Breast – Malignant, Males, Children - Cystic hypersecretory DCIS

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Breast-malignant, males, children

Morphologic variants of DCIS

Cystic hypersecretory DCIS

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

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

Revised: 15 August 2009

Last major update: August 2009

Definition

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● First described in 1984 by Rosen and Scott (AJSP 1984;8:31)

Epidemiology

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● Rare (<100 cases described); usually large palpable mass with pain

● Mean age 55 years, range 32-79 years

● 20% are associated with an invasive component, usually poorly differentiated ductal carcinoma with solid growth pattern and no secretory features

Treatment and prognosis

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● Excision with careful search for invasive component

● May recur as in situ or invasive disease (Ceska Gynekol 2005;70:73, Cancer 1988;61:1611)

Case reports

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● 40 year old woman with cystic, ill-defined breast mass and invasive carcinoma (Archives 2005;129:e79)

● 54 year old woman with large breast mass (Case of the week #35)

X-ray

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● Single, irregular, spiculated mass with occasional calcifications

Gross description

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● Numerous cysts with sticky, mucoid or gelatinous secretions

Microscopic description / grading

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● Dilated ducts and cysts mixed with micropapillary carcinoma in epithelium lining cystic spaces

● Cysts contain eosinophilic secretions resembling colloid

● Secretions may retract from epithelium, causing smooth or scalloped margin

● Associated with cystic hypersecretory hyperplasia with or without atypia

● DCIS is usually low grade

Micro images

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Variably sized cysts Cysts lined by flattened epithelium

Intraluminal secretions show cracks and Cysts lined by micropapillary projections

shrinkage of cyst content with peripheral scalloping with atypical cells containing pleomorphic

nuclei

Cysts contain colloid type material, and epithelium has changes of DCIS

Fig 1: color Doppler is suggestive of cancer; Fig 2: FNA shows sparsely

cellular smears with groups of cells in 3 dimensional clusters, papillary

formation and granular background (inset: hyperchromatic cell with

increased N/C ratio); Fig 3: core biopsy shows dilated ducts with papillary

proliferation; Fig 4: excision shows dilated ducts with micropapillary

architecture and eosinophilic colloid-like material

Micropapillary intraductal carcinoma and Micropapillary type pattern

sparse secretion retracted from epithelium with prominent secretion

Hobnail type cells

Cytology description

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● Distinct granular, colloid-like material in background

● Often reported as negative or suggestive of malignancy

Virtual slides

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33 year old woman

Positive stains

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● Epithelial cells - EMA, androgen receptor (Histopathology 2005;46:43), variable ER and PR

● Myoepithelial cells - S100, smooth muscle actin, p63, CD10

● Secretions - EMA, PAS, Alcian blue (focal)

Negative stains

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● Secretions - thyroglobulin

Differential diagnosis

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● Cystic hypersecretory hyperplasia - no atypia

● Fibrocystic disease with microcyst formation - apocrine metaplasia, benign epithelial lining, no micropapillary formation or colloid-like secretions within cysts, no atypia

● Juvenile papillomatosis - teenagers with "Swiss cheese" pattern of ductal papillomatosis, papillary hyperplasia, sclerosing adenosis, variable atypia

● Metastatic thyroid carcinoma - history, thyroglobulin+

● Mucocele-like lesions

● Mucinous cystadenocarcinoma

● Secretory/juvenile carcinoma - invasive

End of Breast – Malignant, Males, Children > Cystic hypersecretory DCIS

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