|Year : 2014 | Volume
| Issue : 2 | Page : 205-207
Diagnostic dilemma of FNA diagnosis of secretory carcinoma of breast
Archana C Buch, NK Panicker, Sonam Sood, Charusheela R Gore
Department of Pathology, Padmashree Dr. D. Y. Patil Medical College, Hospital and Research Centre, Dr. D. Y. Patil Vidyapeeth, Pune, Maharashtra, India
|Date of Web Publication||4-Feb-2014|
Archana C Buch
B-603 Gold Coast, Ivory Estates, Someshwarwadi, Pune - 411 008, Maharashtra
Source of Support: None, Conflict of Interest: None
Secretory carcinoma (SC) is one of the least common types of breast carcinoma. The tumor has distinctive histologic features with prominent secretory activity similar to lactational change and minimal nuclear atypia. As the cytomorphologic features of SC overlaps benign breast lesions with lactational change and apocrine change, the initial diagnosis of SC may be missed on cytology in some cases. A 29-year-old woman presented with a lump in the left breast since 9 months. The fine needle aspiration cytology (FNAC) suggested proliferative breast disease without atypia. Excision biopsy showed secretory carcinoma. The case is presented to highlight the cytologic features of SC, which may overlap with lactational change and apocrine change.
Keywords: Breast, fine needle aspi ation cytology, secretory carcinoma
|How to cite this article:|
Buch AC, Panicker N K, Sood S, Gore CR. Diagnostic dilemma of FNA diagnosis of secretory carcinoma of breast. Med J DY Patil Univ 2014;7:205-7
|How to cite this URL:|
Buch AC, Panicker N K, Sood S, Gore CR. Diagnostic dilemma of FNA diagnosis of secretory carcinoma of breast. Med J DY Patil Univ [serial online] 2014 [cited 2019 Dec 10];7:205-7. Available from: http://www.mjdrdypu.org/text.asp?2014/7/2/205/126344
| Introduction|| |
Secretory carcinoma (SC) is considered as one of the rarest types of breast carcinomas, accounting for less than 0.15% of all breast cancer.  In 1966, Mc Divitt and Stewart named it as juvenile carcinoma.  Subsequently, a number of cases were reported in adults.  SC elicits pathologic interest because of their unique morphology of abundant eosinophilic secretions and excellent prognosis.  Therefore, the term SC replaced the designation of juvenile carcinoma.
Fine needle aspiration (FNA) diagnosis of this rare type of carcinoma with relatively bland cytology may be extremely difficult, especially in a younger woman in whom benign proliferative and secretory lesions far outnumber carcinoma.
| Case Report|| |
A 29-year-old non lactating woman presented with a lump in the left breast of 9 months duration gradually increasing in size. On examination, the lump was in the lower outer quadrant, painless, solitary, 3 cm × 2 cm in size, firm, freely mobile with well-defined margins. There were no skin changes, nipple retraction, nipple discharge or palpable axillary lymph nodes. Ultrasound of the breast revealed a 3.5 cm × 2 cm well-defined echogenic mass with a smooth outline in the lower outer quadrant of the left breast. (FNAC) of the lump was performed. Smears were moderately cellular with cells arranged in tightly cohesive clusters with some cells having abundant granular and vacuolated cytoplasm and eccentric nuclei. The nuclei were round with no remarkable nuclear pleomorphism or anisocytosis. However, nucleoli could be seen in many cells. The background was fatty mixed with blood [Figure 1]a and b. The cytological diagnosis of proliferative breast disease without atypia was given. Excisional biopsy was advised. Macroscopically, the excised specimen comprised of yellowish white fibrofatty firm tissue mass measuring 3 cm × 2 cm × 0.5 cm. Cut surface showed a firm, fleshy, 2 cm × 1 cm greyish white area in the center. On Microscopic examination, there were lobules of breast tissue with an infiltrating neoplasm composed of cells arranged in sheets and clusters having pale staining granular and foamy cytoplasm. The nuclei were ovoid with small nucleolus. Intracytoplasmic lumina were seen, the fusion of which formed microcystic structures [Figure 2]a. Extracellular secretion was also noted, which were periodic acid Schiff (PAS) positive [Figure 2]b. Mitosis and necrosis were not seen. S-100 was performed, which was positive [Figure 2]c. estrogen receptor, progesterone receptor and herceptin receptor (ER, PR, HER2/neu) were negative. The case was diagnosed as SC of the left breast.
