Giant cystic metaplastic carcinoma of the breast: a case report with diagnosis by fine needle aspiration

BACKGROUND: Breast cysts are mainly benign and are reported in association with fibrocystic disease and phyllodes tumor. Rarely have cystic changes been reported to occur in malignant tumors. They are usually small but large in rare cases. Giant breast cysts are very rare, and only a few cases have been reported. CASE: A 37-year-old woman presented with a rapidly growing breast mass. Mammography showed a huge, well-circumscribed cystic mass (17 x 16 x 16 cm) suggestive of a benign lesion. Cytologic examination revealed a highly cellular tumor composed of malignant cells of various sizes and shapes in a necrotic background. The smears were diagnosed as positive for malignancy and suggested metaplastic carcinoma. Mastectomy was performed, and histologic study confirmed the cytologic diagnosis. CONCLUSION: This is the first reported case of a breast cyst of this size. Clinically the cyst was confused with a benign lesion. The fine needle aspiration aided the diagnosis and planning of treatment.     

Paragonimiasis of the breast. Report of a case diagnosed by fine needle aspiration

BACKGROUND: Paragonimiasis infestation is endemic mostly to Asia, Africa and South and Central America and commonly found in the lung. It is extremely rare in soft tissue. CASE: A case of paragonimiasis occurred in a 66-year-old woman who presented with a left, painful, 2-cm-diameter breast mass and had a history of eating uncooked freshwater crabs. On mammography, an ill-defined, round, isodense mass was detected without calcification. Hemorrhagic material was aspirated by fine needle aspiration (FNA) of the breast mass, which contained many parasitic eggs. They were about 90 microns long, ovoid, yellowish brown, transparent and thick shelled, with a flattened operculum at 1 end. The breast mass was completely excised. Many collapsed eggs of Paragonimus infiltrated the lobules and fibroadipose tissue, with accompanying abscess formation. To confirm the diagnosis, serologic testing for paragonimiasis was performed; it was positive for Paragonimus antibody. CONCLUSION: Paragonimiasis very rarely presents as a breast mass and can be diagnosed by FNA.     

Breast metastasis from uterine leiomyosarcoma diagnosed by fine needle aspiration: a case report

BACKGROUND: Leiomyosarcomas of the breast are a rare subgroup of primary breast sarcomas. Even more rare is breast metastasis of an extramammary leiomyosarcoma. To date, only 4 cases have been reported in the literature. CASE: We report a case of breast metastatic leiomyosarcoma in a 58-year-old woman with a prior history of uterine leiomyosarcoma, resected 18 months earlier. The breast mass was palpable and a fine needle aspiration (FNA) was performed. The microscopic examination showed cellular smears composed of loosely structured clusters and tissue fragments of spindle-shaped and polygonal or rounded malignant cells in disorderly arrangement. The tumor cells were medium- or large-sized, with basophilic cytoplasm and enlarged, irregular, hyperchromatic nuclei with nucleoli. Tumor giant cells and multinucleation were also present. The morphologic features along with immunocytochemical positivity for desmin, muscle-specific actin and vimentin indicated the diagnosis of a metastatic leiomyosarcoma. CONCLUSION: FNA cytology can be a reliable method for the diagnosis of leiomyosarcoma. The morphologic criteria in combination Swith the clinical history and the immunocytochemical findings can indicate a definitive diagnosis and avoid additional painful and time-consuming diagnostic procedures for the appropriate patient's further clinical management.     

Three synchronous primary carcinomas in a patient with HNPCC associated with a novel germline mutation in MLH1: Case report

Background

Adnexal masses are not uncommon in patients with breast cancer. Breast cancer and ovarian malignancies are known to be associated. In patients with breast cancer and co-existing pleural effusions, ascites and adnexal masses, the probability of disseminated disease is high. Nevertheless, benign ovarian masses can mimic this clinical picture when they are associated with Meigs' syndrome making the work-up and management of these patients challenging. To our knowledge, there are no similar reports in the literature and therefore we present this case to highlight this entity.

