Microglandular Adenosis

Microglandular adenosis (MGA) of the breast is a very rare and benign proliferative lesion. Most patients complain of a palpable breast mass that may arouse a clinical suspicion of breast cancer. Histopathologically, it is hard to distinguish MGA from breast cancer because of the lack of a myoepithelial layer and infiltrative proliferation. Several studies have reported a strong relationship between MGA and carcinoma arising in MGA, so the mass should be excised completely in cases of MGA determined from a core needle biopsy rather than observation. A 72-years-old woman presented with a palpable breast mass. On physical examination, a mass was palpable in the right upper outer quadrant area and somewhat fixed to the surrounding tissues and pectoralis major muscle. We could not detect any mass or dense lesion on mammography because of a grade 4 dense breast. Ultrasonographic findings revealed a low echoic lesion with indistinct margins. The result of a core needle biopsy was MGA, which was confirmed by excision. We report one case of MGA, which was believed to breast cancer clinically.     

Metaplastic breast carcinoma with extensive osseous differentiation: a report of two cases and review of the literature

Invasive breast cancer with osseous metaplasia is rare. Here we report two cases of metaplastic breast carcinoma with extensive osseous differentiation. Case 1: The patient was a 60-year-old woman with a right breast tumor, about 4 cm in diameter. Mammogram and ultrasound presented an irregular-shaped mass suspected for malignancy. Core needle biopsy confirmed invasive carcinoma and the patient underwent a modified radical mastectomy. Case 2: The patient was a 48-year-old woman with a left breast tumor, about 3 cm in diameter. Mammogram demonstrated a well-circumscribed mass with extensive dense calcifications. Frozen section biopsy confirmed invasive carcinoma and a modified radical mastectomy was performed. The two patients had no metastatic carcinoma in the axillary lymph nodes and remained free of recurrence and systemic metastases in a 13- and 4-month follow-up period, respectively. Histopathologically, patient 1 had an adenocarcinoma with prominent sarcomatous (osteosarcomatous) differentiation with intervening spindle cells. The sarcomatous areas showed high nuclear atypia, pleomorphism and a high Ki-67 index. In Case 2, the neoplasm consisted of invasive ductal carcinoma of no special type with an osseous metaplasia component and showed a direct transition from the carcinoma to the osseous elements. The distinction between the different types of metaplastic carcinomas, specifically the distinction between benign and malignant metaplastic (osteoid) elements, should be taken into consideration.     

Two cases of breast cancer markedly responded to neoadjuvant chemoendocrine therapy (2 cycles of CMF and tamoxifen, pCR and near pCR)

Case 1 is a 38-year-old woman with a 6 cm tumor in her right breast. After incisional biopsy she received 2 cycles of CMF and tamoxifen in order to effect down staging. The tumor markedly decreased in size. She next underwent breast conserving surgery. Histopathologically, malignant cells completely disappeared (pCR). Case 2 is a 34-year-old woman with a 5.5 cm tumor in her left breast. After incisional biopsy she received the same regimen as in case 1. The tumor diminished significantly in size, and she underwent breast conserving surgery. Histopathologically, only a few fragments of degenerated tumor cells remained. Case 1 was hormone receptor positive, while case 2 was negative. The remarkable responsiveness (pCR and near pCR) to 2 cycles of CMF combined with tamoxifen was interesting. From these results we conclude that the CMF regimen is an useful neoadjuvant chemotherapy alternative to avoid alopecia and GI tract side effects.     

Invasive ductal carcinoma within a fibroadenoma of the breast

A rare case of invasive ductal carcinoma within a fibroadenoma of the breast in a 42-year-old woman is reported. The patient had a well-defined mass, measuring 6.0 × 5.0cm, in the upper lateral quadrant of the left breast. Physical examination suggested fibroadenoma. Ultraso-nography and mammography revealed some malignant findings. Needle biopsy demonstrated fibroadenoma. Frozen section revealed invasive ductal carcinoma, scirrhous type, arising in a fibroadenoma; muscle-preserving mastectomy was performed. Only 16 cases of carcinoma within a fibroadenoma of the breast have been reported in the literature in Japan. Carcinoma in a fibroadenoma should be treated on the basis of the therapeutic criteria for ordinary carcinoma.     

