International Journal of Biomedical and Advance Research 349 A RARE CASE ON METAPLASTIC SQUAMOUS CELL CARCINOMA OF
BREAST
Jasmin Jasani*1, Bijol Gheewala2, Sankalp Sancheti2, Varsha Doctor2, Smruti Patel2
*1Assistant Professor, Pathology Department, SBKS Medical Institute and Research Center,Piparia,
Vadodara, Gujarat, India
2
Resident, Pathology Department, SBKS Medical Institute and Research Center,Piparia, Vadodara,
Gujarat, India
E-mail of Corresponding Author: [email protected]
Abstract
Metaplastic breast carcinomas represent a morphologically heterogeneous group of invasive
breast cancers in which a variable portion of the glandular epithelial cells comprising the
tumor have undergone transformation in an alternate cell type – either a nonglandular
epithelial cell type or a mesenchymal cell type. Metaplastic carcinomas are uncommon
lesions, representing less than < 5% of all invasive breast cancer. This is a case of 51 year
old female with left breast swelling since 3 months. She underwent Modified Radical
Mastectomy. The histopathological findings were in favour of diagnosis invasive metaplastic
carcinoma of breast – squamous cell variant – well differentiated.
Keywords: squamous, metaplastic, radical mastectomy
1. Case Report:
A 51 year old woman presented with
complaints of pain and swelling in lower
outer quadrant of left breast since 3 months
.
There was a single, palpable, firm, mobile
mass measuring 9x 6x 4cm. Overlying skin
was normal, there was no signs of ulceration
or redness. Nipple was also normal. There
was no retraction or inversion of nipple,
neither there was nipple discharge or
ulceration. Patient then underwent Modified
Radical Mastectomy and the specimen was
sent for histopathological examination.
2. Histopathological Examination
2.1 Gross Examination: Modified Radical
Mastectomy
specimen was received with
axillary tail measuring 22x14x7cm. Skin flap
measured 12x10 cm and axillary tail measuring
7x6x4cm. There was a ill- circumscribed
growth with irregular border
just 0.5cm
beneath the nipple measuring 5x4x4 cm with
surrounding necrotic areas. Lower margin of
growth was 1 cm above base. Largest LN
measuring
3x2x1
cm
with
central
hemorrhagic area and second largest LN
measuring 3x2x1 cm with central jelly filled
material. Total 15 LN were identified.
2.2 Microscopic Examination: The sections
from growth showed presence of extensive
IJBAR (2012) 03(05) keratinisation , squamous keratin pearls,
presence of cyst formation , severe chronic
inflammation and tumor necrosis and at
places foci of glandular ductal element was
seen. There was extensive lymph vascular
invasion.
The sections from nipple , all margins and
base were free from tumor invasion.
Out of 15 LN isolated 3 LN showed
evidence of metastasis of metaplastic
carcinoma of breast. Rest of LN showed
extensive sinus histiocytosis.
Thus
patient was diagnosed as Invasive
Metaplastic Carcinoma – Squamous cell
variant – well differentiated –Grade 1. BR
score- 5.
TNM staging was T3pN1a Mx
stage
III3A.
T3p - Tumor size >5cm
N1a - Metastasis in 3 ipsilateral axillary LN
out of 15 LN
Mx - Presence of distant metastasis can not be
assessed
3. Discussion
Metaplastic breast carcinoma is uncommon. It
is thought to constitute between 0.2% and
5% of all breast cancers. The term describes
a range of cancers of mixed epithelial and
mesenchymal origin.6,7,8 Histologically, the
neoplastic epithelial cells show non-glandular
www.ssjournals.com Case Report
Jasani et al
differentiation. The degree of differentiation
varies from small foci to complete glandular
replacement6. Microscopically, the tumour
can show a pure spindle cell pattern or
mixed epithelial and mesenchymal pattern.
The epithelial component is often of a
ductal, non-specific type pattern but may
also have squamous features or apocrine,
medullary and mucinous pattern.
This tumor probably is derived from
myoepithelial cells. The myoepithelial cell
has been suggested as a link that can
differentiate into epithelial as well as
mesenchymal elements 3. The incidence of
lymph node metastasis from metaplastic
carcinoma is lower than might be anticipated
for infiltrating duct carcinoma. Purely
spindled
/
sarcomatoid
tumors
have
significant lower rate of node metastasis than
conventional ductal and lobular carcinomas.
Similar to patients with invasive carcinoma –
NST with IC with regard to age at
presentation, the manner in which these
tumors are detected and location within
breast in which these tumors arise1,2,3
There are no known specific radiological
features of metaplastic breast cancer. Most
cases have presented with masses on
mammography. These vary from relatively
well defined to ill defined and speculated.
The
gross
appearance
of
metaplastic
carcinoma is not distinctive and these tumors
can either be well-circumscribed or show an
indistinct irregular border. Microscopically,
metaplastic carcinomas are highly distinctive
but vary in the types, extent.
