A seventy one year old Caucasian female presented to the breast clinic with a painless growth on her right nipple of six weeks duration. She gave no history of itchiness, discharge or bleeding from the growth. She was otherwise asymptomatic regarding her breasts.
She had previously had no breast problems and had no family history of breast or ovarian carcinoma. She was nulliparous and a teetotaller.
The only medical history of note was severe osteoarthritis of her joints including her shoulder joints.
Clinical findings were threefold.
She had a polypoid hemispherical growth on her right nipple measuring 40 by 25 mm. This appeared extremely vascular with a necrotic slough covered surface (Figures &).
Apocrine carcinoma of the nipple Image 1.
Apocrine carcinoma of the nipple Image 2.
She was also found to have a clinically suspicious firm lump measuring 25 by 25 mm in the lower outer quadrant at 8 o'clock position of her right breast 5 cm from the nipple.
There were no palpable masses in her left breast nor palpable lymph nodes in her right axilla. In her left axilla was an enlarged firm lymph node 20 by 20 mm clinically equivocal.
She had bilateral mammography, ultrasound scan of the lower outer quadrant of her right breast and both axilla. Right breast mammography showed a 30 mm radiologically malignant lesion in the lower outer quadrant of her right breast. The left breast showed no suspicious features. Ultrasound scan of the right axilla was normal. Ultrasound scan of her left axilla showed an enlarged lymph node with poor corticomedullary differentiation; radiologically indeterminate.
She had a clinical trucut biopsy of the lump in her right breast and an ultrasound guided trucut biopsy of the indeterminate lymph node in her left axilla. Trucut biopsy of the lump in the right breast lower outer quadrant showed ductal carcinoma in situ. Trucut biopsy of the radiologically indeterminate lymph node in her left axilla showed reactive changes only.
She went on to have right mastectomy with axillary node sampling in the form of sentinel node biopsy.
The lump in in the lower outer quadrant of the breast was found to be predominantly ductal carcinoma in situ of intermediate and high grade of cribriform and apocrine type. Associated with the ductal carcinoma in situ were two small areas of invasive adenocarcinoma. These were grade 3 carcinomas with no lymphovascular invasion, negative oestrogen receptors and Her 2 status negative.
The proximal ducts approaching the nipple were unremarkable. The nipple was entirely replaced by the polypoid lesion. There was too much cytological atypia to consider this as a nipple adenoma. Purely on the basis of cytology and architecture, the appearances were suggestive of ductal carcinoma in situ. There was no evidence of an invasive lesion in this area. The typical features of Paget's disease of the nipple (intra epithelial tumour cells) were not seen. Further immunohistochemistry was performed on the nipple lesion. The tumour cells were negative for oestrogen receptors. Only an occasional smooth muscle cell was demonstrable within the lesion. The appearances therefore argued against a primary lesion of breast epithelium and suggested instead a skin adnexal tumour i.e. apocrine carcinoma.
Two lymph nodes were sampled which were free of tumour.