Journal of Cytology
Home About us Ahead of print Instructions Submission Subscribe Advertise Contact e-Alerts Login 
Users Online:820
  Print this page  Email this page Small font sizeDefault font sizeIncrease font size


 
 Table of Contents    
CASE REPORT  
Year : 2013  |  Volume : 30  |  Issue : 1  |  Page : 78-80
Role of cytology in fibroadenoma with clinging carcinoma


Department of Pathology, Nizam's Institute of Medical Sciences, Hyderabad, India

Click here for correspondence address and email

Date of Web Publication21-Feb-2013
 

   Abstract 

Fibroadenoma is the most common benign breast tumor in adolescent girls and young women with a peak incidence in the second and third decades of life. Carcinoma arising within a fibroadenoma is rare and is usually discovered incidentally. We describe a case of clinging type of ductal carcinoma in situ (DCIS) arising within a fibroadenoma. Clinging carcinoma, a variant of DCIS is an under recognized entity. Diagnosis of DCIS is made based on architecture and cytology. This case report highlights the role of fine needle aspiration cytology in the diagnosis of this entity coexisting in a fibroadenoma.

Keywords: Clinging carcinoma; ductal carcinoma in situ; fibroadenoma; fine needle aspiration cytology

How to cite this article:
Swetha N, Geetha C H, Prayaga AK. Role of cytology in fibroadenoma with clinging carcinoma. J Cytol 2013;30:78-80

How to cite this URL:
Swetha N, Geetha C H, Prayaga AK. Role of cytology in fibroadenoma with clinging carcinoma. J Cytol [serial online] 2013 [cited 2020 Apr 1];30:78-80. Available from: http://www.jcytol.org/text.asp?2013/30/1/78/107530



   Introduction Top


Clinging carcinoma, a variant of ductal carcinoma in situ (DCIS), is an under recognised entity. [1] It is identified by the presence of cytologic atypia of luminal epithelial cells without simultaneous alterations of basally located myoepithelial cells. Generally, intraluminal proliferation of the involved ducts or ductules is not seen. Fibroadenoma is the most common benign breast tumor in adolescent girls and young women with a peak incidence in the second and third decades of life. It is a biphasic tumor composed of stromal component and epithelial component. [2] The epithelial elements of a fibroadenoma can undergo a variety of proliferative changes similar to that seen elsewhere in the breast. Co-existing carcinoma is rare and is usually discovered incidentally. This case report highlights the role of fine needle aspiration cytology (FNAC) in the diagnosis of this entity coexisting in a fibroadenoma.


   Case Report Top


A 48 years old lady, a known diabetic and hypertensive, presented with bilateral breast lumps of one week duration. There was no family history of breast or ovarian tumors. Patient had regular menstrual cycles in the past. On examination, there was a 4 × 4 cm hard lump in lower inner quadrant of left breast which was fixed to the chest wall and there was a lump in right breast, firm mobile measuring 1 × 1 cm in the lower outer quadrant. Impression of left breast lump on magnetic resonance imaging (MRI) was suspicious of malignancy [Figure 1]. Right breast lump was a 2.3 × 1.5 cm well defined mass lesion with type 1 contrast enhancement pattern (less than 6% malignant probability) with bilateral axillary lymphadenopathy. Ultrasound and bone scan were negative for detectable metastasis.
Figure 1: MRI of bilateral breast lumps- 3.8 × 3.5 × 3 cm irregular speculated mass in left breast (Suspicious of malignancy), 2.3 × 1.5 cm well defined mass lesion in right breast (less than 6% malignant probability)

Click here to view


FNAC was done from both the breast lumps and left axillary lymph node. Right axillary lymph node was clinically not palpable. Smears from the left breast showed poorly cohesive clusters of ductal cells with pleomorphism, hyperchromasia and prominent nucleoli. Myoepithelial cells and bare nuclei were not seen. FNAC from left axillary lymph node also showed similar cells.

The smears from the right breast mass showed three dimensional clusters of cells with hyperchromatic nuclei, prominent nucleoli. There were singly scattered pleomorphic cells with mitotic figures. Admixed with these clusters were benign ductal cells with no nuclear pleomorphism along with myoepithelial cells. A few bare nuclei were also seen. Cytologic diagnosis of duct cell carcinoma of bilateral breast lumps with left axillary lymph node metastasis was made [Figure 2].
Figure 2: (a) Benign ductal epithelial cell cluster (Pap, × 100); (b) Lesion with bare bipolar nuclei in the background (MGG, × 400); (c) and (d) Clusters of cells with hyperchromatic nuclei and prominent nucleoli (MGG, × 400)

Click here to view


Trucut biopsy of left breast lump showed features of infiltrative duct cell carcinoma. Immunohistochemistry was positive for estrogen and progesterone receptors. On the basis of the physical examination results, right breast lump was suspected as a fibroadenoma. Hence, lumpectomy was performed. The specimen grossly was a 1 × 1 cm, circumscribed tumor. Histopathology of multiple and serial sections revealed ductal structures surrounded by hyalinized stroma with focal myxoid areas. The lining of the ductal structures was bilayered. A significant number of ducts showed stratification of the lining epithelium, nuclear hyperchromasia and irregular nuclear contours, but myoepithelial lining was intact. There were no solid or cribriform areas, no stromal infiltration. The latter was confirmed by immunohistochemical staining with smooth muscle actin (SMA) and pancytokeratin (Pan CK). A diagnosis of fibroadenoma with DCIS, clinging type, was made (DCIS) [Figure 3].
Figure 3: (a) Benign glands in fibroadenoma area (H and E, × 100); (b) Dilated duct with necrotic material (H and E, × 400); (c and d) Nuclear hyperchromasia with irregular nuclear contours (H and E, × 400)

