DOI:10.2214/AJR.05.0831
AJR 2007; 188:691-696
© American Roentgen Ray Society
Imaging Features of Metaplastic Carcinoma with Chondroid Differentiation of the Breast
Hee Jung Shin1,
Hak Hee Kim,
Sun Mi Kim,
Dae Bong Kim,
Mi-Jung Kim,
Gyungyub Gong,
Soo Ah Im and
Eun Suk Cha
1 All authors: Department of Radiology, University of Ulsan College of Medicine,
Asan Medical Center, 388-1, Poongnap-dong, Songpa-gu, Seoul, South
Korea.
Received May 16, 2005;
accepted after revision August 9, 2005.
Address correspondence to J. H. Shin
(jhshin{at}amc.seoul.kr).
Abstract
OBJECTIVE. The purpose of this study was to evaluate the imaging
features—including the mammographic, sonographic, MRI, and bone
scintigraphic findings—in 12 patients with metaplastic carcinoma with
chondroid differentiation of the breast and to correlate the imaging findings
with the pathologic features.
CONCLUSION. Metaplastic carcinoma with chondroid differentiation of
the breast manifests as a palpable mass and should be included in the
differential diagnosis of a large indistinct highdensity mass with amorphous
or coarse calcifications on mammography and a relatively circumscribed complex
echoic mass with posterior enhancement on sonography. A relatively
circumscribed mass with a nonenhancing T2 intermediate- to
high-signal-intensity internal component on MRI and an area of intense uptake
of 99mTc methylene diphosphonate (MDP) on bone scintigraphy might
be useful in suggesting the diagnosis of metaplastic carcinoma with chondroid
differentiation.
Keywords: BI-RADS • breast cancer • mammography • oncologic imaging • sonography
Introduction
In fewer than 5% of mammary adenocarcinomas, part or all of the
carcinomatous epithelium is transformed to a nonglandular growth pattern by a
process referred to as "metaplasia"
[1]. Wargotz and Norris
[2] suggested that there are
four variants of metaplastic carcinoma: matrix-producing carcinoma,
carcinosarcoma, squamous cell carcinoma, and spindle cell carcinoma.
Metaplastic carcinoma with chondroid differentiation (MCCD), a
matrix-producing carcinoma, is a distinctive form of metaplastic carcinoma
consisting of overt carcinoma with transition to an abundant cartilaginous,
osseous, or both cartilaginous and osseous stromal matrix in the absence of an
intervening spindle cell component
[2]. The cumulative 5-year
survival rate for patients with MCCD is reported to be 68%, which is
relatively more favorable than that previously reported for metaplastic
carcinoma [2]. Differentiating
among these four subgroups may be useful for the purposes of planning
treatment and determining prognosis
[2].
To our knowledge, only a few reports have been published about the imaging
findings of metaplastic carcinoma
[3-5]
and there are a few pathologic reports about this distinctive subgroup of MCCD
[1,
2]. However, there are no
reports regarding the imaging features of this specific subtype (MCCD) of
metaplastic breast carcinoma. The purpose of this study was to evaluate the
imaging features, including the mammographic, sonographic, MRI, and bone
scintigraphic findings, of MCCD of the breast and to correlate the imaging
findings with the pathologic features.
Materials and Methods
We analyzed 12 cases of pathologically proven MCCD treated at two
institutions between January 1996 and June 2004. The patients ranged in age
from 28 to 79 years (mean, 56.1 years). Mammograms were available in nine
patients and sonograms in 10 patients. One patient underwent MRI, and another
underwent bone scintigraphy.
Mammography in two routine views (craniocaudal and mediolateral oblique)
was performed in nine patients using a Senographe 600T (GE Healthcare),
Senographe DMR (GE Healthcare), or Performa (Instrumentarium) unit. All
mammograms were retrospectively reviewed as a consensus interpretation by four
radiologists who are specialists in breast imaging.
