Journal of Cytology
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ORIGINAL ARTICLE  
Year : 2011  |  Volume : 28  |  Issue : 4  |  Page : 196-199
A cytomorphological study of secretions in breast cancer


Department of Pathology, University College of Medical Sciences and GTB Hospital, Delhi, India

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Date of Web Publication20-Oct-2011
 

   Abstract 

Background: Secretions are seen in a range of breast cancer that includes invasive ductal carcinoma, mucinous carcinoma and secretory carcinoma. Evaluation of the quantity and location of secretions and the contours of the cell clusters complement cell morphology could improve diagnostic cytopathological criteria.
Aim: To identify the range of breast carcinomas with secretions on fine-needle aspiration.
Materials and Methods: A retrospective study of 160 patients with breast carcinoma was carried out. The tumors were typed by evaluating the quantity and location of secretions, cellularity and nuclear grade.
Results: Secretions were seen in 16 of 160 breast carcinomas. Eleven were invasive ductal carcinoma (IDC), three were mucinous and two were secretory carcinomas. In IDC, minimal intracytoplasmic secretions were seen in 10, nuclear grades of 2 and 3 in 9, cell clusters with irregular margins in 6, and necrosis in 4. All mucinous and secretory carcinomas were nuclear grade 1. Extensive extracellular secretions and cell clusters with rounded contours were seen in mucinous carcinomas. In secretory carcinomas, the secretions were predominantly intracellular; stringy vasculature was a unique feature.
Conclusion: Secretions in breast cancer are seen in a range of lesions that include IDC, mucinous, and secretory carcinomas. The quantity and location of secretions in breast cancer offer clues to differentiating these.

Keywords: Breast cancer; fine needle aspiration; secretion

How to cite this article:
Bhatia A, Malhotra G, Grover P, Singh N. A cytomorphological study of secretions in breast cancer. J Cytol 2011;28:196-9

How to cite this URL:
Bhatia A, Malhotra G, Grover P, Singh N. A cytomorphological study of secretions in breast cancer. J Cytol [serial online] 2011 [cited 2014 Jul 24];28:196-9. Available from: http://www.jcytol.org/text.asp?2011/28/4/196/86347



   Introduction Top


The secretory function of the breast becomes apparent with the appearance of secretions in the epithelial cells during the third trimester of pregnancy. Expectedly, therefore, secretions are observed in some lesions of the breast, including carcinomas, which may show intracellular­ [1],[2] or extracellular secretions. [3],[4]

Secretions are seen in mucinous and secretory carcinomas, [1],[2],[3],[4] which are distinct cytomorphological entities. Invasive ductal carcinoma (IDC) and lobular carcinoma can also exhibit secretions. [5]

Mucinous and secretory carcinomas of the breast are uncommon compared to the IDC and lobular variants, but need to be recognized because of their better prognosis and low rate of lymph-node metastasis. [2],[3]

The objective of this study was to a) identify the range of lesions that yielded intracellular and extracellular secretions and b) attempt to distinguish lesions with secretions by evaluating quantity and location of secretions in relation to morphology of the malignant cells on fine-needle aspiration cytology (FNAC).


   Materials and Methods Top


In this retrospective study, cytology smears from 160 patients with diagnoses of carcinoma of the breast over a 2-year period were reviewed. Both May-Grόnwald-Giemsa (MGG) and Papanicolaou stained smears were available. Secretions were assessed on MGG stained smears and nuclear grade was assessed on Papanicolaou. Cases with intracellular and/or extracellular secretion were subclassified into IDC, mucinous carcinoma, and secretory carcinoma by the existing criteria. [1],[2],[3] Cellularity, location and extent of secretion, and nuclear grade [6] (nuclear size, nucleoli, chromatin pattern and nuclear membrane)were documented. The amount of intracellular and/or extracellular secretion was quantified as minimal (less than 10%), moderate (up to 50%), or extensive (more than 50%) of the material present on each slide. Presence and absence of necrosis was also noted.


   Results Top


All 160 patients were females, with age ranging from 25 to 61 years (median 49 years). The lumps varied from 1 to 4 cm in size. Multiple aspirates had been performed in tumors larger than 2 cm. All tumors were unilateral and solitary. Secretions were seen in 16 tumors of three tumor types: IDC (11), mucinous carcinoma (3), and secretory carcinoma (2).