Breast Cancer Arising Adjacent to an Involuting Fibroadenoma: Serial Changes in Radiologic Features

Fibroadenoma is a common benign breast lesion and its malignant transformation is rare. There have been several case reports and studies that retrospectively reviewed breast cancers that arose within fibroadenomas; however, none of these studies reported serial changes in radiologic features of the cancer, including findings from mammography and ultrasound (US). We report a case of breast cancer arising adjacent to an involuting fibro adenoma in a 39-year-old woman who was undergoing serial follow-up after her fibroadenoma was diagnosed. Seven years after her diagnosis, the lesion showed evidence of coarse calcifications, a typical sign of involution. Four years later, US revealed a newly developed hypoechoic lesion with irregular margins and peripherally located calcifications adjacent to the fibroadenoma. A core biopsy was performed, and histopathological examination resulted in a diagnosis of invasive ductal carcinoma. When new suspicious features are observed in a fibroadenoma, radiologists should raise the concern for breast cancer and proceed with diagnosis and treatment accordingly.     

Two case of breast cancer with cartilaginous and osseous metaplasia

Invasive breast cancer (IBC) with cartilaginous or osseous metaplasia is rare. Here we report two cases of this unusual variation. Case 1: The patient was a 33-year-old woman with a right breast tumor, 2.2 cm in size. Mammograms (MMG) presented no specific findings, but ultrasound (US) showed a cystic-like lesion. Excisional biopsy confirmed IBC with cartilaginous and osseous metaplasia. Biopsy was followed with a modified radical mastectomy. One lymph node was positive, and both estrogen receptor (ER) and progesterone receptor (PgR) were negative. Case 2: The patient was a 43-year-old woman with a left breast tumor, 4.2 cm in size. MMGs presented no findings but US showed an irregular shaped, low-echoic area, suggesting malignancy. Core needle biopsy confirmed IBC with cartilaginous metaplasia. A total adenectomy and lymph node dissection with breast reconstruction using a lattisimus dorsi muscle flap were performed. Two of 18 lymph nodes were positive for metastasis and both ER and PgR were negative. IBC with cartilaginous or osseus metaplasia seem to be divided into two types pathologically, with or without intervening spindle cells, which is related to the prognosis. Matrix producing carcinoma (MPC) has no intervening spindle cells and a better prognosis than other types, however, MPC has been reported to have the same prognosis as ordinary breast cancer after for adjusting its stage. Our two cases were MPC's and no recurrence has been detected 5 and 3 years from the initial therapy, respectively.     

A case of non-palpating breast cancer with huge lymph node metastasis

We report a case of non-palpating breast cancer with huge lymph node metastasis. The patient was a 58-year-old woman who had a huge tumor at her right armpit. The tumor was 4 cm in diameter. Aspiration biopsy cytology for the tumor was performed. The diagnosis is Class V. Mammography showed an ill-defined mass at her right breast. Ultrasonography revealed a low echoic mass at the C area of her right breast. A core needle biopsy for the breast tumor led to a diagnosis of an invasive ductal carcinoma positive for estrogen receptor and progesterone receptor, and negative for HER2/neu protein expression. She received 4 cycles of CEF (E: 60 mg/tri-weekly) plus 12 cycles of paclitaxe (l80 mg/weekly). After chemotherapy, she received muscle preserving mastectomy plus axillary lymph nodes dissection. In histopathology, there were no carcinoma cells in resected breast tissue and resected lymph nodes. Therefore, the effect of chemotherapy was diagnosed as a pathological complete response. After operation, she was administered aromatase inhibitor. The patient has been well and remained disease-free during a follow-up period of 6 years.     

Case reports of malignant mucocele-like lesions

Mucocele-like lesions (MLL) of the breast have been reported as extremely rare as well as benign, but now it is believed they can be both malignant and benign. This paper describes two cases of malignant MLL, both subjected to immunohistochemical staining. Case 1: A 42-year-old woman with multiple malignant MLLs without evidence of a mass at presentation to our hospital after biopsy, but whose ultrasonogram showed small multiple hypoechoic lesions. Case 2: A 70-year-old woman, whose left breast cancer was found on routine mammography after modified radical mastectomy for right breast cancer. Pathologically, MLL with intraductal carcinoma was diagnosed. Case 1 underwent two lumpectomies in 3 years, but even now new lesions have developed. However, the patient refused to have another operation. C-erbB2 was negative in both cases. When malignant MLL is histologically of low grade, excisional biopsy is sufficient for a single MLL with intraductal carcinoma, while it may be necessary to perform a subcutaneous mastectomy for multiple lesions.     

