Letter to the editor Strahlenther Onkol 2013 · 189:1049–1050 DOI 10.1007/s00066-013-0461-8 Received: 5 September 2013 Accepted: 11 September 2013 Published online: 27 October 2013 © Springer-Verlag Berlin Heidelberg 2013
C. Franzese1 · G. Zei1 · T. Masoni1 · S. Cecchini1 · E. Monteleone1 · L. Livi1 and G. Biti1 1 Department of Radiation-Oncology, University of Florence, Italy
Adenoid cystic carcinoma of the breast The double face of an exocrine gland carcinoma
Letter to the editor Adenoid cystic carcinoma (ACC) is the most common tumour of the minor salivary glands, but it also represents a rare type of breast cancer, accounting for 0.1– 1% of all breast tumours [1, 2]. ACC of the breast usually presents with a favorable prognosis due to its low incidence of lymph node and distant metastasis [1]. Management is currently similar to that of other breast cancer comprising mastectomy or breast conserving treatment with axillary dissection or sentinel node biopsy, radiotherapy and chemotherapy. We reviewed our experience with patients affected by ACC treated at our institute. Tab. 1 Distribution of cases according to
individual characteristics (n=13) Median age, years 51 (range 39–71) T stage Tis 1 (7.6%) T1c 5 (38.4%) T2 7 (53.8%) Grade 1 9 (69.2%) 2 4 (30.7%) N stage pN0 11 (84.6%) pN2c 2 (15.3%) Estrogen receptor status Negative 9 (69.2%) Positive 4 (30.7%) Progesterone receptor status Negative 9 (69.2%) Positive 4 (30.7%)
From 1990–2007 we treated 13 women affected by ACC, all patients underwent to definitive quadrantectomy, 2 patients underwent sentinel lymphnode biopsy and 11 patients axillary lymph node dissection. Histology confirmed the presence of ACC in all the patients; however in 3 cases it was intermingled with ductal carcinoma. Rare are the cases of ACC intermingled with other types of breast cancer; in literature there are some case reports where ACC is mixed with other histology as small cell carcinoma [3] and spindle cell carcinoma [4]. The analysis showed negative margin with tumor at least 10 mm from the gross margin. Only 2 patients had positive lymph nodes with an N2a stage in both cases. The incidence of lymph node metastasis is very low; in literature axillary involvement appears in approximately 15% [5]. Sumpio et al. [6] showed in 120 cases from the literature, lymph node metastases in only 4 cases. Sentinel biopsy should be proposed in the presence of ACC of the breast, reserving the more invasive axillary dissection to individual cases. Estrogen and progesterone receptors were negative in 9 patients, while HER2 was positive in only 1 case. Very common is the triple negative status in this kind of tumor, e.g. Leeming et al. [7] reviewed 140 cases and found only one case positive ER. All the patients received adjuvant whole breast radiotherapy (range 50– 60 Gy) and 2 patients underwent adjuvant chemotherapy for positive lymph nodes; hormonal therapy was administered in 3
out of the 4 cases of positive receptors. At a median follow-up of 74 months after resection, 1 patient presented local relapse and 1 patient distant metastasis. The patient with local relapse was operated for a tumour of 4 cm, histology was positive for ACC and ductal carcinoma with positive hormonal receptors. Distant metastases occur most frequently in the lung, without sentinel lymph node involvement as in our patient. In our analysis none died from disease. In conclusion, primary treatment of ACC of the breast is surgical and quadrantectomy can be a valid approach if followed by radiation therapy on the whole breast [8]; unknown is the role of chemotherapy. It is important to recognize ACC of the breast as different entity from ACC of head and neck, the implications for management and outcome are significantly different but due to the rarity of the histology there are no standardized guidelines.
Corresponding address C. Franzese, MD Department of Radiation-Oncology University of Florence Viale Morgagni 85 50132 Florence, Italy [email protected]
Strahlentherapie und Onkologie 12 · 2013
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Letter to the editor
Compliance with ethical guidelines Conflict of interest. C. Franzese, G. Zei, T. Masoni, S. Cecchini, E. Monteleone, L. Livi, and G. Biti state that there are no conflicts of interest.
