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LETTER TO THE EDITOR
Year : 2018  |  Volume : 11  |  Issue : 2  |  Page : 194-196  

Carcinoma with medullary features of breast: Diagnosed in cytology


1 Department of Pathology, Institute of Medical Sciences and SUM Hospital, Bhubaneswar, Odisha, India
2 Department of Surgical Oncology, Institute of Medical Sciences and SUM Hospital, Bhubaneswar, Odisha, India

Date of Web Publication18-May-2018

Correspondence Address:
Rashmi Patnayak
Department of Pathology, Institute of Medical Sciences and SUM Hospital, Bhubaneswar, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/MJDRDYPU.MJDRDYPU_91_17

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How to cite this article:
Patnayak R, Agrawal SK, Dasgupta S, Mohapatra D, Devi K, Jena A. Carcinoma with medullary features of breast: Diagnosed in cytology. Med J DY Patil Vidyapeeth 2018;11:194-6

How to cite this URL:
Patnayak R, Agrawal SK, Dasgupta S, Mohapatra D, Devi K, Jena A. Carcinoma with medullary features of breast: Diagnosed in cytology. Med J DY Patil Vidyapeeth [serial online] 2018 [cited 2022 Dec 5];11:194-6. Available from: https://www.mjdrdypv.org/text.asp?2018/11/2/194/232652



Sir,

Many variants of carcinoma of breast on fine-needle aspiration cytology (FNAC) may show a dense lymphocytic infiltrate.[1] Carcinoma with medullary features of breast is usually considered as a possible diagnosis in this scenario. These are rare breast tumors which account for <5% of invasive breast carcinomas.[2] The recent WHO classification of breast carcinoma has grouped medullary carcinoma, atypical medullary carcinoma (AMC), and subset of Invasive breast carcinoma no special type (NST) as carcinoma with medullary features.[3] There is scant literature regarding the cytology of this variant of infiltrating breast carcinoma.[1]

Hereby, we present a case of carcinoma with medullary features of breast, with an emphasis on differential diagnosis, cytohistopathology correlation, and a brief review of literature.

A 54-year-old female presented with a well-circumscribed firm, mobile lump of 3 cm × 2 cm size in the upper outer quadrant of left breast. Her mammogram was reported as carcinoma left breast with metastatic nodes (BIRADS-V). The patient underwent FNAC. The smears were richly cellular and showed predominantly singly scattered ductal epithelial cells admixed with dense lymphoplasmacytic infiltrate. Few tumor giant cells were noted [Figure 1]. The aspiration from left axillary lymph node showed similar morphology. The cytology was reported as carcinoma with medullary features of breast. Subsequently, she underwent left modified radical mastectomy. Grossly, the lesion was well circumscribed and demarcated from the surrounding breast parenchyma. The final histopathology was reported as carcinoma with medullary features. It showed a syncytial pattern of growth occupying more than 75%, moderate-to-marked nuclear pleomorphism, and dense lymphoplasmacytic infiltrate [Figure 2]. There was no ductal carcinomatous component in multiple sections. Out of the 21 axillary lymph nodes, one showed the presence of metastasis. The resected margins including tumor bed were free of tumor. Immunohistochemistry for estrogen receptor (ER), progesterone receptor (PR), and human epidermal receptor growth factor-2 was all negative. The Ki-67 was showing 75% nuclear positivity [Figure 3].
Figure 1: (a) Cellular cytosmear with discretely lying epithelial cells admixed with dense lymphoplasmacytic infiltrate (Giemsa × 40). (b) Dense admixture of lymphoplasmacytic cells with epithelial cells (Giemsa × 100). (c) Tumor giant cell in an inflammatory background (Giemsa × 200). (d) Pleomorphic ductal epithelial cells (Giemsa × 400)

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Figure 2: (a) Cut section showing well-circumscribed lesion. (b) Histologically well-circumscribed lesion (H and E × 40). (c) Tumor cells showing syncytial pattern of growth (H and E × 100). (d) Tumor cells with lymphoplasmacytic infiltrate (arrow) (H and E × 100). (e) Tumor cells showing nuclear pleomorphism (H and E × 200)

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Figure 3: Immunohistochemistry negative for estrogen receptor (IHC × 40). (a) Immunohistochemistry negative for progesterone receptor (IHC × 40). (c) Immunohistochemistry negative for Her-2 (IHC × 40) (d) Immunohistochemistry showing nuclear positivity for Ki67 (IHC × 40)

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She had an uneventful postoperative course. She was referred to medical oncology and is currently doing well.