IDC yielded cellular aspirates (10/11). Predominantly dispersed cells of nuclear grade 2 and 3 were also present in this group. Secretions were minimal and intracellular in the majority (10/11) [Figure 1]. Two patients had extracellular secretions: In one patient, these were minimal and associated with intracellular secretions and in the other, only extracellular secretions in moderate quantity were present [Table 1]. Both these cases were identified as IDC because of their nuclear grade and presence of cell clusters that had irregular margins [Figure 2]. Necrosis was present only in IDC.
Table 1: Comparative cytomorphology of invasive ductal, mucinous and secretory carcinomas of the breast


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Figure 1: IDC: Minimal intracellular secretions (MGG, ×400)

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Figure 2: IDC: Extracellular secretions and cell clusters with irregular margins (MGG, ×200)

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Mucinous carcinomas had abundant, mucoid aspirates. Extensive extracellular secretion predominated. Small cell clusters with rounded contours [Figure 3], single cells, signet cells, and thin-walled "chicken-wire" vascular channels were seen floating in the secretions. Nuclear grade was 1.
Figure 3: Mucinous carcinoma: Extracellular secretion with floating, rounded contoured cell fragments (MGG, ×100)

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Secretory carcinoma had abundant, cellular aspirates of nuclear grade 1. Cells were predominantly in loosely cohesive clusters and some papillary fragments. Small clusters and single polygonal cells appeared strung on capillaries [Figure 4]. Cytoplasm was abundant, foamy or granular, with extensive secretory vacuoles. Signet cells and minimal extracellular mucoid material associated with grape-like mucous globular structures were also present.
Figure 4: Secretory carcinoma: Single and small clusters strung on a capillary (MGG, ×100)

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   Discussion Top


Mucinous and secretory carcinomas of the breast are uncommon and indolent tumors. [7],[8],[9],[10] A conservative surgical approach for treatment is advocated because of their better prognosis. Morphological identification on FNAC is an important step in the workup.

In this study, we quantified the secretions in aspirates from breast carcinomas on a 3-point scale as minimal, moderate and extensive. Both mucinous and secretory carcinomas had extensive secretions. As noted by others, while these were extracellular in mucinous carcinomas, [1],[2],[9],[10] secretory carcinomas were characterized by predominantly intracellular secretions. [3],[4] Thus, quantifying the secretions and characterizing their location appears to be useful in separating these two lesions.

Extracellular secretions have been described in mucinous carcinoma and some IDC. [2] Mucinous carcinoma is characterized by poorly cellular, abundant mucoid aspirate, extensive extracellular secretion, thin-walled vessels and few single and small clusters of cells floating in the secretions. [1],[2],[11],[12],[13],[14] We observed that the cell clusters comprised uniform cells with rounded contours reminiscent of those seen in tissue sections. Conversely, IDC with extracellular secretions, often mistaken for mucinous carcinoma, [2] showed at least some cell clusters with irregular margins as in conventional IDC. Besides, the secretions in IDC were minimal to moderate compared to extensive in mucinous carcinoma. High nuclear grade in IDC with extracellular mucin has been used to differentiate mixed IDC and mucinous carcinoma. [2] We propose that a careful search for the characteristic irregular margins of cell clusters is necessary and should be used as an additional distinguishing feature of IDC.

Mucocoele-like tumors need to be distinguished from mucinous carcinoma; however, being benign lesions, these are outside the scope of this study. In the literature, they are described as being characterized by an abundance of mucin and poor cellularity; the cells are present as monolayered sheets of epithelial cells. [1],[10]

Intracellular secretions have been described in secretory carcinoma, [3],[15],[16],[17] lobular carcinoma [5],[18] and some IDC. Though the morphological features on histopathology suggest that the secretions in secretory carcinoma are extensive in both extracellular and intracellular locations, [7],[16] in cytopathology smears there are predominantly intracellular secretions with minimal mucoid material in proximity to epithelial cells, and mucous globular structures. [3],[16],[17] As visualized by transmission electron microscopy, [19] the secretions are intracellular, within intracytoplasmic lumens, or present in extracellular lumens which are several times larger than the intracellular lumens. The latter are probably the mucous globular structures seen in cytology smears. In both our patients with secretory carcinoma, we observed small cellular clusters and single cells appearing to be strung on capillaries, probably caused by disintegration of papillary structures while smearing.

Intracytoplasmic lumens have also been described in lobular carcinoma and IDC. [20] We did not encounter a single case of lobular carcinoma. Poor cellular yield, small hyperchromatic nuclei and nuclear molding have been described to characterize lobular carcinoma. [5] In contrast, IDC are cellular, with high nuclear grade (nuclear enlargement and pleomorphism), and distinct cytoplasm. [5],[18],[20]

None of our cases of mucinous and secretory carcinomas had necrosis. However, necrosis was encountered in four cases of high-grade ductal carcinomas with secretions. These observations are not unexpected as mucinous and secretory carcinomas are low-grade tumors.

To conclude, secretions are seen in a range of breast cancer that includes invasive ductal carcinoma, mucinous carcinoma and secretory carcinoma. Evaluation of the quantity and location of secretions and the contours of the cell clusters complement cell morphology, and could improve diagnostic cytopathological criteria. Small cellular clusters and single cells appearing to be strung on capillaries should be considered additional distinguishing features of secretory carcinoma.

