Breast – Malignant, Males, Children - Breast cancer

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Breast-malignant, males, children

Breast cancer - spread and metastases

Author: Nat Pernick, M.D, PathologyOutlines.com, Inc.

Reviewer: Daniel Visscher, M.D., University of Michigan Hospitals, February 2009 (see Reviewers page)

Revised: 12 April 2010

Last major update: September 2009

Local spread

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● To skin or chest wall

● Nipple invasion more common if tumors are within 2.5 cm of nipple

● Local recurrence after surgery appears as nodules, often near old scar, but can be simulated by post-surgical granulomas

Nodal metastases

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● Axilla is most common site of nodal metastases

● Also supraclavicular and internal mammary region

Distant metastases

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● Common sites are adrenal gland, bone (desmoplasia may cause dry taps in bone marrow), central nervous system (more often basal-like phenotype - high grade, CK 5/6+, EGFR+, ER negative, Am J Surg Pathol 2006;30:1097), liver, lung/pleura (often mammaglobin+, Mod Pathol 2007;20:208), ovary (60-80% are bilateral, are GCDFP-15+)

● Lobular carcinoma tends to metastasize to abdominal/pelvic cavities including GI tract, ovaries and serosal surfaces

Occult primary

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● If enlarged axillary node contains carcinoma, but no breast mass or other tumor is detected clinically or radiologically, usually a primary breast carcinoma will eventually be found in adjacent breast, although it may be very small (usually < 2 cm)

● Radiation therapy may be adequate therapy for patients with occult primary (Oncology 2006;71:456)

● Melanomas may also present with occult primary

● Metastatic breast carcinomas to GI tract are usually positive for GCDFP-15 (78%), ER (72%), CK5/6 (61%); also PR (33%), androgen receptors and HER2; negative for CDX2 and CK20 (Archives 2005;129:338)

● Androgen receptor nuclear staining suggests breast or ovarian primary (Diagn Pathol 2006;1:34)

Case reports of metastatic sites

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● Colonic polyp (Archives 1984;108:318)

● Endometrial polyp (Case of the Week #125)

● Liver (Archives 2004;128:1418)

● Lung causing cor pulmonale (Archives 1986;110:1197)

● Ovarian granulosa cell tumor (Hum Pathol 2002;33:445)

● Stomach #1 (Archives 2001;125:567), #2 (World J Surg Oncol 2007;5:75)

● Thyroid follicular adenoma (Archives 1994;118:551)

Gross images

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Liver-hepar lobatum (irregular nodularity, usually due to either

tertiary syphilis or metastatic tumor)

Micro images

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Breast cancer metastases

To cervix Source: AFIP

To endometrial polyp (below)

ER PR GCDFP-15

To jaw-mandible

To liver

To lung #1 #2-various stains #3-mammaglobin expression (Fig d)

To oral cavity #1 #2

To ovarian granulosa cell tumor

To skin #1 #2 - tumor is p63 negative

To stomach H&E and stains H&E and stains ER+, PR+, GCDFP-15+

To stomach ER+

To thyroid Lobular carcinoma and entrapped

thyroid follicles (AFIP)

Thyroid - ER stains breast tumor but not False positive thyroglobulin stain due

papillary thyroid carcinoma (AFIP) to diffusion from trapped follicles and

nonspecific absorption (AFIP)

Other images:

Androgen receptor+ ductal, Androgen receptor

lobular and ovarian carcinoma stains nuclei

Virtual slides

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Metastases to heart

Positive stains in unknown primary

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● GCDFP-15, lactalbumin, ER and PR staining are relatively specific for breast primary

● Breast carcinoma is usually CK7+/CK20- (also carcinomas of lung and ovary, but GI, pancreaticobiliary and some ovarian tumors are CK20+)

● Mammaglobulin in more sensitive but less specific than GCDFP-15 (AJCP 2007;127:103)

Markers to distinguish specific primaries

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● Breast vs. lung: GCDFP-15 (breast) and TTF-1 (lung)

● Breast vs. ovary: GCDFP-15 (breast) and WT1 (ovary) (Am J Surg Pathol 2004;28:1076), although breast mucinous carcinomas may also be WT1+ (Mod Pathol 2008;21:1217)

Differential diagnosis

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● Sarcoidosis may mimic metastatic breast cancer (Clin Breast Cancer 2007;7:804)

End of Breast – Malignant, Males, Children > Breast cancer - spread and metastases

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