Case presentation

A 56-year old woman presented with a 4 cm, grade 2, invasive ductal carcinoma of her left breast. Pre-treatment staging investigations showed a 13.5 cm mass in her left ovary, a small amount of ascites and a large right pleural effusion. Serum tumour markers showed a raised CA125 supporting the malignant nature of the ovarian mass. The cytology from the pleural effusion was indeterminate but thoracoscopic biopsy failed to show malignancy. The patient was strongly against mastectomy and she was commenced on neo-adjuvant Letrozole 2.5 mg daily with a view to perform breast conserving surgery. After a good response to the hormone manipulation, the patient had breast conserving surgery, axillary sampling and laparoscopic excision of the ovarian mass which was eventually found to be a benign ovarian fibroma.

Conclusion

Despite the high probability of disseminated malignancy when an ovarian mass associated with ascites if found in a patient with a breast cancer and pleural effusion, clinicians should be aware about rare benign syndromes, like Meigs', which may mimic a similar picture and mislead the diagnosis and management plan.     

Fine needle aspiration cytology of metastatic choriocarcinoma presenting as a breast lump. A case report

BACKGROUND: While choriocarcinoma is a rapidly invasive, widely metastasizing malignancy, it responds well to chemotherapy, so it is important to obtain an early diagnosis. We report the fine needle aspiration cytology (FNAC) of a case of choriocarcinoma metastatic to the breast. CASE: A 48-year-old female presented with a cough, hemoptysis and epistaxis. Chest computed tomography revealed multiple nodules in both lung fields. Also, a firm, slightly tender mass in the lower outer quadrant of the left breast was palpated. The breast mass was clinically suspected to be a metastatic lung cancer. FNAC of the breast showed a malignant tumor that had been misdiagnosed as a metastatic non-small cell carcinoma of the lung. Histologic examination of a nasal biopsy revealed metastatic choriocarcinoma. CONCLUSION: The cytologic features of choriocarcinoma are quite characteristic, with side-by-side, malignant, mononucleated cells and multinucleated giant cells corresponding to cytotrophoblasts and syncytiotrophoblasts, respectively. The disease is possible to diagnose by a careful examination of FNAC samples.     

Cytologic findings of a pleomorphic adenoma of the breast: a case report

BACKGROUND: Pleomorphic adenoma of the breast is a rare benign tumor. Only a few cases have been reported. The histologic features have been described well. However, the cytologic findings have been described in only a few papers. CASE: A 47-year-old female presented with a left breast mass of several months' duration. The clinical and mammographic findings were highly suspicious for malignancy. Following an aspiration biopsy diagnosis of "positive for malignancy," the mass was excised. The histologic diagnosis was pleomorphic adenoma (mixed tumor of salivary gland type) rather than carcinoma. CONCLUSION: The cytologic presentation of pleomorphic adenoma of the breast can masquerade as that of a malignant tumor, in this case colloid carcinoma. This case delineates the cytomorphologicfeatures of pleomorphic adenoma, which may mimic carcinoma.     

Cytological and immunocytochemical evaluation of thyroid and breast masses in patients with a previous neoplasm: case reports

The diagnosis of secondary tumours represents one of the most important fields in the application of fine needle aspiration cytology (FNAC). We studied two patients, one with a history of breast cancer and one with a previous tumour of the thyroid, who showed a second mass, in the thyroid and in the breast, respectively, during follow up. The aim of our study was to evaluate if cytology, performed on FNAC smears, may distinguish a metastatic lesion from a second primary tumour, or if further immunocytochemistry should be performed. Our data demonstrate that, while cytology may be indicative of a second primary tumour, the histotype should be confirmed by immunocytochemical staining.     

