Case Of The Month - October 2013

Case Of The Month - October 2013

Case of The Month

By Dr Jatin S. Gandhi


67 year female, known case of carcinoma breast 10 years back and now presenting with a skin nodule at the operative site which has been gradually increasing in size.



Trucut Biopsy : What is your diagnosis ?

  1. Invasive duct carcinoma, NOS type
  2. Stromal sarcoma of breast
  3. Secondary Angiosarcoma of breast
  4. Invasive lobular carcinoma-Pleomorphic variant



What is your diagnosis now ?

 




Final Diagnosis : Secondary Epithelioid Angiosarcoma Of Breast

Discussion :

A rare malignant tumor showing endothelial differentiation. Mammary angiosarcomas of the breast are categorized into primary and secondary. Primary angiosarcomas are rare but are second most common to mesencymal malignancy after malignant phyllodes tumor with an incidence of 0.05%. (Br J Cancer. 2004 Jul 19;91(2):237-41)

Secondary angiosarcomas of the breast have been diagnosed with increasing frequency since the late 1980’s reflecting the trend towards breast conserving surgery.(Ann Oncol. 2007 Dec;18(12):2030-6, Cancer. 2009 Sep 15;115(18):4055-63.

Mean latent interval following radiotherapy following surgery is 84 to 120 months.

  1. These patients are older than those with de-novo angiosarcomas, 60-80 years
  2. Size of these tumors range from 1-25cms , usually involves the skin

On FNAC large atypical cells were seen scattered singly and in small aggregates. In addition, few stromal fragments were also seen which showed increased cellularity with atypia.

  1. On small biopsy sheets of atypical cells with epithelioid features arranged focally in psuedoalveolar pattern was observed.On IHC (trucut biopsy)tumor cells expressed PAN-CK and were negative for CD34 and CD31

On excision specimen a tumor measuring 4.5 X 2.8 X 2.5 cm was seen which microscopically showed complex anastomosing and dissecting channels lined by atypical cells with vesicular nuclei and prominent nucleoli. Mitotic activity was readily observed. Few of the areas showed hyper chromatic nuclei.

  1. On IHC the tumor expressed CK, CD31(focally), thrombomodulin and D2-40. It was negative for CD34

Angiosarcomas of the breast are rare tumors with following differential :

  1. Metaplastic carcinoma of breast
  2. Psuedoangiomatous stromal hyperplasia
  3. Benign vascular proliferations

When these tumors strongly express CK on IHC, they become a great diagnostic challenge and an exisicion sample with extensive sampling needs to be done to demonstrate anastomosing vascular spaces containing RBC’s. The expression of CD31 could be heterogenous(as in this case) within the tumor hence the trucut biopsy can be a diagnostic pitfall. (WHO Classification of Tumours, Volume 4 IARC WHO Classification of Tumours,2012).

Pitfalls of FNAC and Trucut Biopsy and where extensive sampling is recommended

FNAC and core biopsy can be very challenging and certain types of lesions in core biopsies can be associated with pitfalls in diagnosis and may require complete excision and immunohistochemical work up for an accurate assessment. Such lesions could be the following:

  1. Fibroepithelial lesions and stromal tumors of breast
  2. Pseudoangiomatous stromal hyperplasia (PASH), Angiosarcomas
  3. Atypia:atypical ductal hyperplasia (ADH), lobular neoplasia, radiation atypia, flat epithelial atypia
  4. Papillary lesions, Mucinous lesions, Radial scar, complex sclerosing lesion, Microcalcifications not associated with a specific pathology
  5. Malignant processes that mimic benign lesion

 

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