.
Calcifications may be in the form of microcalcifications
[3] or a dense nidus within the
mass [4]. Diffuse infiltration
of breast parenchyma (6%), although rare, has also been reported
[2].
On sonography, metaplastic carcinoma may appear as a well-circumscribed
mass mimicking benign solid nodules or a microlobulated mass
[5]. Complex internal
echogenicity with solid and cystic components may be present, which correlates
with necrosis and cystic degeneration at histopathologic evaluation.
Histopathologically, carcinoma with osseous metaplasia, a variant of
metaplastic carcinoma associated with osseous and chondroid differentiation,
frequently contains chondroid areas
[6]. The carcinoma component is
usually an infiltrating ductal carcinoma separated from osseous areas by a
zone of stromal cells. Osseous or chondroid areas may be benign or
malignant.
Axillary nodal involvement is less common in metaplastic carcinomas than in
nonmetaplastic carcinomas [7].
However, these tumors often metastasize directly to distant sites such as
lungs, pleura, and bones. The prognostic significance of atypical bone and
chondroid formation is not well known. Compared with patients with
infiltrating duct carcinoma, the overall 3-year survival rate of 53-60% in
this group appears to be more favorable after adjustment for nodal metastases
and their sizes [7].
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