Two cases of occult breast cancer in which PET-CT was helpful in identifying primary tumors

We report two cases of occult breast cancer in which masses were completely nonpalpable and positron emission tomography-computed tomography (PET-CT) was extremely helpful in identifying the primary tumor. Case 1 involved a 56-year-old woman with enlarged lymph nodes 3 cm in size in the axilla. Based on excisional biopsy, axillary lymph node metastasis of breast cancer was suspected but an obvious primary tumor in the breast was not identifiable on mammography, contrast-enhanced CT, or ultrasonography. Faint accumulation of fluorodeoxyglucose (FDG) was noted only on PET-CT, so the site was considered to be the primary site, and operation was performed. As a result of postoperative pathological examination, ductal carcinoma in-situ (DCIS) was diagnosed. Case 2 involved a 55-year-old woman with enlarged lymph nodes 3 cm in size in the axilla. Based on the excisional biopsy, axillary lymph node metastasis of breast cancer was suspected. In this case as well, an obvious primary tumor was not identifiable with palpation or mammography. On PET-CT, faint accumulation of FDG was noted in the vicinity of the CD regions, or upper and lower outer quadrants. When contrast-enhanced CT and ultrasonography were performed, a faint nodular opacity less than 1 cm in size corresponding to this site was found and diagnosed as the primary site, operation was subsequently performed. Pathologic diagnosis indicated invasive cancer. PET-CT is a helpful option for the diagnosis of occult breast cancer with primary sites that conventional imaging studies have difficulty identifying.     

Primary infiltrating ductal carcinoma arising in aberrant breast tissue of the axilla: a rare entity. Report of a case

A 52-year-old woman presented with a palpable nodule in the right axilla. Physical examination revealed a 2.5 x 2.5 cm, nontender, firm, brownish, and peripherally hyperemic mass with overlying skin retraction on the right anterior axillary fold. Bilateral mammogram was negative. Ultrasonography of the right axillary region showed a 1.8 x 1.1 cm, poorly defined hypoechoic mass with irregular margins and posterior acoustic shadowing. Fine-needle aspiration biopsy of the mass revealed malignant epithelial cells. The patient underwent a wide local excision of the right axillary lesion with en bloc axillary lymph node dissection. Histopathological examination revealed an infiltrating ductal carcinoma. Here we report this case of carcinoma originating from aberrant breast tissue in the axilla. It is suggested that subcutaneous lesions of uncertain origin around the periphery of the breast should be suspected for breast carcinoma and treated appropriately.     

Primary squamous cell carcinoma of the breast during lactation: a case report

A case of primary squamous cell carcinoma of the breast during lactation is reported. The patient was a 32-year-old woman, in post-partum lactating 18 months after delivery, who was referred to our hospital following detection of a lump in her left breast during physical examination in mass screening for breast cancer. The tumor, palpated in the upper outer quadrant of the left breast, was firm, well-defined and 2.8 x 2.6 cm in size. Ultrasonograms identified an irregular-shaped hypoechoic lesion and mammograms revealed a well-defined, circumscribed tumor. Based on these findings, breast cancer was suspected and an excisional biopsy was performed. The resected specimen was a firm, solid and circumscribed tumor with central hemorrhage. Microscopic findings demonstrated that the tumor consisted of an invasive ductal carcinoma with marked squamous metaplasia, such as keratinization and squamo-columnar junction. Breast-conserving surgery was performed and no lymph node involvement was noted. Both estrogen and progesterone receptors of the tumor were negative. Generally, the size of both squamous cell carcinoma and carcinoma during the lactation period tends to be larger than ordinary carcinomas. In this case, the cancerous lesion was detected at a relatively early stage. Although the cancerous lesion was detected at a relatively early stage and no lymph node involvement was noted, lung metastases occurred within 12 months of the surgery. Malignant potential is generally considered to be high in cases of squamous cell carcinoma of the breast with lactation and thus intensive treatment potentially resulting in severe side effects was considered to be necessary for this patient.     

Local control of advanced breast cancer with mohs'paste

We report two cases of primary advanced breast cancer that was locally controlled by using Mohs'paste. CASE 1: A 70- year-old woman was suffering massive exudates and offensive smell from her right giant breast tumor. Histopathological examination showed an invasive ductal carcinoma. However, she didn't have distant metastases. The patient received chemotherapy and the breast tumor has been fixed using Mohs'paste, and dissected. The giant tumor became flat and dry, so we could perform a radical operation. Then, she had contra-lateral axillary lymph node metastases. We performed a resection of left axillary lymph node and radiation therapy. After two years, we have not found a new lesion. CASE 2: A 54-year- old woman with right local advanced breast cancer discharged massive exudates and oozed blood. Histopathologically, she had an invasive ductal carcinoma. Moreover, she had lung and contra-lateral axillary lymph node metastases. She received chemotherapy and the breast tumor has been fixed using Mohs'paste, and dissected. The bleeding and exudates stopped almost completely, and the breast tumor became flat and dry. Both patients had experienced a mild pain, but their QOL improved remarkably. It is suggested that the patient with local advanced breast cancer may be controlled by using Mohs' paste.     