Sonography was performed in 10 patients with a broadband linear array
transducer (5-12-MHz) and Ultramark 9, HDI-3000, HDI-5000 (all, Philips
Medical Systems), or Acuson 128XP (Siemens Medical Solutions) system. The
sonographic images were reviewed after the mammograms during the same
evaluation session. Mammographic and sonographic findings were evaluated using
BI-RADS [6].
An MR examination was performed in one patient using a 1.5-T unit (Intera,
Philips Medical Systems) with a dedicated breast coil. We obtained axial
fat-saturated T2-weighted images and dynamic 3D T1-weighted images before and
after the IV administration of gadolinium (gadopentetate dimeglumine
[Magnevist, Berlex Laboratories]; 0.16 mmol/kg; injection rate, 2 mL/s). Six
contrast-enhanced sequences were performed. Postprocessing manipulation
included subtraction images and maximum-intensity-projection images.
Bone scintigraphy was performed in another patient with 99mTc
methyl diphosphonate (MDP). The dose of 99mTc MDP was 22 mCi (814
MBq), and a high-resolution collimator was used.
Gross and microscopic slides of surgical specimens were reviewed by two
pathologists who are breast pathology specialists. Pathologic reports
regarding preoperative fine-needle aspiration cytology (FNAC) using a 25-gauge
needle (n =3) or core needle biopsies using a 14-gauge needle
(n = 2) were available for five patients. The gross pathologic size
and cellularity of the tumor; the amount of chondroid matrix, cyst, or
necrosis in the tumor; the presence of calcifications; and each patient's
lymph node status, steroid receptor status, P53 gene, and
c-erbB2 were evaluated as far as possible. Mammographic and
sonographic findings were then correlated with histopathology.
Results
All 12 patients presented with a palpable breast mass first found by the
patient before presentation (range, 1-24 months before presentation; mean,
12.1 months) and five noted rapid growth.
The mammographic, sonographic, and pathologic findings for the 12 patients
are summarized in Table 1. On
mammography, all nine patients had irregular-shaped high-density masses (Figs.
1A,
1B,
1C,
1D,
1E,
1F,
2A,
2B,
2C,
2D,
2E,
3A,
3B,
3C,
3D). The margins of the masses
were partially indistinct in five patients (Figs.
3A and
3B) and indistinct in four
patients (Figs. 1A and
1B). Calcifications in the
masses were seen in six patients. The patterns of calcifications were
amorphous and coarse (n = 3) (Figs.
1A and
1B), amorphous (n =1),
coarse (n = 1), and punctate (n =1). Neither enlarged lymph
nodes nor associated architectural distortion was seen on mammography in any
of these patients.
View this table:
[in this window]
[in a new window]
|
TABLE 1: Mammographic, Sonographic, and Pathologic Findings in 12 Patients with
Metaplastic Carcinoma with Chondroid Differentiation of the Breast
|
|
View larger version (92K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1A —48-year-old woman (patient 7 in
Table 1) with metaplastic
carcinoma with chondroid differentiation. Mammograms show huge indistinct
irregular-shaped high-density mass (arrows, A) with extensive
amorphous and coarse calcifications (arrowheads, A) that are
typical in chondroid calcifications.
|
|
View larger version (111K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1B —48-year-old woman (patient 7 in
Table 1) with metaplastic
carcinoma with chondroid differentiation. Mammograms show huge indistinct
irregular-shaped high-density mass (arrows, A) with extensive
amorphous and coarse calcifications (arrowheads, A) that are
typical in chondroid calcifications.
|
|
View larger version (126K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1C —48-year-old woman (patient 7 in
Table 1) with metaplastic
carcinoma with chondroid differentiation. Sonograms show huge relatively
circumscribed complex echoic mass with posterior enhancement and
calcifications (arrowheads). Doppler study (not shown) revealed
increased vascularity.
