|CASE IN POINT: BREAST ONCOLOGY
|Year : 2015 | Volume
| Issue : 1 | Page : 46-48
Invasive ductal carcinoma of breast with granulomatous reaction
Varsha Sul, Sagar C Mhetre, Fahim M Goliwale
Department of Pathology, Care Multispecialty Diagnositca, South Sadar Bazar, Lashkar, Solapur, Maharashtra, India
|Date of Web Publication||26-Oct-2015|
Dr. Varsha Sul
Care Multispecialty Diagnositca, Shop No. 5, Laxmi Narayan Apartment South Sadar Bazar, Lashkar - 413 003, Solapur, Maharashtra
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Sul V, Mhetre SC, Goliwale FM. Invasive ductal carcinoma of breast with granulomatous reaction. Astrocyte 2015;2:46-8
Granulomatous diseases of the breast are frequently contributed to chronic granulomatous mastitis, panniculitis, foreign body reaction, infections, and rarely, therapeutically induced sarcoidosis. However, the association of breast cancer and granulomatous host reaction is unusual. The exact cause of this phenomenon is not known.
Also, the presence of amyloid-like material within the mammary tissue has rarely been described.,,
We report a case of invasive ductal carcinoma showing intratumoral noncaseating sarcoid-like granulomas and the same reaction is also observed in draining lymhnodes.
A 45-year-old female presented with a subareolar mass in left breast along with clinically axillary lymphadenopathy. The patient underwent left modified radical mastectomy and the specimen was evaluated for histopathological details.
The cut section of the breast tissue showed a gray-white, firm mass in central quadrant measuring 5 × 4 × 3 cm with infiltrating margins. The rest of parenchyama and all surgical margins were grossly unremarkable. Axillary tail dissection revealed 11 lymphnodes.
Multiple sections of breast mass studied showed the neoplastic cells arranged in nests and cords with very scanty ductal structures. No necrosis and elastosis was observed. A diffuse granulomatous reaction with mononuclear infiltration was admixed with carcinoma [Figure 1] and [Figure 2]. These were noncaseting sarcoid-like granulomas exhibiting giant cells with peripherally located nuclei resembling the Langhan's giant cell. Asteroid or Schumn bodies were not found. The same reaction was also seen in 4 out of 11 lymphnodes draining the carcinoma [Figure 3]. Ziehl Neelsen staining for Acid Fast Bacilli was negative also no evidence of any mycosis was noted. The tumor was graded as Grade II according to World Health Organization (WHO). We also observed some eosinophilic homogenous amyloid-like material, which is PAS positive, deposited in haphazard manner in between the tumor cells [Figure 4].
|Figure 1: Invasive ductal carcinoma along with stromal noncaseating granulomas with langhans type giant cells (H and E, X100).|
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|Figure 2: Invasive ductal carcinoma along with stromal noncaseating granulomas with langhans type giant cells (H and E, X400).|
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|Figure 3: Draining lymph node with metastasis and similar granulomatous reaction (H and E, X400).
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|Figure 4: Haphazard deposition of homogeneous eosinophilic amyloid-like material in between the tumor cells (H and E, X400)|
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The presence of sarcoid-like noncaseating granulomas is an unusual tissue response to breast carcinoma. Such type of stromal reaction has been reported by Oberman in 1987. However, granulomatous response in lymph nodes draining the cancer was first reported by Gorton and Lineti. By definition, to label a granuloma as tumor-related sarcoid reaction, patient should not have signs and symptoms suggesting other granulomatus pathologies including systemic sarcoidosis.
Incidence of sarcoid reaction occur in 4.4% of carcinomas, 13.8% of Hodgkins disease, 7.3% of nonHodgkins lymphoma, 50% of seminomas, and 0.4% of sarcomas. Some authors propose the term "Cancer–Sarcoid Syndrome" to appoint association between these two.
The giant cells in our case are that of Langhan's type and clearly differ from stromal giant cells described by Rosen  and Martinelli. They neither have hyperchromatic nuclei nor megakaryocytic features.