A case of intracystic papillary carcinoma accompanying widespread ductal carcinomain situ

A 39-year-old Japanese woman noticed a right breast tumor in July 2004. Mammography (MMG) demonstrated an oval tumor without calcification. Dynamic Magnetic Resonance Imaging (D-MRI) demonstrated a high-intensity mass on T2-weighted images, showing mild enhancement during the arterial phase and persistent enhancement during the arterial late phase. Core needle biopsy revealed papillary carcinoma suggestive of Intracystic Papillary Carcinoma (IPC). Auchincloss operation was performed following a partial mastectomy, as the surgical margin after partial mastectomy was positive for carcinoma. Histopathologic mapping of her right breast revealed wide and extensive intraductal spread of DCIS around the IPC. IPC was originally reported to be a localized non-invasive mammary carcinoma. But approximately, half of IPC cases are associated with invasive carcinoma or DCIS beyond the tumor. Careful selection of operative procedure is needed after localized non-invasive IPC or IPC associated with DCIS around the main tumor or invasive carcinoma is diagnosed.     

Ductal Carcinomain-situ of the breast detected by [F-18] fluorodeoxyglucose positron emission tomography

A 48-year-old Japanese woman underwent [F-18] fluorodeoxyglucose positron emission tomography (FDG-PET) as part of her medical examination. A small hot spot was detected in her right breast. Quadrantectomy with sentinel lymph node (SN) biopsy using an endoscope was performed, and ductal carcinoma in-situ of the breast was diagnosed. The tumor size was 0.9 cm in its greatest diameter, and there were no cancer cells detected in the SN on frozen hematoxylin-eosin staining and cytokeratin immunohistochemical staining. We reported this rare case of ductal carcinoma in-situ detected by FDG-PET as past of a medical checkup.     

A case of multicentric breast cancer in which an effect of neoadjuvant chemotherapy had a disparity

A 61-year-old woman was visited our hospital for a left breast tumor. Ultrasonography (US) demonstrated two tumors comprising a tumor 3.3 cm in diameter in the A area and another one 0.9 cm in diameter in the C area of the left breast, and US-guided core needle biopsy (CNB) was performed. The histological findings showed invasive ductal carcinoma, ER (+)/PR (-)/HER2 (+) in the A lesion and ER (+)/PR (+)/HER2 (-) in the C lesion. At this point in time, US demonstrated a new tumor 1.9 cm in diameter in the outside C area of the left breast, and CNB was performed. The histological findings showed invasive ductal carcinoma, ER (+)/PR (+)/HER2 (-) in the outside C lesion. Chemotherapy was estimated as PD, and an operation was performed (Bt + Ax). Histopathological examination showed pCR in the A lesion, invasive lobular carcinoma in the C lesion and solid-tubular carcinoma in the outside C new lesion. Depend on each subtype, HER2/new targeting trastuzumab therapy, radiation therapy and ER/PR targeting hormone therapy were tried as a post operative treatment.     

A long-term survival case of progressive breast cancer detected in gastric metastasis

A 51-year-old postmenopausal woman was diagnosed as having adenocarcinoma (gastric cancer type 4) from gastric biopsy by upper endoscopy. Her chief complaint was abdominal dilatation. Meanwhile, a breast CT suggested tumor in her left breast and was diagnosed as an invasive lobular carcinoma based on a core needle biopsy. After gastric biopsy, tissues are stained by ER and PgR in immunohistochemistry. The diagnosis was modified from gastric cancer to T2N1M1, stage IV left breast cancer, accompanied by a treatment. Chemotherapy with EC 6 course consisted of a weekly PTX 4 course (epirubicin, cyclophosphamide-weekly paclitaxel) was performed. After the chemotherapy, breast mass, ascites and tumor marker were dramatically improved. Then hormonal therapy was administered. She passed away 2 and 1/2 years after her first visit to the hospital. Metastatic gastric tumors simulating type 4 advanced gastric cancer (MGTS type 4) and invasive lobular carcinoma are known to have an unfavorable prognosis. There is no doubt, however, that the multidisciplinary treatments have brought a satisfaction to her and family. We should keep in mind a possibility of gastric metastasis of breast cancer, when consulting a female patient with gastric cancer type 4.     