References 1. Kontos M, Fentiman IS (2003) Adenoid cystic carcinoma of the breast. Int J Clin Pract 57:669–672 2. Law YM, Quek ST, Tan PH et al (2009) Adenoid cystic carcinoma of the breast. Singapore Med J 50:e8–e11 3. Cabibi D, Cipolla C, Florena AM et al (2005) Solid variant of mammary “adenoid cystic carcinoma with basaloid features” merging with “small cell carcinoma”. Pathol Res Pract 201:705–711 4. Noske A, Schwabe M, Pahl S et al (2008) Report of a metaplastic carcinoma of the breast with multidirectional differentiation: an adenoid cystic carcinoma, a spindle cell carcinoma and melanoma. Virchows Arch 452:575–579 5. Arpino G, Clark GM, Mohsin S et al (2002) Adenoid cystic carcinoma of the breast. Molecular markers, treatment and clinical outcome. Cancer 94:2119– 2127 6. Sumpio BE, Jennings TA, Merino MJ et al (1987) Adenoid cystic carcinoma of the breast. Data from the Connecticut Tumor Registry and a review of the literature. Ann Surg 205:295–301 7. Leeming R, Jenkins M, Mendelson G (1992) Adenoid cystic carcinoma of the breast. Arch Surg 127:233–235 8. Fisher B, Anderson S, Bryant J et al (2002) Twentyyear follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of breast cancer. N Engl J Med 347:1233–1241
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Strahlentherapie und Onkologie 12 · 2013
C. Franzese1 · G. Zei1 · T. Masoni1 · S. Cecchini1 · E. Monteleone1 · L. Livi1 and G. Biti1 1 Department of Radiation-Oncology, University of Florence, Italy
Adenoid cystic carcinoma of the breast The double face of an exocrine gland carcinoma
Letter to the editor Adenoid cystic carcinoma (ACC) is the most common tumour of the minor salivary glands, but it also represents a rare type of breast cancer, accounting for 0.1– 1% of all breast tumours [1, 2]. ACC of the breast usually presents with a favorable prognosis due to its low incidence of lymph node and distant metastasis [1]. Management is currently similar to that of other breast cancer comprising mastectomy or breast conserving treatment with axillary dissection or sentinel node biopsy, radiotherapy and chemotherapy. We reviewed our experience with patients affected by ACC treated at our institute. Tab. 1 Distribution of cases according to
individual characteristics (n=13) Median age, years 51 (range 39–71) T stage Tis 1 (7.6%) T1c 5 (38.4%) T2 7 (53.8%) Grade 1 9 (69.2%) 2 4 (30.7%) N stage pN0 11 (84.6%) pN2c 2 (15.3%) Estrogen receptor status Negative 9 (69.2%) Positive 4 (30.7%) Progesterone receptor status Negative 9 (69.2%) Positive 4 (30.7%)
From 1990–2007 we treated 13 women affected by ACC, all patients underwent to definitive quadrantectomy, 2 patients underwent sentinel lymphnode biopsy and 11 patients axillary lymph node dissection. Histology confirmed the presence of ACC in all the patients; however in 3 cases it was intermingled with ductal carcinoma. Rare are the cases of ACC intermingled with other types of breast cancer; in literature there are some case reports where ACC is mixed with other histology as small cell carcinoma [3] and spindle cell carcinoma [4]. The analysis showed negative margin with tumor at least 10 mm from the gross margin. Only 2 patients had positive lymph nodes with an N2a stage in both cases. The incidence of lymph node metastasis is very low; in literature axillary involvement appears in approximately 15% [5]. Sumpio et al. [6] showed in 120 cases from the literature, lymph node metastases in only 4 cases. Sentinel biopsy should be proposed in the presence of ACC of the breast, reserving the more invasive axillary dissection to individual cases. Estrogen and progesterone receptors were negative in 9 patients, while HER2 was positive in only 1 case. Very common is the triple negative status in this kind of tumor, e.g. Leeming et al. [7] reviewed 140 cases and found only one case positive ER. All the patients received adjuvant whole breast radiotherapy (range 50– 60 Gy) and 2 patients underwent adjuvant chemotherapy for positive lymph nodes; hormonal therapy was administered in 3
out of the 4 cases of positive receptors. At a median follow-up of 74 months after resection, 1 patient presented local relapse and 1 patient distant metastasis. The patient with local relapse was operated for a tumour of 4 cm, histology was positive for ACC and ductal carcinoma with positive hormonal receptors. Distant metastases occur most frequently in the lung, without sentinel lymph node involvement as in our patient. In our analysis none died from disease. In conclusion, primary treatment of ACC of the breast is surgical and quadrantectomy can be a valid approach if followed by radiation therapy on the whole breast [8]; unknown is the role of chemotherapy. It is important to recognize ACC of the breast as different entity from ACC of head and neck, the implications for management and outcome are significantly different but due to the rarity of the histology there are no standardized guidelines.
Corresponding address C. Franzese, MD Department of Radiation-Oncology University of Florence Viale Morgagni 85 50132 Florence, Italy [email protected]
Strahlentherapie und Onkologie 12 · 2013
| 1049
Letter to the editor
Compliance with ethical guidelines Conflict of interest. C. Franzese, G. Zei, T. Masoni, S. Cecchini, E. Monteleone, L. Livi, and G. Biti state that there are no conflicts of interest.
References 1. Kontos M, Fentiman IS (2003) Adenoid cystic carcinoma of the breast. Int J Clin Pract 57:669–672 2. Law YM, Quek ST, Tan PH et al (2009) Adenoid cystic carcinoma of the breast. Singapore Med J 50:e8–e11 3. Cabibi D, Cipolla C, Florena AM et al (2005) Solid variant of mammary “adenoid cystic carcinoma with basaloid features” merging with “small cell carcinoma”. Pathol Res Pract 201:705–711 4. Noske A, Schwabe M, Pahl S et al (2008) Report of a metaplastic carcinoma of the breast with multidirectional differentiation: an adenoid cystic carcinoma, a spindle cell carcinoma and melanoma. Virchows Arch 452:575–579 5. Arpino G, Clark GM, Mohsin S et al (2002) Adenoid cystic carcinoma of the breast. Molecular markers, treatment and clinical outcome. Cancer 94:2119– 2127 6. Sumpio BE, Jennings TA, Merino MJ et al (1987) Adenoid cystic carcinoma of the breast. Data from the Connecticut Tumor Registry and a review of the literature. Ann Surg 205:295–301 7. Leeming R, Jenkins M, Mendelson G (1992) Adenoid cystic carcinoma of the breast. Arch Surg 127:233–235 8. Fisher B, Anderson S, Bryant J et al (2002) Twentyyear follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of breast cancer. N Engl J Med 347:1233–1241
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Strahlentherapie und Onkologie 12 · 2013