|
|
View larger version (129K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1D —48-year-old woman (patient 7 in
Table 1) with metaplastic
carcinoma with chondroid differentiation. Sonograms show huge relatively
circumscribed complex echoic mass with posterior enhancement and
calcifications (arrowheads). Doppler study (not shown) revealed
increased vascularity.
|
|
View larger version (82K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1E —48-year-old woman (patient 7 in
Table 1) with metaplastic
carcinoma with chondroid differentiation. Photograph of cross-section of
pathologic specimen shows huge and relatively well-circumscribed mass beneath
skin. Cut surface of mass is yellowish-gray, solid, and heterogeneous with
multiple foci of hemorrhage and necrosis (arrowheads).
|
|
View larger version (95K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1F —48-year-old woman (patient 7 in
Table 1) with metaplastic
carcinoma with chondroid differentiation. Photomicrograph shows that tumor
consists of tumor cell nests and large area of necrosis (arrowheads)
admixed with chondroid matrix. Microcalcification (arrows) is also
noted. (H and E, x40)
|
|
View larger version (156K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 2A —54-year-old woman (patient 3 in
Table 1) with metaplastic
carcinoma with chondroid differentiation. Sonogram shows relatively
circumscribed irregular-shaped complex echoic mass with posterior enhancement
and calcifications (arrows) and its parallel orientation to skin.
|
|
View larger version (159K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 2B —54-year-old woman (patient 3 in
Table 1) with metaplastic
carcinoma with chondroid differentiation. Sonogram shows relatively
circumscribed irregular-shaped complex echoic mass with posterior enhancement
and calcifications (arrows) and its parallel orientation to skin.
|
|
View larger version (141K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 2C —54-year-old woman (patient 3 in
Table 1) with metaplastic
carcinoma with chondroid differentiation. MR image shows relatively
circumscribed mass with internal high-signal-intensity portion
(arrows) on T2-weighted image (TR/TE, 5,000/120; acquisition matrix,
512 x 512); this high-signal-intensity portion corresponds to chondroid
matrix in pathologic specimen (not shown).
|
|
View larger version (112K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 2D —54-year-old woman (patient 3 in
Table 1) with metaplastic
carcinoma with chondroid differentiation. On dynamic contrast-enhanced
T1-weighted imaging (TR/TE, 7.9/3.9; acquisition matrix, 512 x 512),
both early (D) and delayed (E) images show early enhancement and
delayed washout and plateau enhancement in peripheral rim with nonenhancing
internal components (arrows).
|
|
View larger version (114K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 2E —54-year-old woman (patient 3 in
Table 1) with metaplastic
carcinoma with chondroid differentiation. On dynamic contrast-enhanced
T1-weighted imaging (TR/TE, 7.9/3.9; acquisition matrix, 512 x 512),
both early (D) and delayed (E) images show early enhancement and
delayed washout and plateau enhancement in peripheral rim with nonenhancing
internal components (arrows).
|
|
View larger version (53K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 3A —78-year-old woman (patient 12 in
Table 1) with metaplastic
carcinoma with chondroid differentiation. Reprinted with permission from
[13]. Mammograms show
partially indistinct irregular-shaped high-density mass (arrows) in
upper outer quadrant of right breast.
|
|
View larger version (45K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 3B —78-year-old woman (patient 12 in
Table 1) with metaplastic
carcinoma with chondroid differentiation. Reprinted with permission from
[13]. Mammograms show
partially indistinct irregular-shaped high-density mass (arrows) in
upper outer quadrant of right breast.
|
|
View larger version (110K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 3C —78-year-old woman (patient 12 in
Table 1) with metaplastic
carcinoma with chondroid differentiation. Reprinted with permission from
[13]. Right anterior
(C) and right anterior oblique (D) bone scans show intense
uptake of 99mTc methylene diphosphonate (arrows) in right
breast.
|
|
View larger version (105K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 3D —78-year-old woman (patient 12 in
Table 1) with metaplastic
carcinoma with chondroid differentiation. Reprinted with permission from
[13]. Right anterior
(C) and right anterior oblique (D) bone scans show intense
uptake of 99mTc methylene diphosphonate (arrows) in right
breast.
|
|
On sonography, all 10 masses were irregularly shaped and had posterior
acoustic enhancement. Seven masses had relatively circumscribed margins (Figs.
