Nodular Fasciitis of the Breast Previously Misdiagnosed as Breast Carcinoma

Zusammenfassung

Hintergrund

Die noduläre Fasciitis ist eine seltene benigne Erkrankung der Mamma, die klinisch, radiologisch und histopathologisch Brustkrebs imitieren kann.

Fallbericht

Wir stellen den Fall einer 18 Jahre alten Patientin vor, die wegen einer Geschwulst in ihrer linken Brust in einer anderen Klinik vorstellig wurde. Die dortige Untersuchung ergab einen palpablen Knoten im linken oberen äuβeren Quadranten. Die Sonographie zeigte eine hypodense Raumforderung. Es folgte eine Exzisionsbiopsie mit einer histopathologischen Untersuchung, die diesen Knoten als mesenchymalen Tumor deutete. Zur weiteren Untersuchung wurde die Patientin in unsere Klinik überwiesen. Nach Überprüfung der histopathologischen Diagnose musste diese revidiert werden. Es zeigte sich das Bild einer nodulären Fasciitis und die Einweisungsdiagnose Tumor wurde verworfen.

Schlussfolgerung

Das Wissen um die Möglichkeit dieser seltenen Erkrankung, noduläre Fasciitis, könnte die Fehldiagnose Mammakarzinom vermeiden.     

Invasive Lobular Carcinoma of the Breast

Invasive lobular carcinoma of the breast is a distinct histologic type with specific clinical, radiologic, and microscopic features, which is increasing in incidence in the Western World. Routine pathologic prognostic factors, including grade, lymph node stage, and size are of significance in predicting outcome in this group of patients who, overall, have survival comparable to those with other subtypes of breast cancer. Variants, however, are seen and these, as well as other standard factors such as histologic grade, have prognostic significance and should be recorded in pathology reports.     

Re-Excision Rates of Invasive Ductal Carcinoma with Lobular Features Compared with Invasive Ductal Carcinomas and Invasive Lobular Carcinomas of the Breast

Background

Invasive ductal carcinoma (IDC) with lobular features (IDC-L) is not recognized as a subtype of breast cancer. We previously showed that IDC-L may be a variant of IDC with clinicopathological characteristics more similar to invasive lobular carcinoma (ILC). We sought to determine the re-excision rates of IDC-L compared with ILC and IDC, and the feasibility of diagnosing IDC-L on core biopsies.

Methods

Surgical procedure, multiple tumor foci, tumor size, and residual invasive carcinoma on re-excision were recorded for IDC-L (n = 178), IDC (n = 636), and ILC (n = 251). Re-excision rates were calculated by excluding mastectomy as first procedure cases and including only re-excisions for invasive carcinoma. Slides of correlating core biopsies for IDC-L cases initially diagnosed as IDC were re-reviewed.

Results

For T2 tumors (2.1–5.0 cm), re-excision rates for IDC-L (76 %) and ILC (88 %) were higher than that for IDC (42 %) (p = 0.003). Multiple tumor foci were more common in IDC-L (31 %) and ILC (26 %) than IDC (7 %) (p < 0.0001), which was a significant factor in higher re-excision rates when compared with a single tumor focus (p < 0.001). Ninety-two of 149 patients (62 %) with IDC-L were diagnosed on core biopsies. Of the 44 patients initially diagnosed as IDC, 30 were re-reviewed, of which 24 (80 %) were re-classified as IDC-L.

Conclusions

Similar to ILC, re-excision rates for IDC-L are higher than IDC for larger tumors. Patients may need to be counseled about the higher likelihood of additional procedures to achieve negative margins. This underscores the importance of distinguishing IDC-L from IDC on core biopsies.     

Lobular Carcinoma In Situ of the Breast

LCIS was first described in 1941 as a distinct pathologic entity by Foote and Stewart who called it a "rare form of mammary carcinoma." It is thought to represent a transitional intra-epithelial, or in situ, stage in the evolution of breast cancer from hyperplastic breast epithelium. With the wide application of mammography, its detection has increased in recent years, being found in approximately 1% of all breast biopsy specimens and 5% of all breast malignancies. Its true incidence is unknown, because the absence of any clinical or radiographic manifestations makes its detection completely arbitrary and random. LCIS has distinct pathologic features characterized by proliferation of bland, homogeneous malignant cells within the terminal duct-lobular apparatus. The lobular architecture and investing basement membrane remain intact with no evidence of invasion into the surrounding stoma. It is assumed to be widely disseminated throughout all breast tissue whenever it is found, having close to 100% incidence of multicentricity and bilaterality. The cells are typically of low histologic and nuclear grade, highly estrogen receptor positive, and have tumor marker characteristics of indolent growth and good prognosis. This is very different from its noninvasive ductal counterpart, DCIS, which is typified by more aggressive cytologic and biologic characteristics. Although LCIS imparts as much as a 12-fold increased risk of subsequent invasive breast carcinoma, its natural history suggests it is more of a marker of risk rather than a true premalignant lesion. Most subsequent malignancies occur more than 15 years after diagnosis, and are ductal rather than lobular. This risk is also equally applied to both breasts, regardless of which breast contains the diagnosed focus. Subsequent invasive breast cancers are typically early with very low mortality, most likely due to the strict mammographic surveillance provided to these women. Although originally treated by mastectomy, most now manage LCIS by careful non-operative observation, in the same way that other risk factors such as family history or atypical hyperplasia are managed. In fact, it has been questioned whether there should be any real distinction between lobular hyperplasia and LCIS. There is no role for excision of biopsy sites of LCIS to obtain clear margins, nor for cytotoxic chemotherapy. However, the NSABP P-1 Prevention Trial strongly suggests that subsequent risk can be significantly reduced by tamoxifen. The only rational surgical treatment, if ablation is judged necessary, would be bilateral mastectomy, which appears far too aggressive in view of its low overall risks. Further investigation should clarify the optimal management of LCIS.     