These reactions of varying intensity are not caused by tumor necrosis or microbial infection. Although Rosen refers to the possibility that "traces of fibrinoid necrosis may be found to in cellular lesion", necrosis was absent in our case. Pathogenetically, such reactions are interpreted as T cell mediated immune response to antigen expression of carcinoma acting as local trigger. The intensity reflects immunological hypersensitivity reaction. In a study by Hall et al., they suggested that the local granulomatous response is a reaction to the presence of necrotic and poorly viable tumor while the granulomas in nearby lymphnodes may be a response to tumor derived debris.
Previously it was reported that amyloid deposition in breast occurs exclusively around ducts and vessels along with foreign body giant cell., Surprisingly, in our case, this amyloid-like material was found haphazardly scattered in between tumor cells. Unfortunately, we could not carry out electron microscopic investigation or special stains to confirm this as amyloid. But this finding leads us to suspect its association with an abnormal immunological response.
The patient has been screened out to rule out any localized or widespread infectious disease. There were no hints of generalized sarcoidosis. The patient was followed up and she is well without recurrence 6 months after treatment.
There is subtle but definite association between malignancy and granulomatous inflammation. As the patients may be immune compromised due to neoplastic process or chemotherapy, multiple etiologies are responsible for the coexistence of these two pathologies. Hence there is need to perform multiple sectioning of the tissue and complete work up of the patients is essential to label this phenomenon as "Sarcoid reaction".
Apart from clinical challenges, the biological significance of such granulommas in including the remission or shielding tumor cells from host lymphocytes is also an area open for future research.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Santini D, Pasquinelli G, Alberghini M, Martinelli GN, Taffurelli M. Invasive breast carcinoma with granulomatous response and deposition of unusual amyloid. J Clin Pathol 1992;45:885-8.
Lipper S, Kahn LB. Amyloid tumor. A clinicopathologic study of four cases. Am J Surg Pathol 1978;2:141-5.
Lew W, Seymour AE. Primary amyloid tumor of the breast. Case report and literature review. Acta Cytol 1985;29:7-11.
Silverman JF, Dabbs DJ, Norris HT, Pories WJ, Legier J, Kay S. Localized primary (AL) amyloid tumor of the breast. Cytologic, histologic, immunocytochemical and ultrastructural observations. Am J Surg Pathol 1986;10:539-45.
Tavassoli FA, Devilee P, editors. World Health Organisation Classification of Tumours. Pathology and Genetics Tumours of the Breast and Female Genital Organs. Lyon: IARC Press; 2003. p. 19-20.
Alujevic A, Juric G, Separovic V, Kruslin B. Invasive breast carcinoma with granulomatous stromal response. Zentralbl Gynakol 1997;119:343-5.
Oberman HA. Invasive carcinoma of the breast with granulomatous response. Am J Clin Pathol 1987;88:718-21.
Gorton G, Linell F. Malignant tumours and sarcoid reactions in regional lymph nodes. Acta radiol 1957;47:381-92.
Brincker H. Interpretation of granulomatous lesions in malignancy. Acta Oncol 1992;31:85-9.
Brincker H. Sarcoid reactions in malignant tumours. Cancer Treat Rev 1986;13:147-56.
Shigemitsu H. Is sarcoidosis frequent in patients with cancer? Curr Opin Pulm Med 2008;14:478-80.
Rosen PP. Multinucleated mammary stromal giant cells: A benign lesion that simulates invasive carcinoma. Cancer 1979;44:1305-8.
Martinelli G, Santini D, Bazzocchi F, Pileri S, Casanova S. Myeloid metaplasia of the breast. A lesion which clinically mimics carcinoma. Virchows Arch A Pathol Anat Histopathol 1983;401:203-7.
Hall PA, Kingston J, Stansfeld AG. Extensive necrosis in malignant lymphoma with granulomatous reaction mimicking tuberculosis. Histopathology 1988;13:339-46.
Hardy TJ, Myerowitz RL, Bender BL. Diffuse parenchymal amyloidosis of lungs and breast. Its association with diffuse plasmacytosis and kappa-chain gammopathy. Arch Pathol Lab Med 1979;103:583-5.
Isobe T, Osserman EF. Patterns of amyloidosis and their association with plasma-cell dyscrasia, monoclonal immunoglobulins and Bence-Jones proteins. N
Engl J Med 1974;290:473-7.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]