A case of primary breast cancer who responded remarkably to the neoadjuvant chemotherapy with the combination of docetaxel and cyclophosphamide

A 67-year-old woman visited our hospital with suspicion of right breast cancer. She underwent core needle biopsy, and her disease was diagnosed as breast cancer (invasive ductal carcinoma, ER- and PgR- positive, HER2-negative). We chose neoadjuvant chemotherapy, because the tumor size was over 3 cm in diameter and she wished to conserve her breast. She was elderly, and so without anthracycline base, we used a combination of docetaxel (75 mg/m(2)) and cyclophosphamide (600 mg/m(2)) q3w 6 cycles followed by breast-conserving therapy. During treatment, the patient remained very well and showed no major side effects except grade 4 neutropenia on an outpatient basis. After 6 cycles, ultrasonography and mammography indicated the residual tumor, but breast MRI did not detect any tumor. Pathological examination showed absence of invasive tumor or only focal residual tumor cells (QpCR). We concluded that the combination of docetaxel and cyclophosphamide was a good option for neoadjuvant chemotherapy for early breast cancer.     

Two cases of recurrent breast cancer with regional lymph node metastases showing a complete response to trastuzumab and paclitaxel treatment

We report two cases of recurrent breast cancer with regional lymph node metastases that responded completely to treatment with trastuzumab and paclitaxel. Case 1: A 52-year-old woman, who presented with left breast cancer, underwent mastectomy and axillary lymph node dissection in July 2002. Pathological findings were as follows: invasive ductal carcinoma (scirrhous type), 2.2 cm in size, histological grade 3, positive invasion to the lymphatic and blood vessels, negative nodal status (0/11), negative ER/PgR status, and overexpression of HER 2/neu. Left axillary lymph node metastasis was noted after five months, ie, in December 2002. Four cycles of chemotherapy with doxorubicin and cyclophosphamide were administered from January 2003; however, they were not effective. The patient showed a complete response after three months of chemotherapy with trastuzumab and paclitaxel. This treatment was stopped in September 2003. She has maintained a complete response for two and a half years and was not administered any further treatment as of February 2006. Case 2: A 59-year-old woman, who presented with right breast cancer, underwent mastectomy and axillary lymph node dissection in May 2002. Pathological findings were as follows: invasive ductal carcinoma (scirrhous type), 1.8 cm in size, histological grade 2, positive invasion to the lymphatic and blood vessels, negative nodal status (0/5), positive ER and uncertain PgR status, and overexpression of HER 2/neu. She had received adjuvant hormonal therapy with tamoxifen; however, a right supraclavicular lymph node metastasis was noted in October 2004. Treatment with exemestane was not effective. However, a complete response was observed with trastuzumab and paclitaxel for four months. She has maintained a complete response for six months and was not administered any further treatment as of February 2006.     

A case of ectopic breast cancer with a literature review

A 63-year-old woman was referred to our hospital because of a right axillary nodule in 2004. Physical examination showed a spherical nodule measuring 0.5 cm in diameter in the right axilla. No mass was palpable in either breast. Mammograms were normal. Ultrasonography revealed a subcutaneous hypoechoic mass 0.7 mm in maximum diameter in the right axilla. The patient underwent an excisional biopsy. Histological examination revealed an invasive ductal carcinoma (scirrhous carcinoma) in ectopic breast tissue. The patient subsequently underwent a wide local excision of the tissue surrounding the biopsy scar, with axillary lymph node dissection. Histologically, no residual tumor or nodal metastasis was found. Postoperatively, she received endocrine therapy and remains well, without any evidence of recurrence 4 years 10 months after operation. Cancer of the ectopic breast tissue is rare, and most cases present as a solitary axillary mass. Long-term outcomes remain unclear. We present a case of breast carcinoma in the axillary ectopic mammary gland and summarize the clinical features of 94 cases, including ours, in Japan. We also compare long-term survival between ectopic breast cancer and usual breast cancer according to TNM T stage and lymph node metastasis.     

Invasive ductal carcinoma of the nipple: A case report

We report a very rare case of breast carcinoma which possibly arose from the duct of the nipple and formed a nipple mass. A 71-year-old woman presented with an elastically hard and enlarged right nipple, 3.5x 2.8 cm in size. Mammograms and ultrasonograms suggested a benign tumor of the nipple, but histological examination revealed invasive ductal carcinoma. No Paget's cells were found in the epidermis. Modified radical mastectomy was performed. Both estrogen and progesterone receptors were positive. One of the nine axillary nodes dissected had metastatic foci. To our knowledge, this case is only the second reported case of invasive ductal carcinoma originating from the nipple. Differential diagnosis and histogenesis are discussed.