1C,
1D,
2A, and
2B), whereas three masses had
well-circumscribed margins. In seven patients, the masses showed complex
echogenicity with both solid and cystic components (Figs.
1C,
1D,
2A, and
2B). The remaining three
patients had hypoechoic masses. Calcifications in the masses were seen in six
patients.
For our study, we reviewed the MRI results for one patient and bone
scintigraphy findings for another patient. On MRI, T2-weighted images showed a
large relatively circumscribed mass with internal intermediate- to
high-signal-intensity components (Fig.
2C), and on dynamic enhancement T1-weighted images, there was
early enhancement and a delayed washout and plateau pattern with nonenhancing
internal components (Figs. 2D
and 2E). These nonenhancing T2
intermediate- to high-signal-intensity internal components corresponded to the
necrosis, cyst, and chondroid matrix on pathologic examination.
On bone scintigraphy, there was an intense uptake of 99mTc MDP
in the tumor (Figs. 3C and
3D), and the pathologic
specimens showed abundant chondroid and osteoid matrix in the tumor.
The longest diameter of the masses on pathologic examination ranged from
2.0 to 9.0 cm (mean, 4.3 cm). Axillary lymph nodes were positive in three
(25%) of the 12 patients who underwent axillary node dissection. Preoperative
biopsy was performed in five patients. A malignant tumor with a myxoid or
mucoid stroma was diagnosed using FNAC, and metaplastic carcinoma with
chondroid differentiation was diagnosed using core needle biopsy. In the
remaining three patients, the pathologic results (FNAC, n =2; core
needle biopsy, n = 1) were proven to be ductal carcinoma, and the
final diagnosis of MCCD was revealed at surgery.
A gross specimen showed a circumscribed tumor with necrosis and hemorrhage,
and the cut surface was yellowish-gray, solid, and heterogeneous
(Fig. 1E). Calcifications in
the masses were found in nine of the 12 patients (focal, n = 6;
multifocal, n = 3). In all patients, the masses had a chondroid
matrix, and cyst and necrosis were found in the chondroid matrix in 11 of the
12 patients (Fig. 1F). These
findings may be correlated with posterior acoustic enhancement and complex
echogenicity on sonography.
Ten (83%) of the 12 patients had a negative estrogen-receptor (ER) status
and nine (75%) had a negative progesterone-receptor (PR) status. Tumors in
five (42%) of 12 patients had a positive P53 status, and tumors in
four patients (33%) had overexpression of c-erbB2.
Discussion
Metaplastic carcinomas of the breast comprise a heterogeneous group of
neoplasms that are regarded as ductal carcinomas that undergo metaplasia into
a nonglandular growth pattern
[2,
3,
5]. The mixed cell origin is
corroborated by histopathologic staining for mesenchymal cells (vimentin),
epithelial cells (cytokeratin), and myoepithelial cells (S-100 protein, actin,
and highmolecular-weight cytokeratin)
[5]. In most metaplastic
carcinomas, the foci of transition between invasive ductal carcinoma and
metaplastic elements are detected and, for this reason, extensive sampling
should be performed [4].
Tavassoli and Devilee [7]
established two main categories and eight histologic variants of metaplastic
carcinoma. They found that MCCD is a distinctive form of metaplastic carcinoma
with a relatively more favorable prognosis than other subtypes of metaplastic
carcinomas [7].
The diagnosis of MCCD was made in 12 of approximately 8,000 patients
(
0.15%) who underwent surgery for breast cancer at our institutions
during the period of study. The first presenting symptom of metaplastic
carcinoma is usually a relatively rapid-growing palpable mass; axillary lymph
node metastasis is infrequent. In our study, all patients had palpable masses.