Click here to view



   Discussion Top


The term "clinging carcinoma in situ" was coined by Azzopardi when a carcinoma was missed and the patient developed infiltrating ductal carcinoma 8 years later. [3] It is characterized by atypical cells replacing the single layer of luminal epithelial cells in a flat fashion without any proliferation or micropapillary structure formation. Though it was ignored for a long time, there is a renewed interest as Moinfar and Schnitt [1] equated it with high grade flat epithelial atypia.

In the present case, the cytologic features of the lesion were unequivocally malignant. Lower magnification of histologic sections resembled a fibroadenoma. A detailed evaluation of tubules and the lining epithelium showed foci with intraluminal necrotic debris and occasional rigid tubule. The involved structures showed hyperchromatic nuclei of epithelial cells.

Epithelial hyperplasia developing within a fibroadenoma is a common finding. There are a few case reports with in situ/invasive ductal and lobular carcinoma in a fibroadenoma which are either cribriform/solid variants. [4],[5],[6] There are no reported cases of clinging carcinoma with fibroadenoma. An important differential diagnosis for clinging carcinoma is low grade flat epithelial atypia. Since both are architecturally similar, significant cytologic atypia is the differentiating feature. The incidence of carcinoma within fibroadenoma is reported to be between 0.1% and 0.3%, with a peak age between 42 and 44 years. [5],[6],[7] The biological behavior of carcinoma occurring within fibroadenoma does not differ from that of breast carcinoma which is unrelated to fibroadenoma. [5] Preoperative clinical and radiological diagnosis of malignancy in a fibroadenoma, especially of in situ carcinoma, is usually not possible.

FNAC is a useful test that guides the clinician to decide further step of patient management. However, FNAC diagnosis may not always represent the actual lesion. This occurs due to sampling error which is a known drawback of cytology. Surprisingly, in the present case, though the clinical examination was suggestive of fibroadenoma and MRI was suspicious of malignancy, FNAC revealed features of duct cell carcinoma which was confirmed as clinging carcinoma on histopathology.


   Conclusion Top


Cytology is advantageous in the diagnosis of clinging carcinoma. We stress upon the need for compulsory excision of clinically diagnosed fibroadenomas and also the importance of histopathological evaluation of all breast masses irrespective of their clinical diagnosis as benign lesions. Special attention is warranted in women older than 35 years and with risk factors for carcinoma breast presenting with a fibroadenoma.

 
   References Top

1.Schnitt SJ. Clinging carcinoma: An American perspective. Semin Diagn Pathol 2010;27:31-6.  Back to cited text no. 1
[PUBMED]    
2.Bellocq JP, Magro G. Fibroepithelial tumours. In: Tavassoli FA, Devilee P, editors. Tumors of the breast and female genital organs. World Health Organization Classification of Tumours. Lyon: IARC Press; 2003. p. 63-73.  Back to cited text no. 2
    
3.Moinfar F. Flat ductal intraepithelial neoplasia of the breast: A review of diagnostic criteria, differential diagnoses, molecular-genetic findings, and clinical relevance-it is time to appreciate the Azzopardi concept. Arch Pathol Lab Med 2009;133:879-92.  Back to cited text no. 3
[PUBMED]    
4.Carter CL, Corle DK, Micozzi MS, Schatzkin A, Taylor PR. A prospective study of the development of breast cancer in 16, 692 women with benign breast disease. Am J Epidemiol 1988;128:467-77.  Back to cited text no. 4
    
5.Ozello L, Gump FE. The management of patients with carcinomas in fibroadenomatous tumors of the breast. Surg Gynecol Obstet 1985;160:99-104.  Back to cited text no. 5
    
6.Pick PV, Iossifides IA. Occurrence of breast carcinoma within a fibroadenoma. A review. Arch Pathol Lab Med 1984;108:590-4.  Back to cited text no. 6
    
7.Buzanowski-Konakry K, Harrison EG Jr, Payne WS. Lobular carcinoma arising in fibroadenoma of the breast. Cancer 1975;35:450-6.  Back to cited text no. 7
[PUBMED]    

Top
Correspondence Address:
Aruna K Prayaga
Department of Pathology, Nizam's institute of Medical Sciences, Punjagutta, Hyderabad - 500 082
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9371.107530

Rights and Permissions


    Figures

  [Figure 1], [Figure 2], [Figure 3]

This article has been cited by
1 mr diffusion-weighted imaging and dynamic contrast-enhanced imaging in diagnosis of breast fibroadenoma
xue, m. and li, j. and zhou, c.-w. and li, e.-n.
chinese journal of medical imaging technology. 2013; 29(11): 1769-1773
[Pubmed]



 

Top
 
 
  Search
 
  
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Email Alert *
    Add to My List *
* Registration required (free)  


    Abstract
   Introduction
   Case Report
   Discussion
   Conclusion
    References
    Article Figures

 Article Access Statistics
    Viewed2698    
    Printed69    
    Emailed1    
    PDF Downloaded133    
    Comments [Add]    
    Cited by others 1    

Recommend this journal