Spindle cell malignant melanoma metastatic to the breast from a pigmented lesion on the back. A case report

BACKGROUND: Tumors metastatic to the breast are quite unusual (1.2% of all tumors). Malignant melanoma is an exception and is one of the principal metastasizing tumors, described mainly as a primary tumor. There are 5 different cytologic patterns; the spindled pattern is very uncommon, more difficult to diagnose and can be confused with a wide range of sarcomatous lesions. Nevertheless, there are some cytologic features that allow differentiation from similar tumors. CASE: A 30-year-old woman presented with a firm, deep, nontender mass in the upper outer quadrant of the right breast. Fine needle aspiration cytology was performed, and the aspiration smears showed spindle-shaped neoplastic cells arranged singly or in clusters with marked nuclear atypia. Melanin pigment was sometimes seen in the cytoplasm of some cells. Pathologic study of the breast tumor corroborated the diagnosis, and later study revealed lymph node metastases and relapse in the breast area and on a scar on the back. Two years earlier, biopsy of a pigmented lesion on the back was diagnosed as a cellular blue nevus. CONCLUSION: The cytologic features of spindle cell melanoma are distinctive. The presence of atypical fusiform cells with elongated cytoplasm; enlarged nuclei, some of them binucleated or multinucleated; prominent nucleoli; intranuclear cytoplasmic inclusions; and melanin pigment can help to diagnose these unusual metastases to the breast. This case was the first of malignant metastatic melanoma with the spindled pattern in which the diagnosis was made by fine needle aspiration cytology.     

Ectopic lesions as potential pitfalls in fine needle aspiration cytology: a report of 3 cases derived from the thyroid, endometrium and breast

BACKGROUND: Ectopic lesions are rarely encountered. Those that are derived from thyroid, breast, endometrium and salivary glands present with palpable masses that can mimic malignancy. Fine needle aspiration cytology (FNAC) is a practical procedure for the differential diagnosis of such lesions but can reveal surprising images for a cytopathologist. CASES: Three cases of discrete, ectopic lesions at different locations occurred. Case 1 was a 27-year-old woman. Upon diagnosis of a submandibular mass with a diameter of 1 cm, FNAC was performed. The smears showed crowded thyroid follicular cells comprising papillary clusters. A cytologic diagnosis of papillary thyroid lesion was rendered, Histopathology revealed that this lesion was ectopic thyroid tissue with focal chronic thyroiditis. Case 2 was a 38-year-old woman who presented with a painful mass with a diameter of 2.5 cm in the abdominal wall. The patient had undergone cesarean section 3 years earlier. The case was diagnosed on FNAC as low grade malignancy in which an adenocarcinoma/mesenchymal tumor distinction could not be made. The pathologic examination revealed endometriosis. Case 3 was a 31-year old woman who presented with a palpable nodule in the axillary region with a diameter of 1 cm. The patient had given birth 1 month earlier and was nursing. An FNAC diagnosis of lactation ectopic breast tissue was made. The mass disappeared by the end of lactation. CONCLUSION: FNAC of ectopic lesions may prove to be a diagnostic pitfall for cytopathologists. A cytopathologist who encounters a cellularpicturefrom a lesion that is outside the normal anatomic location must use a cautious diagnostic approach. Unless there are clear findings, the cytopathologist must refrain from a diagnosis of malignancy.     

Fine needle aspiration cytology of malignant schwannoma metastatic to the breast

A case of malignant schwannoma metastatic to the breast is reported. The tumor was found as a solitary breast lump in a 43-year-old woman and was clinically considered to be a primary tumor. Fine needle aspiration (FNA) smears of the mass were interpreted cytologically as a malignant neurogenic tumor, compatible with a malignant schwannoma. The patient did not have multiple neurofibromatoses. Eight months previously, an excision of a solitary nodule located in the left axilla had been performed in another hospital. Comparison of the histologic section from that excision with the FNA confirmed that the breast tumor was a metastatic malignant schwannoma, and the patient was treated accordingly.     

Chronic diarrhea due to metastatic breast cancer

We report the case of a patient with chronic diarrhea due to infiltrative cancer to the colon from the breast. A 49-year-old woman with a history of metastatic breast cancer to the bones was admitted to hospital with 4 weeks of watery diarrhea. Computed tomography (CT) scan of the abdomen showed pancolitis. Colonoscopy showed patchy subepithelial hemorrhages, most prominently in the ascending colon and sigmoid colon, but no mass lesion. Random biopsies taken throughout the colon showed infiltrative adenocarcinoma of breast origin in multiple specimens. Infectious work-up was negative.     

