A 55-year-old female patient presented with a 4-month history of a mass in the right breast. Physical examination revealed erythema, hyperemia and tenderness to the touch of the right breast. A palpable mass, hard in consistency and measuring about 15 cm, was present in the right superior and inferior lateral quadrants. Mammography showed a round, high-density mass with almost regular but partially irregular margins, measuring approximately 10 cm with calcifications suspicious of malignancy, and skin thickening (fig. ). Ultrasound examination of the right breast showed a solid, heterogeneous mass.
Craniocaudal mammogram showing a mass with calcifications (black arrows) and skin thickening (white arrows).
Ultrasound-guided core needle biopsy (CNB) of the mass was performed. Microscopic examination of the CNB showed extensive infiltration by a malignant epithelial-type neoplasm, consisting of solid nidi of atypical cells with ample clear cytoplasm, which had distinct and well-defined borders, was optically empty and ‘vegetaloid’ in appearance (fig. ), interspersed with small areas of respected mammary parenchyma and extensive areas of necrosis. The nuclei were small and round with hyperchromasia and moderate pleomorphism, and showed a moderate mitotic index. No areas of carcinoma in situ were observed.
Photomicrograph of the tumor (H&E; ×200). The tumor cells show ample clear cytoplasm with well-defined limits and a ‘vegetaloid’ appearance.
On histochemical examination, the neoplastic cells were intensely positive for periodic acid-Schiff (PAS) staining (fig. ), cytokeratin AE1/AE3, cytokeratin 7 and E-cadherin, and negative for PAS diastase, HER2, and estrogen and progesterone receptors. A total absence of basal cells was shown by staining with P-63. The histopathological diagnosis was GRCC-infiltrating ductal carcinoma.
Positive (PAS; ×400). PAS reactivity is strong.
The patient received neoadjuvant therapy consisting of epirubicin 75 mg/m2 and docetaxel 75 mg/m2 every 3 weeks for 3 cycles. The clinical response to the chemotherapy treatment was partial. Moreover, the patient presented with a skin ulcer in the area corresponding to the tumor. A modified radical mastectomy with axillary lymph node dissection was performed.
Macroscopic examination of the modified radical mastectomy specimen showed a skin ulcer, below which was a necrotic-looking tumor measuring 7 × 7 × 4 cm. Microscopic examination showed a neoplasm made up of solid nidi of atypical cells with clear cytoplasm and the same histopathological characteristics as described for the CNB. Inside the neoplasm we observed extensive areas of necrosis, as well as fibrosis, acute and chronic inflammatory reactions with the presence of spumous histiocytes, multinucleate giant cells and multiple foci of calcifications located in the midst of the necrotic areas (fig.
). The pathological diagnosis of GRCC carcinoma, established by CNB, was confirmed. The pathological tumor response after treatment (Miller and Payne system) [11
] was stage G2 with a discrete reduction in infiltrating tumor cellularity of less than 30% of the tumor mass. Twelve of the axillary lymph nodes removed were histologically tumor-free. Pathology revealed a T4N0M0 GRCC carcinoma.
Photomicrograph of the tumor (H&E; ×100). Abundant calcifications and inflammatory infiltrate with multinucleate giant cells in the midst of the tumor necrosis.
The patient was later submitted for chemotherapy (3 cycles of 75 mg/m2 epirubicin and docetaxel) followed by radiotherapy of the chest wall and lymph nodes within the axillary and supraclavicular regions (50 Gy). Diagnostic work-up (bone scintigraphy, thoracic, abdominal and pelvic CT scans) revealed no local or distant metastases. Fourteen months after surgery, the patient remains asymptomatic and disease-free.