DOI:10.2214/AJR.07.3004
AJR 2008; 190:W237-W239
© American Roentgen Ray Society
Radiologic–Pathologic Conferences of Nagoya University
Hospital |
Radiologic–Pathologic Conferences of the Nagoya University Hospital: Centrally Necrotizing Carcinoma of the Breast
Koji Oda1,2,
Hiroko Satake3,
Akiko Nishio3,
Shu Ichihara4,
Yoshie Shimoyama5,
Tsuneo Imai2 and
Masato Nagino1
1 Division of Surgical Oncology, Department of Surgery, Nagoya University
Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550,
Japan.
2 Department of Breast and Endocrine Surgery, Nagoya University Hospital,
Nagoya, Japan.
3 Department of Radiology, Nagoya University Hospital, Nagoya, Japan.
4 Department of Pathology, Nagoya Medical Center, Nagoya, Japan.
5 Department of Pathology, Nagoya University Hospital, Nagoya, Japan.
Received August 3, 2007;
accepted after revision October 23, 2007.
Address correspondence to K. Oda
(odak{at}med.nagoya-u.ac.jp).
WEB
This is a Web exclusive article.
Keywords: basal-like carcinoma • breast cancer • centrally necrotizing carcinoma of the breast • MRI
Arepresentative case is presented, in which the characteristic clinical and
radiologic features led to a preoperative diagnosis of centrally necrotizing
carcinoma of the breast [1].
The patient was a 57-year-old woman with a left breast tumor at the boundary
between the upper quadrants. The tumor was mobile, elastic, and hard and was 4
cm in diameter.
The mammograms revealed a well-circumscribed round tumor without calci
fication. Sonograms showed a cystic tumor measuring 32 x 24 x 33
mm with solid parts and septal structures. Power Doppler sono graphy revealed
increased flow signals in the solid and septal parts of the tumor and in the
breast tissue surrounding the tumor. The solid part and septal structures were
enhanced on dynamic contrast-enhanced CT.
T2-weighted coronal MRI with fat suppression showed high signal intensity
in the cystic part and a very low signal in the thick cyst wall, suggesting
hemosiderin deposits. The T1-weighted coronal image had a high-intensity
signal in the cystic part of the tumor. These findings were suggestive of
massive fresh and old hemorrhage in the tumor. In the gadolinium
contrast-enhanced MRI, solid and septal parts of the tumor showed marked
enhancement in the rapid and delayed phases (Figs.
1A,
1B,
1C,
1D, and
1E). Aspiration cytology was
not successful because as much as 10 mL of fresh blood was aspirated in two
punctures.
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Fig. 1A —57-year-old woman with tumor in left breast. Mammogram
(A), sonogram (B), T2-weighted coronal MR image (C),
T1-weighted coronal MR image (D), and gadolinium contrast-enhanced
T1-weighted coronal MR image (E) show tumor.
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Fig. 1B —57-year-old woman with tumor in left breast. Mammogram
(A), sonogram (B), T2-weighted coronal MR image (C),
T1-weighted coronal MR image (D), and gadolinium contrast-enhanced
T1-weighted coronal MR image (E) show tumor.
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Fig. 1C —57-year-old woman with tumor in left breast. Mammogram
(A), sonogram (B), T2-weighted coronal MR image (C),
T1-weighted coronal MR image (D), and gadolinium contrast-enhanced
T1-weighted coronal MR image (E) show tumor.
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Fig. 1D —57-year-old woman with tumor in left breast. Mammogram
(A), sonogram (B), T2-weighted coronal MR image (C),
T1-weighted coronal MR image (D), and gadolinium contrast-enhanced
T1-weighted coronal MR image (E) show tumor.
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Fig. 1E —57-year-old woman with tumor in left breast. Mammogram
(A), sonogram (B), T2-weighted coronal MR image (C),
T1-weighted coronal MR image (D), and gadolinium contrast-enhanced
T1-weighted coronal MR image (E) show tumor.
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Radiologic and clinical findings suggested that this well-circumscribed
tumor had a solid portion consisting of viable tumor cells with an abundant
blood supply. The cystic portions were filled with fresh blood that was
probably formed from hemorrhagic necrosis of the tumor cells. A review of the
literature showed that these clinical and radiologic findings are consistent
with a previously reported subtype of carcinoma: centrally necrotizing
carcinoma of the breast. Because of the suspected risk of this lesion to
hemorrhage, the patient was counseled about the risks and benefits of surgery
and a lumpectomy was performed. Macro scopically, the tumor was well
circumscribed. The surgical margins were clear of tumor. The lesion consisted
of a prominent central hypocellular zone filled with hemorrhagic and necrotic
debris surrounded by a ringlike hypercellular area with accom panying myxoid
stroma (Figs. 1F,
1G, and
1H).
Cytokeratin 34bE12 was positive immunohistochemically, and a histologic
diagnosis of centrally necrotizing carcinoma of the breast with focal
basal-like carcinoma components was made
[1–3].
Centrally necrotizing carcinoma of the breast shows an aggressive and rapidly
progressive clinical course. The mortality was reported as 59% (median time to
death, 22.5 months) in one reported series of 34 cases
[1]. The characteristic
histologic feature of centrally necrotizing carcinoma of the breast is a large
hemorrhagic central necrotic zone with variable fibrosis surrounded by a rim
of residual tumor cells.
In the present case, the preoperative radiologic studies, especially MRI,
showed the expected characteristic features of centrally necrotizing carcinoma
of the breast. The corresponding macroscopic findings at surgery and
cytopathology confirmed the diagnosis.
The preoperative diagnosis of centrally necrotizing carcinoma of the breast
is important for breast surgeons and radiologists in performing aspiration
cytology or core needle biopsy because of the vascular nature of the lesion.
Thorough hemostasis is necessary after careful percutaneous sampling because
of the risk of hemorrhage.
References
- Jimenez RE, Wallis T, Visscher DW. Centrally necrotizing carcinomas
of the breast: a distinct histologic subtype with aggressive clinical
behavior. Am J Surg Patholol 2001;25
: 331-337[CrossRef]
- Jones C, Ford E, Gillett C, et al. Molecular cytogenetic
identification of subgroups of grade III invasive ductal breast carcinomas
with different clinical outcomes. Clin Cancer Res2004; 10(18 Pt 1):5988
-5997[Abstract/Free Full Text]
- Fadare O, Tavassoli FA. The phenotypic spectrum of basal-like
breast cancers: a critical appraisal. Adv Anat Pathol2007; 14:358
-373[CrossRef][Medline]
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