Pneumothorax after a clinical breast fine-needle aspiration of a lump in a patient with Poland's syndrome

We report the first case in the medical literature of a pneumothorax complicating fine needle aspiration cytology (FNAC) of a breast lump in a woman with a mild form of Poland's syndrome. The pneumothorax was treated conservatively. This is the first case of breast FNA-related pneumothorax seen in our clinical practice. We believe that the absence of pectoral muscles has increased the risk of this complication. We have also diagnosed an incidental screen-detected breast cancer affecting the ipsilateral breast in the same patient. We conclude that caution should be exercised when performing FNAC of breast lesions in patients with Poland's syndrome. The procedure should be preferably performed under image guidance in such patients in order to minimise the risk of this complication.     

Diagnostic Challenge of Pheochromocytoma in a Patient Receiving Levodopa for Parkinson's Disease

ObjectiveThe diagnosis of pheochromocytoma in patients receiving levodopa is challenging because the standard diagnostic biochemical tests may be confounded by dopaminergic therapy. We aim to showcase our experience with the diagnosis of pheochromocytoma in a patient with a known case of Parkinson’s disease who was receiving levodopa.MethodsWe present the case of an elderly male who was diagnosed as having pheochromocytoma while receiving dopaminergic therapy for Parkinson’s disease.ResultsA 75-year-old man presented with vague abdominal symptoms. Computed tomography revealed a 3.5 × 3.2 cm right adrenal mass with a well-defined margin. As revealed by magnetic resonance imaging, the mass was hypointense on T1-weighted and hyperintense on T2-weighted images. Biochemical tests revealed elevated levels of urinary dopamine, which was considered to be caused by levodopa therapy. However, concurrent elevation in urinary adrenaline and his metanephrine and vanillylmandelic acid levels suggested an underlying case of pheochromocytoma. An ¹²³I-metaiodobenzylguanidine (¹²³I-MIBG) scintigraphy scan performed under levodopa therapy showed positive tracer uptake in the right adrenal gland. Histopathology of the adrenalectomy specimen confirmed the diagnosis of pheochromocytoma.ConclusionOur experience with the present case indicates that although the standard diagnostic biochemical tests for pheochromocytoma may be confounded by dopaminergic therapy, ¹²³I-MIBG scintigraphy has diagnostic value for confirming pheochromocytoma even in patients receiving dopaminergic therapy. (Endocr Pract. 2014;20:e112-e115)     

Radiation induced esophageal adenocarcinoma in a woman previously treated for breast cancer and renal cell carcinoma

ABSTRACT: BACKGROUND: Secondary radiation-induced cancers are rare but well-documented as long-term side effects of radiation in large populations of breast cancer survivors. Multiple neoplasms are rare. We report a case of esophageal adenocarcinoma in a patient treated previously for breast cancer and clear cell carcinoma of the kidney CASE PRESENTATION: A 56 year-old non smoking woman, with no alcohol intake and no familial history of cancer; followed in the National Institute of Oncology of Rabat Morocco since 1999 for breast carcinoma, presented on consultation on January 2011 with dysphagia. Breast cancer was treated with modified radical mastectomy, 6 courses of chemotherapy based on CMF regimen and radiotherapy to breast, inner mammary chain and to pelvis as castration. Less than a year later, a renal right mass was discovered incidentally. Enlarged nephrectomy realized and showed renal cell carcinoma. A local and metastatic breast cancer recurrence occurred in 2007. Patient had 2 lines of chemotherapy and 2 lines of hormonotherapy with Letrozole and Tamoxifen assuring a stable disease. On January 2011, the patient presented dysphagia. Oesogastric endoscopy showed middle esophagus stenosing mass. Biopsy revealed adenocarcinoma. No evidence of metastasis was noticed on computed tomography and breast disease was controlled. Palliative brachytherapy to esophagus was delivered. Patient presented dysphagia due to progressive disease 4 months later. Jejunostomy was proposed but the patient refused any treatment. She died on July 2011 CONCLUSION: we present here a multiple neoplasm in a patient with no known family history of cancers. Esophageal carcinoma is most likely induced by radiation. However the presence of a third malignancy suggests the presence of genetic disorders.     

