Home Print this page Email this page Users Online: 989
Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 


 
 Table of Contents  
CASE REPORT
Year : 2014  |  Volume : 2  |  Issue : 2  |  Page : 113-116

Metaplastic breast carcinoma with osteogenic component


1 Department of Surgery, University of Dammam, Dammam, Saudi Arabia
2 Department of Radiology, University of Dammam, Dammam, Saudi Arabia
3 Department of Pathology, University of Dammam, Dammam, Saudi Arabia
4 Department of Medicine, University of Dammam, Dammam, Saudi Arabia

Date of Web Publication18-Jul-2014

Correspondence Address:
Maha SA Abdel Hadi
Department of Surgery, University of Dammam, P.O. Box 40293, Al Khobar 31952, Dammam
Saudi Arabia
Login to access the Email id

DOI: 10.4103/1658-631X.137008

Rights and Permissions
  Abstract 

Metaplastic breast carcinomas (MBC) are rare primary breast malignancies characterized by the co-existence of carcinoma with non-epithelial cellular elements. They can be classified as monophasic spindle cell (sarcomatoid) carcinoma, biphasic carcinosarcoma, adenocarcinoma with divergent stromal differentiation (osseous, chondroid and rarely rhabdoid) as well as adenosquamous and pure squamous cell carcinomas. Nearly all reports portrait women in their forties or older, yet younger affected females in their twenties have been reported. The usual presentation included firm painless breast mass ranging between 1.4 and 14 cm in diameter, with no evidence of loco-regional or distal metastasis. Mammary osteosarcomas are aggressive tumors with a propensity for blood-borne rather than lymphatic spread. Metastatic disease expected to develop at a mean of 10.5 and 14.5 months from the initial diagnosis and demise followed within 20 months of the onset of metastasis. MBC remains a rare entity with poor response to both chemo-radiotherapy, histological diagnosis is challenging yet it is the main stay in outlining the management. The surgical option remains the only successful current treatment in the form of simple Mastectomy to achieve negative margins sparing the patients axillary node dissection.

  Abstract in Arabic 

ملخص البحث:
يعتبر حدوث سرطان الثدي المتحول من سرطانات الثدي الأولية النادرة . ويتميز هذا النوع بمصاحبة السرطان ذي العناصر الخلوية غير الظهارية . ويمكن تصنيف هذه السرطانات إلى سرطان أحادي الطور ، ثنائي الطور ، سرطان غددي ، سرطان غددي حرشفي وسرطان الخلايا الحرشفية المحض. يصيب هذا المرض النساء في الأربعينات من أعمارهن وقد يحدث لمن هن أقل عمرًا . يتمثل الشكل المعتاد للمرض في كتلة قاسية وغير مؤلمة بالثدي يتراوح قطرها بين 4.1 - 41 سم دون انتشار للمرض . يتميز السرطان الثديي العظمي بأنه أكثر حدة ويميل إلى الانتشار عن طريق الدم وليس الجهاز اللمفاوي . يتوقع أن يحدث انتشار المرض خلال سنة من التشخيص الأولي . والخلاصة أن سرطان الثدي المنتشر يظل حالة نادرة نسبيًا ولا يستجيب عادة للعلاج الكيميائي الإشعاعي. يعتبر العلاج الجراحي بالاستئصال البسيط للثدي هو الانجح دون الحاجة لإزالة العقد اللمفاوية الابطية.

Keywords: Breast, osteogenic, sarcoma, carcinoma


How to cite this article:
Abdel Hadi MS, Al-Madi M, Wahba T, Ghallab K, Al-Amri AM. Metaplastic breast carcinoma with osteogenic component. Saudi J Med Med Sci 2014;2:113-6

How to cite this URL:
Abdel Hadi MS, Al-Madi M, Wahba T, Ghallab K, Al-Amri AM. Metaplastic breast carcinoma with osteogenic component. Saudi J Med Med Sci [serial online] 2014 [cited 2020 May 29];2:113-6. Available from: http://www.sjmms.net/text.asp?2014/2/2/113/137008


  Introduction Top


Metaplastic breast carcinoma (MBC) is a rare entity that creates perplexity in reaching the diagnosis. This is mainly attributed to the diverse types of tissues present with the lesion. [1]

Its accurate incidence is difficult to be determined despite the fact that it is a recognized entity since 1952. [2]

It is speculated that it may arise from both benign and malignant tissues due to an error in the makeup engineering, or maybe due to type 4 collagenase excreted by malignant cells and other proteases which degrade the basement membrane and break down the cellular matrix. [3]

Reaching the diagnosis in our patient was quite challenging that mandated extensive tissue analysis and reviews from many pathologists before the diagnosis was finalized.