WHO has grouped overlapping group of tumors with more or less “medullary” features such as medullary carcinoma, AMC, and a subset of invasive breast carcinoma NST as carcinoma with medullary features.[3]

Medullary carcinoma of breast is a variant of invasive breast carcinoma. This type is rather uncommon and constitutes about 1%–7% of all breast cancers. They have a better prognosis despite an aggressive histopathological appearance.[2]

The histopathological criteria for the diagnosis of typical medullary carcinoma include (A) syncytial growth pattern cells in more than 85% of the tumor, (B) admixed diffuse lymphoplasmacytic infiltrate, (C) complete histological circumscription, (D) moderate-to-marked nuclear pleomorphism, and (E) absence of glandular structures.[2]

AMCs are those tumors which show a predominantly syncytial architecture, with only two or three of the other criteria. The prognosis of AMC is less favorable compared to medullary carcinoma. Hence, few authors advocate the term infiltrating ductal carcinoma with medullary features rather than AMC.

Medullary breast carcinoma cytology reveals highly cellular smears containing large atypical cells arranged in syncytial sheets and intimately admixed with lymphocytes, plasma cells, and neutrophils. The nuclear-to-cytoplasmic ratio is high in tumor cells. Tumor cells had predominantly abundant finely granular, eosinophilic cytoplasm and moderate-to-marked nuclear pleomorphism with prominent nucleoli.[4]

The differential diagnosis includes high-grade ductal carcinoma, lymphoma, Epstein–Barr virus-associated lymphoepithelioma-like carcinomas, or metastasis to breast or intramammary lymph nodes. Hence, histopathological analysis is required for definitive diagnosis. In lymphomas, there is a lack of syncytial pattern and circumscription. Lymphoepithelioma-like carcinoma has infiltrative borders.[5] In difficult cases, immunohistochemistry for lymphoid antigen and keratin will help to arrive at a particular diagnosis.[6]

The axillary lymph node metastasis is low in cases of medullary carcinoma. Lymph nodal metastasis is present in 19%–46% of cases. This may be explained by the expression of the intercellular adhesion molecule-1 and of E-cadherin by the tumor. Medullary breast carcinomas typically lack ER and PR expression and have a low incidence of ERB 2 overexpression. Genetically, they are often associated with breast carcinoma (BRCA-1) oncogene mutations and TP53 alterations.[7]

The treatment options include modified radical mastectomy along with radiotherapy and chemotherapy depending on the stage and histopathological grade. The overall 5-year survival rate is approximately 78% for medullary carcinoma, which is better compared to infiltrating duct carcinoma of not otherwise specified type.[2]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kleer CG, Michael CW. Fine-needle aspiration of breast carcinomas with prominent lymphocytic infiltrate. Diagn Cytopathol 2000;23:39-42.  Back to cited text no. 1
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2.
Sinn HP, Kreipe H. A brief overview of the WHO classification of breast tumors, 4th edition, focusing on issues and updates from the 3rd edition. Breast Care (Basel) 2013;8:149-54.  Back to cited text no. 2
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3.
Santosh T, Bal AK, Patro MK, Choudhury A. Medullary breast carcinoma: A case report and review of literature. J Cancer Sci Ther 2015;7:142-4.  Back to cited text no. 3
    
4.
Akbulut M, Zekioglu O, Kapkac M, Ozdemir N. Fine needle aspiration cytologic features of medullary carcinoma of the breast: A study of 20 cases with histologic correlation. Acta Cytol 2009;53:165-73.  Back to cited text no. 4
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5.
Lymphoepithelioma like Carcinomas. PathologyOutlines.com website. Available from: http://www.pathologyoutlines.com/breastmalignantLEL.html. [Last accessed on 2017 Jul 28].  Back to cited text no. 5
    
6.
Racz MM, Pommier RF, Troxell ML. Fine-needle aspiration cytology of medullary breast carcinoma: Report of two cases and review of the literature with emphasis on differential diagnosis. Diagn Cytopathol 2007;35:313-8.  Back to cited text no. 6
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7.
Galzerano A, Rocco N, Accurso A, Ciancia G, Campanile AC, Caccavello F, et al. Medullary breast carcinoma in an 18-year-old female: Report on one case diagnosed on fine-needle cytology sample. Diagn Cytopathol 2014;42:445-8.Sir,  Back to cited text no. 7
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