Current Trends in and Indications for Endoscopy-Assisted Breast Surgery for Breast Cancer: Results from a Six-Year Study Conducted by the Taiwan Endoscopic Breast Surgery Cooperative Group

Background

Endoscopy-assisted breast surgery (EABS) performed through minimal axillary and/or periareolar incisions is a possible alternative to open surgery for certain patients with breast cancer. In this study, we report the early results of an EABS program in Taiwan.

Methods

The medical records of patients who underwent EABS for breast cancer during the period May 2009 to December 2014 were collected from the Taiwan Endoscopic Breast Surgery Cooperative Group database. Data on clinicopathologic characteristics, type of surgery, method of breast reconstruction, complications and recurrence were analyzed to determine the effectiveness and oncologic safety of EABS in Taiwan.

Results

A total of 315 EABS procedures were performed in 292 patients with breast cancer, including 23 (7.8%) patients with bilateral disease. The number of breast cancer patients who underwent EABS increased initially from 2009 to 2012 and then stabilized during the period 2012–2014. The most commonly performed EABS was endoscopy-assisted total mastectomy (EATM) (85.4%) followed by endoscopy-assisted partial mastectomy (EAPM) (14.6%). Approximately 74% of the EATM procedures involved breast reconstruction, with the most common types of reconstruction being implant insertion and autologous pedicled TRAM flap surgery. During the six-year study period, there was an increasing trend in the performance of EABS for the management of breast cancer when total mastectomy was indicated. The positive surgical margin rate was 1.9%. Overall, the rate of complications associated with EABS was 15.2% and all were minor and wound-related. During a median follow-up of 26.8 (3.3–68.6) months, there were 3 (1%) cases of local recurrence, 1 (0.3%) case of distant metastasis and 1 (0.3%) death.

Conclusion

The preliminary results from the EABS program in Taiwan show that EABS is a safe procedure and results in acceptable cosmetic outcome. These findings could help to promote this under-used surgical technique in the field of breast cancer.     

Fine needle aspiration cytodiagnosis of leiomyosarcoma of the breast. A case report

BACKGROUND: Leiomyosarcoma of the breast is a rare tumor. Here we present a case in an elderly female in which the diagnosis was suggested from an aspirate sample. CASE: An 80-year-old female presented with an irregular, firm mass in the left breast of a few months' duration. In view of the clinical suspicion of a tumor, fine needle aspiration was performed. It showed a large number of dissociated cells and compact sheets of spindly and round cells with pleomorphic, hyperchromatic and anaplastic nuclei; mitoses; nucleoli; and somewhat-vacuolated, eosinophilic cytoplasm. Examination of the cell block, tumor tissue and immunostaining further suggested the cytologic impression of a leiomyosarcoma. CONCLUSION: Although leiomyosarcoma of the breast is very rare, fine needle aspiration cytology may allow the diagnosis to be suggested. Correlation with cell block findings and the application of appropriate immunostains as an adjuvant to standard cytologic and histologic stains may allow a more confident diagnosis.     

Breast carcinoma with tumor giant cells. Report of a case with fine needle aspiration cytology

A 31-year-old woman presented with a cystic mass in the left breast. At fine needle aspiration (FNA), the mass felt gritty, and a firm mass remained after drainage of the cyst. Cytologic examination of the aspirate showed mononucleated malignant cells and an array of bizarre malignant multinucleated giant cells. A diagnosis of carcinoma of breast with malignant giant cells was made. Subsequent histologic study of the lesion showed a central cystic cavity lined by bizarre tumor giant cells. Immunocytochemistry and lectin cytochemistry confirmed the epithelial nature of the malignant giant cells. The entities that may yield giant cells on FNA of breast masses are discussed.     