  Case report Top


The present case report is about a 45-year-old pre-menopausal woman of African descent, residing in Saudi Arabia since 10 years, presented with painless left breast lump of 3 months duration with no associated local or systemic symptoms. She gave a history of 5 full term pregnancies with no family history of breast cancer. Systemic clinical examination was unremarkable. Local examination revealed a non-tender, smooth, well-defined, 10 cm × 7 cm mass occupying the central aspects of the left breast. Skin appeared thickened and edematous with evident peau' d orange. No palpable axillary nodes were detected [Figure 1].
Figure 1: The discrepancy in breast shape and size at the time of presentation

Click here to view


Appropriate imaging modalities in the form of ultrasound (US), mammogram and computerized tomography (CT) scan were utilized. Mammogram showed a large size with ill-defined breast mass occupying the left breast and distorting most the breast parenchyma sparing only a narrow rim of tissue at the medial aspect of the breast. It also demonstrates associated overlying skin and subcutaneous tissue thickening [Figure 2]. US showed areas of extensive necrosis, [Figure 3] however the CT scan image was instructive demonstrating the lesion localized to the left breast with no evidence of axillary node metastasis [Figure 4]. Tissue diagnosis with fine-needle aspiration cytology (FNAC) and core biopsy initially indicated a diagnosis of invasive ductal carcinoma with sarcomatoid changes. In view of the lesion size, Neo-adjuvant chemotherapy was administered, however, the patient developed paradoxical increase in size with each cycle of treatment. The tumor size increased by 40%. Her condition was further complicated by febrile Neutropenia rendering the chemotherapeutic treatment not the ideal choice for treating this patient. In view of the unfavorable response to chemotherapy, surgical intervention in the form of the modified radical mastectomy with wide local excision and skin grafting. Lymph node sampling was also performed due to the questionable initial invasive ductal carcinoma diagnosis [Figure 5].
Figure 2: Cranio-caudal view of the left breast in mam mographic examination revealed an ill defi ned large breast mass which is distorting and replacing the most of the breast parenchyma sparing a narrow area on the medial aspect of the breast

Click here to view
Figure 3: Sonographic examination of the left breast using 7.5 MHz transducer reveals a large heterogeneous mass lesion with areas of cystic necrosis replacing the whole of the breast namely the lateral and retroareolar regions of about 13 cm in diameter with invasion to the underlying muscles and the overlying skin

Click here to view
Figure 4: Coronal reconstruction computerized tomography of the chest post contrast study showing a large hypo dense left breast necrotic mass replacing and invading the breast parenchyma with irregular multilobulated mildly enhancing borders. Invasion of the underlying pectoralis major muscle, thickened overlying skin and subcutaneous tissue with marginal micro and macro-calcifi cations

Click here to view
Figure 5: Modifi ed radical mastectomy demonstrating total excision of the breast and infi ltrated muscle with gross safety margin

Click here to view


Patient had an uneventful post-operative course with no evidence of local reoccurrence or distance metastasis at 36 months follow-up.


  Discussion Top


MBCs are rare primary breast malignancies characterized by the co-existence of carcinoma with non-epithelial cellular elements. They can be classified as monophasic spindle cell (sarcomatoid) carcinoma, biphasic carcinosarcoma, adenocarcinoma with divergent stromal differentiation (osseous, chondroid and rarely rhabdoid) as well as adenosquamous and pure squamous cell carcinomas. [4]

It contains a mixture of malignant mesenchymal and epithelial elements, accounting for only about 0.02% of all breast cancers. It is an aggressive cancer and tends to present at a more advanced stage and has a high propensity for local recurrence. Occasionally, it is confused with primary osteogenic sarcoma which are extremely rare. However, the actual incidence of which is difficult to determine, because some of the approximately 100 previously-reported cases probably included metaplastic carcinomas, as well as osteogenic sarcomas arising in association with a biphasic tumour, such as phyllodes tumour or carcinosarcoma. [5]

Nearly all reports portrait women in their forties or older, yet younger affected females in their twenties have been reported. The usual presentation included firm painless breast mass ranging between 1.4 and 14 cm in diameter, with no evidence of loco-regional or distal metastasis. They are aggressive tumors with a propensity for blood-borne rather than lymphatic spread. Metastatic disease expected to develop at a mean of 10.5 and 14.5 months from the initial diagnosis and demise may follow within 20 months of the onset of metastasis. [6]

Clinical examination may reveal the presence of the mass but no distinct clinical characteristics are found to aid in the diagnosis. However, mammogram and US appearance may aid in confirming the clinical suspicion.