Three of our patients (25%) had axillary lymph node metastasis, which is
similar to the 19-25% incidence noted in previous reports
[5,
7]. All three patients with
axillary lymph node metastasis and one other patient without axillary lymph
node metastasis had a recurrence. In these four patients, the recurrence
developed from 2 to 36 months (mean, 14 months) after surgery. The masses in
two of the three patients with axillary lymph node metastasis had high
cellularity. The size of the initially detected tumor in the four patients
with recurrence was larger (mean size, 6.5 cm; range, 4.0-9.0 cm) than that in
the patients without recurrence (mean size, 3.2 cm; range, 2.0-3.5 cm); these
results concur with data from a previous report
[2].
MCCDs were frequently ER- and PR-negative. Overexpression of
c-erbB2 was seen in four patients (33%), which is more frequent than
the previous report about metaplastic breast carcinoma
[8]. Patients with metaplastic
breast carcinomas tend to have poor outcomes and a high risk of recurrence
after surgery [8]. Because our
series is small and 10 of the 12 patients had received adjuvant therapy, it
was not possible to examine differences in outcomes between those treated and
those observed after surgery.
To our knowledge, neither the mammographic nor the sonographic appearance
of MCCD has been described in previous studies. Evans et al.
[9] described a predominantly
circumscribed mass with a densely calcified center and an osteoid matrix. In
our series, all the tumors were irregular in shape and of high density and the
tumor margins were either indistinct or partially indistinct on mammography.
Six of nine patients had calcifications that were either amorphous and coarse
(n = 3), amorphous (n = 1), coarse (n = 1), or
punctate (n = 1).
On sonography, all masses were irregular in shape and showed posterior
acoustic enhancement. Seven (70%) of 10 masses in our series had complex
internal echogenicity with solid and cystic components that were consistent
with necrosis, cystic degeneration, and chondroid matrix on pathologic
examination. Only three masses had hypoechogenicity. These results concur with
the sonographic features of metaplastic carcinoma in previous reports
[3]. The margins of the masses
were either circumscribed or relatively circumscribed. Six masses had
calcifications.
To our knowledge, the MRI findings of metaplastic breast carcinoma have
been described in only two previous reports. Chang et al.
[10] in their study of two
patients and Velasco et al.
[11] in their study of 12
patients described the mass as relatively well defined with internal
high-signal-intensity necrotic or cystic components on T2-weighted images and
rimlike enhancement on dynamic enhancement images. In our patient, the
T2-weighted image showed a relatively circumscribed mass with internal
intermediate- to high-signal-intensity components, and on the dynamic
enhancement T1-weighted image, there was early enhancement and a delayed
washout and plateau pattern with nonenhancing internal components. These
nonenhancing T2 high-signal-intensity internal components corresponded to
necrosis, cyst, and chondroid matrix on pathologic examination. These imaging
features of MCCD might be expected findings in a partially necrotic
malignancy. However, MCCD of the breast could be considered in the
differential diagnosis of a mass with these MRI features.
Evans et al. [9] and
Pickhardt and McDermott [12]
described the intense uptake of 99mTc MDP in mammary carcinomas
with osseous sarcomatoid metaplasia. Uptake of 99mTc MDP can be
observed in other breast tumors with an osteoid matrix, but this is extremely
rare. In addition, uptake may occur both in benign and malignant neoplasms,
such as fibroadenomas, phyllodes tumors, extraskeletal osteosarcomas, ductal
carcinomas with osseous metaplasia, and tumors that are histologically similar
to mixed tumors of the salivary gland, and in nonneoplastic lesions, such as
fat necrosis and hematomas [9].
In our patient, there was an area of intense uptake of 99mTc MDP in
the tumor, and the pathologic specimen showed an abundant chondroid-osteoid
matrix in the tumor.