 
   References Top

1.Sohn JH, Kim LS, Chae SW, Shin HS. Fine needle cytology findings of breast mucinous neoplasms. Acta Cytol 2001;45:723-9.  Back to cited text no. 1
    
2.Ventura K, Cangiarella J, Lee I, Moreira A, Waisman J, Simsir A. Aspiration biopsy of mammary lesions with abundant extracellular mucinous material. Review of 43 cases with surgical follow-up. Am J Clin Pathol 2003;120:194-202.  Back to cited text no. 2
    
3.Shinagawa T, Tadokoro M, Kitamura H, Mizuguchi K, Kushima M. Secretory carcinoma of the breast. Correlation of aspiration cytology and histology. Acta Cytol 1994;38:909-14.  Back to cited text no. 3
    
4.Vesoulis Z, Kashkari S. Fine needle aspiration of secretory breast carcinoma resembling lactational changes. A case report. Acta Cytol 1998;42:1032-6.  Back to cited text no. 4
    
5.Jayaram G, Swain M, Chew MT, Yip CH. Cytological appearance in invasive lobular carcinoma of the breast. A study of 21 cases. Acta Cytol 2000;44:169-74.  Back to cited text no. 5
    
6.Robinson A, Mckee G, Nicholson A, D'Arcy J, Jackson PA, Cook MG, et al. Prognostic value of cytological grading of fine-needle aspirates from breast carcinoma. Lancet 1994;343:947-9.  Back to cited text no. 6
    
7.Rosen PP, Cranor ML. Secretory carcinoma of the breast. Arch Pathol Lab Med 1991;115:141-4.  Back to cited text no. 7
    
8.Komaki K, Sakamoto G, Sugano H, MorimotoT, Monden Y. Mucinous carcinoma of the breast in Japan: A prognostic analysis based on morphologic features. Cancer 1988;61:989-96  Back to cited text no. 8
    
9.André S, Cunha F, Bernardo M, Meneses e Sousa J, Cortez F, Soares J. Mucinous carcinoma of the breast: a pathological study of 82 cases. J Surg Oncol 1995;58:162-7.  Back to cited text no. 9
    
10.Bhargava V, Miller TR, Cohen MB. Mucocele- like tumors of the breast. Cytological finding in two cases. Am J Clin Pathol 1991;95:875-7.  Back to cited text no. 10
    
11.Sharma S, Bansal R, Khare A, Agrawal N. Mucinous carcinoma of breast: Cytodiagnosis of a case. J Cytol 2011;28:42-4.  Back to cited text no. 11
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12.Krishnamurthy J, Nagappa DK. The cytology of micropapillary variant of colloid carcinoma of breast: A report of two cases. J Cytol 2010;27:71-3.  Back to cited text no. 12
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13.Muddegowda PH, Lingegowda JB, Kurpad R, Konapur PG, Shivarudrappa AS, Subramaniam PM. The value of systematic pattern analysis in FNAC of breast lesions: 225 cases with cytohistological correlation. J Cytol 2011;28:13-9.  Back to cited text no. 13
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14.Sharma S, Bansal R, Khare A, Agrawal N. Mucinous carcinoma of breast: Cytodiagnosis of a case. J Cytol 2011;28:42-4.  Back to cited text no. 14
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15.Oh YH, Jang KS, Son YS, Paik SS, Park YW, Chon SH. Secretory carcinoma of the breast diagnosed by fine needle aspiration. Acta Cytol 2005;49:343-4.  Back to cited text no. 15
    
16.Dominguez F, Riera JR, Junco P, Sampedro A. Secretory carcinoma of the breast. Acta Cytol 1992;36:507-10.  Back to cited text no. 16
    
17.Gupta RK, Kenwright D, Naran S, Lallu S, Fauck R. Fine needle aspiration cytodiagnosis of secretory carcinoma of the breast. Cytopathol 2000;11:496-502.  Back to cited text no. 17
    
18.Robinson IA, McKee G, Jackson PA, Cook MG, Kissin MW. Lobular carcinoma of the breast: cytologic features supporting the diagnosis of lobular cancer. Diagn Cytopathol 1995;13:196-201.  Back to cited text no. 18
    
19.Tavassoli FA, Norris HJ. Secretory carcinoma of the breast. Cancer 1980;45:2404-13.  Back to cited text no. 19
    
20.Syre G, Sehn M. Intracellular storage of IgA and secretory component in carcinoma of the female breast. Virchows Arch 1981;393:315-20.  Back to cited text no. 20
    

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Correspondence Address:
Navjeevan Singh
Department of Pathology, University College of Medical Sciences and GTB Hospital, Delhi - 110 095
India
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DOI: 10.4103/0970-9371.86347

PMID: 22090695

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