The mammographic findings is of a well-circumscribed, dense lesion with prominent calcifications within the mass. Targeted breast US usually confirms the presence of a well-defined mass, hypoechoic with an echogenic center, due to the existence of calcifications. [7]

FNAC remains an accepted and cost-effective tool to aid in the initial diagnosis. It has proved helpful in demonstrating the subset of malignant cells of mesenchymal origin accounting for 0.71%. [8]

Reaching the diagnosis can be tricky and sometimes impossible pre-excision. The presence of osteogenic components can only be proven when other chest wall lesions are excluded. Gross surgical findings and histo-pathology report usually confirm the diagnosis. [9]

The role of scintigraphy is recognized as an important tool in detecting soft tissue spread. [10]

The employment of Tc-99m methylene diphosphonate (MDP) scintimammography and a whole-body bone scan can aid in the diagnosis of osteogenic sarcoma by denoting tumor area of intense uptake. [11]

Combination chemotherapy and local radiotherapy have been proposed for treatment, yet, no distinct treatment strategy which has a proven beneficial impact in long-term survival. [12],[13]

In this current case, the patient has shown a paradoxical effect with chemotherapeutic agents with increase in both size and weight of the breast. This increased resistance to chemotherapeutic agents may be explained by the report from Japan suggesting that the elevated aldehyde dehydrogenase 1 (ALDH1) has been proposed as one of the possible candidates for a stem cell maker that can be used for the isolation of cancer stem cells from cancers such as leukemia and breast cancer. The presence of increased ALDH1 activity in populations of human sarcoma cell lines and sphere forming populations exhibit drug resistance properties. [14]

MBC is associated with poor prognostic indicators such as tumor size, number of mitoses, presence of stromal atypia, histological subtype and resection margin involvement. Increased, expression of epidermal growth factor receptor (HER1) provides an opportunity for targeted tumor therapy. [15]


  Conclusion Top


MBC remain a rare entity with poor response to chemo-radiotherapy. Histological diagnosis is challenging, yet, it is the main stay in outlining the management. Outcomes comparable to typical breast cancer cases can be achieved with routine aggressive multidisciplinary care.

 
  References Top

1.Jacob S, Japa D. Primary osteogenic sarcoma of the breast. Indian J Pathol Microbiol 2010;53:785-6.  Back to cited text no. 1
[PUBMED]  Medknow Journal  
2.Sun PY. Osteogenic sarcoma of the breast; review of literature and report of a case. Chin Med J 1952;70:47-53.  Back to cited text no. 2
[PUBMED]    
3.Kim WH, Kim CW, Noh DY, Kim YI. Differential pattern of perivascular type IV collagen deposits in phyllodes tumors of the breast. J Korean Med Sci 1992;7:360-3.  Back to cited text no. 3
    
4.Barnes PJ, Boutilier R, Chiasson D, Rayson D. Metaplastic breast carcinoma: Clinical-pathologic characteristics and HER2/neu expression. Breast Cancer Res Treat 2005;91:173-8.  Back to cited text no. 4
    
5.Dragoumis D, Bimpa K, Assimaki A, Tsiftsoglou A. Primary osteogenic sarcoma of the breast. Singapore Med J 2008;49:e315-7.  Back to cited text no. 5
    
6.Silver SA, Tavassoli FA. Primary osteogenic sarcoma of the breast: A clinicopathologic analysis of 50 cases. Am J Surg Pathol 1998;22:925-33.  Back to cited text no. 6
    
7.Vorobiof G, Hariparsad G, Freinkel W, Said H, Vorobiof DA. Primary osteosarcoma of the breast: A case report. Breast J 2003;9:231-3.  Back to cited text no. 7
    
8.Chhieng DC, Cangiarella JF, Waisman J, Fernandez G, Cohen JM. Fine-needle aspiration cytology of spindle cell lesions of the breast. Cancer 1999;87:359-71.  Back to cited text no. 8
    
9.Ogundiran TO, Ademola SA, Oluwatosin OM, Akang EE, Adebamowo CA. Primary osteogenic sarcoma of the breast. World J Surg Oncol 2006;4:90.  Back to cited text no. 9
    
10.Arrington ER, Eisenberg B, Orrison WW Jr, Williamson MR. Scintigraphic appearance of uncommon soft-tissue osteogenic sarcoma metastases. J Nucl Med 1990;31:679-81.  Back to cited text no. 10
    
11.Lee JK, Sun SS. Primary osteogenic sarcoma of the breast demonstrated by Tc-99m MDP scintigraphy. Clin Nucl Med 1998;23:619.  Back to cited text no. 11
    
12.Allan CJ, Soule EH. Osteogenic sarcoma of the somatic soft tissues. Clinicopathologic study of 26 cases and review of literature. Cancer 1971;27:1121-33.  Back to cited text no. 12
[PUBMED]    
13.Brustugun OT, Reed W, Poulsen JP, Bruland OS. Primary osteosarcoma of the breast. Acta Oncol 2005;44:767-70.  Back to cited text no. 13
    
14.Honoki K, Fujii H, Kubo A, Kido A, Mori T, Tanaka Y, et al. Possible involvement of stem-like populations with elevated ALDH1 in sarcomas for chemotherapeutic drug resistance. Oncol Rep 2010;24:501-5.  Back to cited text no. 14
    
15.Beatty JD, Atwood M, Tickman R, Reiner M. Metaplastic breast cancer: Clinical significance. Am J Surg 2006;191:657-64.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
   Abstract
  Introduction
  Case report
  Discussion
  Conclusion
   References
   Article Figures

 Article Access Statistics
    Viewed2507    
    Printed65    
    Emailed0    
    PDF Downloaded296    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]