In conclusion, imaging features of MCCD on routine studies such as
mammography, sonography, and MRI might be nonspecific, and this rare tumor is
usually an unexpectedly specific category of carcinoma. However, although our
series was small, MCCD of the breast should be included in the differential
diagnosis of an indistinct high-density mass with amorphous or coarse
calcifications on mammography and a relatively circumscribed complex echoic
mass with posterior enhancement on sonography. A relatively circumscribed mass
with a nonenhancing T2 intermediate- to high-signal-intensity internal
component on MRI and an area of intense uptake of 99mTc MDP on bone
scintigraphy also might be useful in suggesting the diagnosis of MCCD.
Acknowledgments
We thank Bonnie Hami, department of radiology, University Hospitals Health
System, Cleveland, OH, for her editorial assistance in the preparation of this
manuscript.
References
- Rosen PP. Rosen's breast pathology, 2nd ed.
Philadelphia, PA: Lippincott-Williams & Wilkins, 2001:425
-453
- Wargotz ES, Norris HJ. Metaplastic carcinomas of the breast. I.
Matrix-producing carcinoma. Hum Pathol1989; 20:628
-635[CrossRef][Medline]
- Park JM, Han BK, Moon WK, Choe YH, Ahn SH, Gong G. Metaplastic
carcinoma of the breast: mammographic and sonographic findings. J
Clin Ultrasound 2000; 28:179
-186[CrossRef][Medline]
- Patterson SK, Tworek JA, Roubidoux MA, Helvie MA, Oberman HA.
Metaplastic carcinoma of the breast: mammographic appearance with pathologic
correlation. AJR 1997;169
: 709-712[Abstract/Free Full Text]
- Gunhan-Bilgen I, Memis A, Ustun EE, Zekioglu O, Ozdemir N.
Metaplastic carcinoma of the breast: clinical, mammographic, and sonographic
findings with histopathologic correlation. AJR2002; 178:1421
-1425[Abstract/Free Full Text]
- American College of Radiology. Breast imaging reporting
and data system (BI-RADS), 4th ed. Reston, VA: American College
of Radiology, 2003
- Tavassoli FA, Devilee P. Pathology and genetics. In: Jaffe ES,
Harris NL, Stein H, Vardiman JW, eds. World Health Organization
classification of tumours: tumours of the breast and female genital
organs. Lyon, France: IARC Press, 2003:37
-41
- Barnes PJ, Boutilier R, Chiasson D, Rayson D. Metaplastic breast
carcinoma: clinical-pathologic characteristics and HER2/neu
expression. Breast Cancer Res Treat 2005;91
: 173-178[CrossRef][Medline]
- Evans HA, Shaughnessy EA, Nikiforov YE. Infiltrating ductal
carcinoma of the breast with osseous metaplasia: imaging findings with
pathologic correlation. AJR 1999;172
: 1420-1422[Free Full Text]
- Chang YW, Lee MH, Kwon KH, et al. Magnetic resonance imaging of
metaplastic carcinoma of the breast: sonographic and pathologic correlation.
Acta Radiol 2004;45
: 18-22[CrossRef][Medline]
- Velasco M, Santamaria G, Ganau S, et al. MRI of metaplastic
carcinoma of the breast. AJR 2005;184
: 1274-1278[Abstract/Free Full Text]
- Pickhardt PJ, McDermott M. Intense uptake of technetium-99m-MDP in
primary breast adenocarcinoma with sarcomatoid metaplasia. J Nucl
Med 1997; 38:528
-530[Abstract/Free Full Text]
- Cha ES, Park MDYH, Shinn KS, Yoo JY, Jeon JS. Metaplastic carcinoma
of the breast: a case report. J Korean Radiological
Soc 1998; 39:1021
-1024
CiteULike 
Complore 
Connotea 
Del.icio.us 
Digg 
Reddit 
Technorati What's this?
Top
Abstract
Introduction
