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BRIEF CASE REPORT
Year : 2018  |  Volume : 11  |  Issue : 3  |  Page : 239-241  

Utility of fine-needle aspiration cytology in diagnosis of rare breast malignancy-mucinous carcinoma with lymph node metastasis


Department of Pathology, Belagavi Institute of Medical Sciences, Belagavi, Karnataka, India

Date of Web Publication29-Jun-2018

Correspondence Address:
Milind M Kesarkhane
Department of Pathology, Belagavi Institute of Medical Sciences, Belagavi, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/MJDRDYPU.MJDRDYPU_44_17

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  Abstract 


Mucinous carcinoma (MC) of the breast is a rare, malignant tumor accounting for 2% of all breast cancers with better prognosis, usually seen in postmenopausal women with only 0%–4% lymph node metastasis. Cytologic findings of MC overlap with other benign and malignant breast lesions making the cytodiagnosis challenging. Here, we report two cases of MC of the breast in reproductive age females and one case showed axillary lymph node metastasis. A 30-year-old female presented with firm, nontender lump in the right breast of 8 months' duration, measured 3 cm × 2 cm with palpable right axillary lymph nodes. A 28-year-old female presented with firm, nontender lump in the left breast of 7 months' duration, measured 6 cm × 5 cm. Cytologically, one case diagnosed as MC with lymph node metastasis and other case reported as MC; subsequently, both cases confirmed by histopathology, thus highlighting the role of fine-needle aspiration cytology in diagnosis of MC.

Keywords: Breast, lymph node metastasis, mucinous carcinoma


How to cite this article:
Kesarkhane MM, Aruna S, Jadhav MN, Kittur SK. Utility of fine-needle aspiration cytology in diagnosis of rare breast malignancy-mucinous carcinoma with lymph node metastasis. Med J DY Patil Vidyapeeth 2018;11:239-41

How to cite this URL:
Kesarkhane MM, Aruna S, Jadhav MN, Kittur SK. Utility of fine-needle aspiration cytology in diagnosis of rare breast malignancy-mucinous carcinoma with lymph node metastasis. Med J DY Patil Vidyapeeth [serial online] 2018 [cited 2020 Oct 19];11:239-41. Available from: https://www.mjdrdypv.org/text.asp?2018/11/3/239/235565




  Introduction Top


Mucinous carcinoma (MC) of the breast is a relatively rare, accounting for 2% of breast cancers. It occurs in wide age range but is more common in postmenopausal women. Traditionally, there are two variants, pure and mixed. Pure MC has far better prognosis than the mixed variety and is usually seen in postmenopausal women.[1] The incidence of lymph node metastasis of MC has been described as very low, i.e., 0%–4%. The abundant mucin may act as a crude mechanical barrier and diminish the tumor cell burden in MC at the invasive margins.[2],[3]

Cytodiagnosis of MC is challenging as cytologic findings of MC overlap with other benign and malignant breast lesions. Here, we report two cases of pure MC of the breast in reproductive age group females, one case showed axillary lymph node metastasis. Cytodiagnosis for both the cases were confirmed by histopathology.


  Case Reports Top


Case 1

A 30-year-old female presented with lump in the right breast of 8 months' duration. On examination, lump was in the upper outer quadrant, firm, mobile, nontender and measured 3 cm × 2 cm with palpable right axillary lymph node palpable measured 1.5 cm × 1 cm. Other laboratory investigations were unremarkable.

Fine-needle aspiration (FNA) aspirated jelly-like material. Giemsa- and Papanicolaou-stained smears showed tightly cohesive clusters of ductal epithelial cells with high nucleocytoplasmic ratio, pleomorphic nuclei with prominent nucleoli. Few cells showed vacuolated cytoplasm. Background showed abundant mucoid material [Figure 1]a. Aspirate from lymph node showed cells with above-described morphology with background mucoid material [Figure 1]b.
Figure 1: Case 1 - Photomicrograph of fine-needle aspiration smear. (a) Mucinous carcinoma with tumor cells in background of mucin (Giemsa, ×400). (b) Smear from lymph node showing metastasis (Giemsa, ×100)

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Cytodiagnosis of MC with axillary lymph node metastasis was made.

Subsequently, modified radical mastectomy was done and specimen sent for histopathological examination. On gross examination, tumor was in the upper and outer quadrant which was well circumscribed and measured 2.5 cm × 2 cm. Cut surface of tumor was slimy. All resected surgical margins, skin, nipple, and areola, were not involved grossly. On serial sectioning, six lymph nodes were isolated [Figure 2]a.
Figure 2: Case 1 – (a) Gross photograph of well-circumscribed mass with gelatinous area (green arrow) and lymph nodes (red arrow). (b) Photomicrograph of histopathological section – Island of tumor cells in pool of mucin (H and E, ×100). (c) Photomicrograph of special periodic acid–Schiff-positive stain for mucin (periodic acid–Schiff, ×100). (d) Photomicrograph of histopathological section – lymph node metastasis (H and E, ×100)

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Microscopy revealed features of an invasive MC. All surgical margins, overlying skin, nipple, and areola, were uninvolved. Out of six axillary lymph nodes, two lymph nodes showed metastatic deposits. Tumor and metastatic lymph nodes were positive for periodic acid–Schiff stain for mucin [Figure 2]b, [Figure 2]c, [Figure 2]d.