Aspiration cytology of fibrosarcomatous variant of dermatofibrosarcoma protuberans with osteoclastlike giant cells in the chest wall: a case report

BACKGROUND: A case of fibrosarcomatous variant of dermatofibrosarcoma protuberans (FS-DFSP) with osteoclastlike giant cells involved the dermis and subcutaneous tissue of the chest wall. This case was misdiagnosed as primary breast tumor clinically and had cytologic features similar to those of the metaplastic breast carcinoma (MRBC). CASE: A 53-year-old female presented with a nodular breast mass enlarging slowly over a long period of time and growing rapidly for about 3 months. The aspirates showed high cellularity with both individually scattered and fascicular arrays of spindle cells. A few multinucleated giant cells without nuclear atypia were intermixed with dissociated spindle cells. There was no epithelial component in the smear. Cytologic evaluation suggested the possibility of a low grade spindle cell sarcoma as well as MBC. Subsequently, the patient underwent modified radical mastectomy, and the diagnosis of FS-DFSP was made. CONCLUSION: Distinguishing FS-DFSP with osteoclastlike giant cells from other spindle cell tumors of the breast, especially MBC showing predominantly spindle cell components, may pose significant challenges to the pathologist. However, clinical and radiologic findings and a meticulous search for other components raised the possibility of FS-DFSP on aspiration cytology.     

Signet ring cell lobular carcinoma of the breast presenting in a cervicovaginal smear. A case report

BACKGROUND: The presence of extragenital malignant cells in cervicovaginal smears is a rare and usually late event in a patient with a long history of cancer. This, to the best of our knowledge, is the first case of breast cancer initially diagnosed on a Pap smear. CASE: A 50-year-old woman presented with abdominal distension and weight gain. A Pap smear showed numerous signet ring cells and was diagnosed as signet ring cell adenocarcinoma, most likely metastatic from the breast or stomach. Subsequent evaluation revealed bilateral adnexal masses and inguinal lymphadenopathy, leading to hysterectomy and bilateral salpingo-oophorectomy. The ovaries, corpus and cervix were involved by signet ring cell carcinoma. The metastatic tumor proved to be positive for CK7, CEA, estrogen receptor and progesterone receptors and negative for CK20. Despite the absence of a discrete palpable breast mass, a mammogram was recommended based on these results, and an ensuing breast biopsy showed the presence of an infiltrating lobular carcinoma. CONCLUSION: Lobular carcinoma of the breast may present in a cervicovaginal smear. Correct interpretation of signet ring cells as metastatic, most likely from the breast or stomach, is helpful in guiding management.     

Malignant fibrous histiocytoma,giant cell type,of the breast mimicking metaplastic carcinoma. A case report

BACKGROUND: We report a case of malignant fibrous histiocytoma, giant cell type (MFHGC), of the breast. A review of the literature failed to reveal cytology-based reports on this entity. The cytologic similarity of breast MFHGC on fine needle aspiration biopsy (FNAB) to other malignant breast neoplasms, including carcinoma with osteoclastlike giant cells, metaplastic carcinoma and breast sarcomas, as well as benign reactive processes, makes the recognition of this tumor challenging. CASE: A 72-year-old woman presented with a 5-month history of an enlarging breast mass. FNAB of the mass showed a hypercellular smear composed of cohesive, branching clusters of spindle cells with ovoid, focally hyperchromatic nuclei and inconspicuous nucleoli. Interspersed osteoclastlike giant cells, some associated with clusters of spindle cells, were uniformly seen throughout the smear. The background was hemorrhagic, with cellular debris and occasional spindle cells and lymphocytes. No ductal epithelial or myoepithelial cells were seen. An incisional biopsy was performed, followed by radical mastectomy. The histologic examination was diagnostic of MFHGC. The diagnosis was supported by immunohistochemical and electron microscopic studies. CONCLUSION: MFHGC, also called primary giant cell tumor of soft tissues, is composed of a mixture of histiocytes, fibroblasts and bland-appearing osteoclastlike giant cells with a multinodular growth pattern. Although MFHGC rarely occurs in the breast and the definitive diagnosis is difficult based on cytology alone, the diagnosis can be considered when a cytologic examination reveals a hypercellular, spindle cell smear with osteoclastlike giant cells in the absence of ductal epithelial or myoepithelial cells.