Tongue Metastasis from a Poorly Differentiated Urothelial Carcinoma of the Bladder

Chemotherapy may cause oral ulceration but a thorough investigation of symptoms and signs is important to determine the underlying diagnosis accurately. We describe a case of a patient with a poorly differentiated urothelial carcinoma of the bladder developing a tongue metastasis. This is a challenging diagnosis to make given the rarity of the presentation but it illustrates the need to evaluate any new symptoms fully.     

The Significance of Lobular Carcinoma In Situ and Atypical Lobular Hyperplasia of the Breast

Background

The significance of lobular neoplasia (LN), lobular carcinoma in situ (LCIS) and atypical lobular hyperplasia (ALH)) found at core needle biopsy (CNB) of the breast remains uncertain. There is a consistent risk of underestimating malignancy after the diagnosis of LN on CNB. The aim of this study was to determine if patients with a CNB result of LN need surgical excision.

Methods

Patients were identified by searching the institutions pathology database for the terms ??lobular carcinoma in situ?? and ??atypical lobular hyperplasia?? over 20?years. Excluded from this study were those with core needle biopsy (CNB) results of ductal carcinoma in situ, atypical ductal hyperplasia, radial scar, or papilloma. Upgrade was defined as final surgical pathology of invasive carcinoma and/or ductal carcinoma in situ that was directly correlated to the site of the initial biopsy containing LN.

Results

LN was found at CNB in 285 patients, and 71?% (n?=?201) had subsequent surgical excisions. All patients with pleomorphic LCIS (pLCIS) underwent surgical excision. Following patients with pLCIS, patients with the diagnosis of LCIS were most likely to undergo surgical excision (80?%). Final pathology of the surgically excised specimens confirmed LN in 72?% (n?=?144). Also, 13?% (n?=?26) of the operated patients were upgraded to malignancy, including 8?% of ALH and 19?% of LCIS cases.

Conclusion

This is the largest series of surgical excisional pathology following LN on CNB ever reported. The likelihood of finding malignancy at surgical excision after CNB showing LN was 13?%. Patients with the diagnosis of LN on CNB should be considered for surgical excision.     

Surgical Treatment of Patients with Poorly Differentiated Pancreatic Neuroendocrine Carcinoma: An NCDB Analysis

Annals of Surgical Oncology - Consensus guidelines discourage resection of poorly differentiated pancreatic neuroendocrine carcinoma (panNEC) given its association with poor long-term survival....     

Mammary Lobular Carcinoma-Like Salivary Gland Carcinoma: Report of a Rare Case

Salivary and mammary glands are both exocrine organs sharing multiple tumorigenic processes. To the best of our knowledge, salivary gland tumors mimicking invasive lobular carcinoma of the breast have not yet been described. Herein, we report a case of a 62-year-old male who presented with progressive facial paralysis. Pathologic examination revealed an ill-defined epithelial neoplasm exhibiting discohesive growth set within an extensively fibrotic stroma. Both perineural and intraneural invasion were present. E-cadherin and p120 immunostaining showed aberrant cytoplasmic expression. Targeted next-generation sequencing detected a frameshift mutation of the CTNNA1 gene as the only known pathogenic variant. The patient was treated with surgical resection, immunotherapy, and chemotherapy. Currently, he is alive with disease twenty months after disease onset.     

ASO Author Reflections: Reconsidering Resection for Patients with Poorly Differentiated Pancreatic Neuroendocrine Carcinoma

Annals of Surgical Oncology -     

Myoepithelial Carcinoma of the Breast with Focal Rhabdoid Features

Myoepithelial carcinoma of the breast is extremely rare and only 33 cases have been reported in the English literature. Herein, we report a case of myoepithelial carcinoma of the breast with focal rhabdoid features. The patient was a 67‐year‐old woman, who presented with a lump of the left breast that rapidly grew to 3 cm in diameter within 3 months. Lumpectomy revealed a solid and whitish colored tumor, which was composed mainly of elongated spindle‐shaped cells with mild atypia, focal necrosis, and infiltrative margin. In a small area of the lesion, ovoid tumor cells exhibited eccentric nuclei with centrally located nucleoli and plump cytoplasm including round eosinophilic inclusions, resembling a rhabdoid tumor. Immunohistochemically, both types of tumor cells exhibited a myoepithelial phenotype. MIB‐1 index was 30%. The cytoplasmic inclusion of the ovoid cells exhibited immunopositivity for both vimentin and cytokeratin. From these findings, this tumor was diagnosed as a myoepithelial carcinoma with focal rhabdoid features. Although rhabdoid features have been reported in some types of malignant and benign tumors, this is the first report of such features in myoepithelial carcinoma of the breast.     

Lobular Neoplasia of the Breast

Abstract: Lobular neoplasia is increasingly being detected, probably due to the widespread screening for breast malignancies. The understanding of lobular neoplasia is undergoing a paradigm shift, from being considered a predictor of recurrence to being considered a pre‐invasive lesion, based on molecular studies suggesting a clonal link with invasive lobular cancer. The management of patients diagnosed to have lobular neoplasia is in evolution, with the increasing need for risk stratification and hence the necessity to identify this entity separately as either lobular carcinoma in‐situ and atypical lobular hyperplasia. The indications for wide local excision for patients diagnosed to have lobular neoplasia on biopsy are being defined. The evidence for preventive strategies like hormonal treatment with Tamoxifen or aromatase inhibitors for high risk patients is increasing, with the results from prospective interventional trials. The role of screening magnetic resonance imaging for surveillance of high risk patients with lobular neoplasia is under evaluation.