|Figure 1: (a) Highly cellular smear with mild anisonucleosis (H and E, ×400). (b) Abundant granular cytoplasm with lilac granules (×400 Giemsa). (c) Comparison with smear having lactational change (×400 Giemsa) (d) Comparison with smear having apocrine change (H and E, ×400)|
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|Figure 2: (a) Photomicrograph demonstrating ductular structures containing eosinophilic secretions (H and E, ×400). (b) Cells showing PAS positive secretions (×400, PAS). (c) Cells showing immunopositivity for S-100|
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| Discussion|| |
SC of the breast is an unusual neoplasm and has been recognized as a distinct entity. 
SC occurs in both children and adults with a wide range of 3-83 years with a median age of 25 years. The typical clinical presentation is a slow growing, painless, well-circumscribed, mobile, palpable mass. The most common location appears to be the upper outer quadrant, but it can occur in any part of the breast.  Axillary lymph node metastasis is uncommon, especially if tumors are less than 2 cm. If it occurs, it rarely involves more than 3 lymph nodes. 
The differential diagnosis of SC needs exclusion of a wide range of breast lesions. These include benign proliferative changes such as those in pregnancy and lactation, benign tumors with or without apocrine or secretory change, secretory adenomas and other miscellaneous non tumorous proliferations. A few types of carcinomas showing cytoplasmic vacuolation or secretions such as lobular, mucinous, tubular, adenoid cystic, signet ring, lipid rich and metastatic carcinoma also need consideration. Typical features on cytology include highly cellular material, mild nuclear pleomorphism and the presence of prominent intracytoplasmic vacuolation, which is the cytologic hallmark of SC. The presence of grape like clusters of mucous globular structures has been considered a distinctive feature for distinguishing SC from other benign and malignant breast lesions. 
The cytologic features of SC may almost completely overlap with those of lactational change or lactating adenoma [Figure 1]c. Important diagnostic clues are high cellularity of the FNA cytologic material and absence of bipolar naked nuclei. These features are unusual for benign conditions.  The differential diagnosis between SC and lactational change in the FNA specimen could be very difficult in young patients, particularly those with a recent history of pregnancy or lactation. Excisional biopsy should be performed to confirm the diagnosis. 
Apocrine carcinomas are invasive ductal carcinomas in which all or nearly all of the tumor cells have apocrine cytologic features including prominent eosinophilic, flocculent cytoplasm with sharply defined cell borders and large nuclei containing prominent macronucleoli. In addition, the intracellular vacuoles characteristically seen in SC are absent in apocrine change [Figure 1]d. 
We too had difficulty in diagnosing SC on cytology due to young age of the patient, lack of nuclear atypia and abundant foamy cytoplasm. However, few clusters with lack of myoepithelial cells and high cellularity pointed to the suspicion of malignancy.
Recent studies have shown the characteristic molecular feature : a0 balanced translocation t (12; 15), resulting in an ETS variant 6-neurotrophic tyrosine kinase receptor type 3 fusion gene encoding a chimeric tyrosine kinase. 
Although rare events of axillary lymph node or distant metastasis have been documented, the prognosis is generally excellent. Surgical excision is the primary mode of treatment for SC.  Modified radical mastectomy (MRM) has been favoured in cases with tumor sizes greater than 2 cm and poor gross circumscription. Although local recurrence does not seem to affect the favorable clinical course, adjuvant radiotherapy may be indicated after conservative surgery in adults but not in children because of the risk of significant complications.  Adjuvant chemotherapy is used in patients with node positive disease.
In our case, MRM was performed and the patient is on regular follow-up.
In conclusion, SC should be included in the differential diagnosis of FNA from a breast mass with secretory change. Hypercellularity and absence of bipolar naked nuclei are important clues in recognition of SC.
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