Case 2

A 28-year-old female presented with lump in the left breast of 7 months' duration. On examination, nodular lump was present involving the inner upper and outer upper quadrant and measured 6 cm × 5 cm. Skin, nipple, and areola were unremarkable. There was no lymphadenopathy. On ultrasonography, it was diagnosed as lobulated benign lesion. All other laboratory investigations were unremarkable.

FNA yielded jelly-like material. Giemsa- and Papanicolaou-stained smears showed loosely cohesive ductal epithelial cells with mild pleomorphism, high nucleocytoplasmic ratio, hyperchromatic nuclei, and few cells with vacuolated cytoplasm. Background showed abundant mucoid material [Figure 3].
Figure 3: Case 2 - Photomicrograph of fine-needle aspiration smear from the left breast lump showing mucinous carcinoma (Giemsa, ×400)

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Cytodiagnosis of MC of the breast was made.

Subsequently, lumpectomy was done. On gross examination, tumor was well circumscribed and measured 5 cm × 5 cm. Cut surface was mucoid [Figure 4]a.
Figure 4: Case 2 – (a) Gross photograph of tumor mass with gelatinous area. (b) Photomicrograph of histopathological section – clusters of tumor cells with mucin (H and E, ×100)

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Microscopy showed features of invasive MC of the breast [Figure 4]b.


  Discussion Top


MC of the breast is a rare malignant tumor, commonly occurs in postmenopausal females, and shows more favorable clinicopathological characteristics such as lower incidence of nodal metastasis, higher expression of estrogen and progesterone receptor, and differentiated grade. Here, we report two cases of MC in reproductive age females and one case showed axillary lymph node metastasis. These lesions tend to be well defined with smooth outline, hard and mobile and hence may be mistaken clinically for mucoid fibroadenoma and mucocele-like lesion.[4]

MC is associated with a very low incidence (0%–4%) of nodal metastases. It carries an excellent short-term prognosis particularly when the tumor measures <3 cm in diameter. The death from this tumor can occur many years after therapy indicating the need for a long-term follow-up. The pure type is the classical type composed entirely of MC and can be further subdivided into cellular and hypocellular variants based on the degree of cellularity. When the mucinous component is mixed with another tumor type, then it is mixed mucinous cancer which is most commonly ductal type (mucinous-ductal).[5] It should be noted that some subtypes of the MC have worse prognosis than others such as the micropapillary pattern. In the study of Barbashina et al., more than half of the patients with this particular type of pattern showed vascular invasion and axillary lymph node metastasis.[6]

The cytological differential diagnosis of MC includes mucocele-like lesion, mixed mucinous infiltrating carcinoma, mucoid fibroadenoma, secretory carcinoma, and mucinous cystadenocarcinoma.[7]

Fanning et al. described cytological features of MC and are identical to the cytological features noted here for both the cases.[8]

Adhikari et al. studied cytodiagnosis of eight cases of MC with mean age of patients 63 years. The study concluded that MC appears benign clinically and radiologically; FNA cytology plays important role in correct preoperative diagnosis.[9]


  Conclusion Top


Although cytologic features are characteristic, definitive cytodiagnosis of MC of the breast has not been well established. Mucoid background is also seen in benign and other malignant breast tumors. The cases are presented for their rarity and unusual age presentation. The cases emphasize distinctive cytomorphological appearance which enables correct cytodiagnosis of MC and hence early prompt treatment leading to increased survival in prognostically good breast cancers.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Ellis IO. Tumors of the breast. In: Fletcher DM, editor. Diagnostic Histopathology of Tumors. 4th ed. Philadelphia. Elsevier; 2013. p. 1060-5.  Back to cited text no. 1
    
2.
Rasmussen BB, Rose C, Christensen IB. Prognostic factors in primary mucinous breast carcinoma. Am J Clin Pathol 1987;87:155-60.  Back to cited text no. 2
    
3.
Paramo JC, Wilson C, Velarde D, Giraldo J, Poppiti RJ, Mesko TW. Pure mucinous carcinoma of the breast: Is axillary staging necessary? Ann Surg Oncol 2002;9:161-4.  Back to cited text no. 3
    
4.
Rosen PP. Mucocele-like tumors of the breast. Am J Surg Pathol 1986;10:464-9.  Back to cited text no. 4
    
5.
Ranade A, Batra R, Sandhu G, Chitale RA, Balderacchi J. Clinicopathological evaluation of 100 cases of mucinous carcinoma of breast with emphasis on axillary staging and special reference to a micropapillary pattern. J Clin Pathol 2010;63:1043-7.  Back to cited text no. 5
    
6.
Barbashina V, Corben AD, Akram M, Vallejo C, Tan LK. Mucinous micropapillary carcinoma of the breast: An aggressive counterpart to conventional pure mucinous tumors. Hum Pathol 2013;44:1577-85.  Back to cited text no. 6
    
7.
Ramraje S, Ansari S, Sisodia S, Chaturvedi N, Bhatia V, Goel A. Pure mucinous carcinoma of the breast. Iran J Pathol 2013;8:199-203.  Back to cited text no. 7
    
8.
Fanning TV, Sneige N, Staerkel G. Mucinous breast lesions: Fine needle aspiration findings. Acta Cytol 1990;34:754-5.  Back to cited text no. 8
    
9.
Adhikari RC, Jha A, Sayami G. Fine needle aspiration cytology findings of mucinous carcinoma of breast: A study of eight cases with histological correlation. Nepjol 2012;2:285-8.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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