Most reports divide metaplastic carcinomas
into two broad categories: those that show
squamous differentiation4 and those that
feature heterologous elements, such as,
cartilage, bone, muscle, adipose tissue,
vascular elements, and even melanocytes,
among others3,8.
Investigators at the Armed Forces Institute
of
Pathology
categorize
metaplastic
carcinoma into five categories: squamous cell
carcinomas5,
spindle
cell
carcinomas9,
10
carcinosarcoma ,
matrix-producing
carcinomas4, and carcinomas with osteoclastlike giant cells11.
Squamous differentiation can range from well to
poorly differentiated.
In
some
tumors
composed primarily of squamous cells, there
is prominent cystic degeneration. Spindle-cell
differentiation is common in metaplastic
IJBAR (2012) 03(05) 350
carcinomas, and is frequently seen in
association with squamous differentiation.
There are no data on specific treatment for
metastatic breast cancer.
The
determination
of
prognosis
for
metaplastic breast carcinoma is limited by
the uncommon occurrence of this cancer. In
a study of 29 metaplastic breast carcinomas
from Michigan3, it was suggested that
prognosis best correlated with the size of the
lesion rather than with the nodal status. The
study indicated that patients with tumors less
than 4 cm had a better prognosis than those
with larger lesions. Microscopic pattern had
no correlation with prognosis. Tumour size,
nodal status, grade, histological type and
treatment are the usual determinants of
prognosis. The degree of differentiation and
morphological type might also affect
outcome. Previous studies show 5-year
survival rates ranging from 38 to 86%. The
study concluded that duration of symptoms,
TNM stage, tumour size, and nodal status
were significant prognostic factors for
survival. The conclusion was that patients
with metaplastic carcinomas might have a
favourable prognosis.
Most metaplastic carcirnomas are negative
for ER and PR & HER 2/neu
and are
managed by radical mastectomy followed by
radiation and chemotherapy.
Conclusion:
In conclusion, metastatic breast SCC is an
extremely rare and aggressive disease.
Associated with frequent loco regional and
distant relapses and resultant deaths. Better
systemic therapy is therefore needed to improve
patient outcomes. Therefore, pathological
examination of these breast lump and other body
lesion is must.
References
1. Oberman HA: Metaplastic carcinoma of the
breast: A clinicopathologic study of 29
patients. Am J Surg Pathol 1987; 11:918–
929.
2. Pitts WC, Rojas VA, Gaffey MJ, et al.:
Carcinomas with metaplasia and sarcomas
of the breast. Am J Clin Pathol 1991;
95:623 632.
3. Patterson SK, Tworek JA, Roubidoux
MA, et al.: Metaplastic carcinoma of the
breast: Mammographic appearance with
www.ssjournals.com Case Report
351
Jasani et al
4.
5.
6.
7.
8.
9.
10.
11.
pathologic correlation. AJR 1997; 169:709–
712.
Wargotz ES, Norris HJ:
Metaplastic
carcinoma of the breast:
I. Matrixproducing carcinoma. Hum Pathol 1989;
20:628–635.
Wargotz ES, Norris HJ:
Metaplastic
carcinomas of the breast. IV. Squamous cell
carcinoma of ductal origin. Cancer 1990;
65:272– 276.
Rosen PP, Ernsberger D: Low-grade
adenosquamous carcinoma.A variant of
metaplastic mammary carcinoma. Am J
Surg Patho l1987;115:351–358
Hennesy BT, Giordano S, Broglio K, Duan
Z et al. Biphasic Metaplastic Sarcomatiod
carcinoma of breast. Annals of Oncology
2006: 17: 605-13.
JohnsonTL, Kini SR. Metaplastic breast
carcinoma. a cytohistologic and clinical
study of 10 cases. Diagn Cytopathol1996;
14: 226–32.
Wargotz ES, Deos PH, Norris HJ:
Metaplastic carcinomas of thebreast: II.
Spindle cell carcinoma. Hum Pathol 1989;
20:732–740.
Wargotz ES, Norris HJ:
Metaplastic
carcinomas
of the
breast:
III.
Carcinosarcoma. Cancer 1989; 64:1490–
1499.
Wargotz ES, Norris HJ:
Metaplastic
carcinomas of the breast. V. Metaplastic
carcinoma with osteoclastic giant cells.
Hum Pathol1990;21:1142–115
Figure :- 02 keratinisation , squamous
keratin pearls, at places foci of glandular
ductal element was seen. [H & E 10X]
Figure: - 03 squamous keratin pearls
[H & E 40X]
Figure: - 04 From Lymph node shows
squamous metaplasia [H & E 10X]
Figure :- 01 The sections from growth
showed presence of extensive
keratinisation, squamous keratin pearls,
severe chronic inflammation
[H & E 10X]
IJBAR (2012) 03(05) www.ssjournals.com