94 • robinson et al.
involved by sparganosis. Clinical symptoms vary depending on the anatomic site involved. On biopsy, the features of Sparganosis are characteristic. Importantly, Spirometra must be distinguished from other cestodes recognized in clinical practice, such as Taenia solium causing Cysticerosis. The Cysticercus larva has a similar stroma, but also contains a scolex, hooks, and a surrounding fluid-filled cyst called a bladder. In addition, cysticerci do not display the longitudinal smooth muscle fibers that are characteristic of the sparganum. Finally, Cysticercosis often presents with multiple lesions and is classically associated with involvement of the brain, skeletal and cardiac muscle. The distinction between cysticercosis and sparganosis is relevant because the two cestodes have distinct modes of transmission and thus any required
public health measures in response to cases of infection would be best tailored with an accurate diagnosis. On clinical follow-up, no recent potential exposure to untreated water or snake meat was identified. The patient, however, provided a history of occasional frog meat consumption greater than 10 years ago while residing in the Philippines. It remained unclear how the frog meat was prepared, but it was presumed to be raw or undercooked, given that complete cooking kills the infective larvae. After subsequent clinical evaluation, no additional foci of Sparganosis were noted. In summary, we illustrate a unique case of Sparganosis with emphasis on the distinguishing morphologic features of the organism.
Malignant Adenomyoepithelioma: A Rare Entity Angelica Robinson, MD,* Jennifer Mayne, MD,* Nahal Boroumand, MD,† H. Colleen Silva, MD, FACS,‡ Mahmoud Eltorky, MD, PhD,† and Joshua Mayne, MD† *Department of Radiology, Medical Branch, University of Texas, Galveston, Texas; †Department of Pathology, Medical Branch, University of Texas, Galveston, Texas; ‡Department of Surgery, Medical Branch, University of Texas, Galveston, Texas
I
n August 2012, a 49-year-old female presented to our breast center requesting a second opinion. At that time, she stated that her symptoms of right breast enlargement, discomfort, and yellow nipple discharge had begun in September 2011. By March 2012, the nipple discharge had become spontaneous and bloody. Subsequently, between March 2012 and August 2012, she received various diagnostic studies and interventional procedures (at an outside institution), which included at least two vacuum-assisted ultrasound-guided core biopsies and two surgical excisional biopsies. The pathology from these biopsies revealed no atypia or malignancy; Address correspondence and reprint requests to: Jennifer Mayne, Department of Radiology, Medical Branch, University of Texas, Galveston, TX, USA, or e-mail: [email protected] DOI: 10.1111/tbj.12214 © 2013 Wiley Periodicals, Inc., 1075-122X/14 The Breast Journal, Volume 20 Number 1, 2014 94–96
however, benign findings such as papillomatosis, ductal hyperplasia, and sclerosing adenosis were reported. Following the second excisional biopsy, the patient experienced no additional nipple discharge. On our initial physical examination in August 2012, no dominant breast masses were palpated. Review of the patient’s initial outside facility mammogram (Fig. 1) showed heterogeneously dense breasts with a 5-cm oval mass with partially obscured margins at 10 o’clock posterior depth, which had subsequently been excised. No additional imaging or intervention was performed, and a period of healing was advised, given her recent history of multiple right breast interventions. In October 2012, the patient followed up at our facility complaining of a recurrence of her palpable right breast mass. Physical examination now revealed a 7 9 7 cm palpable mass encompassing most of the upper outer quadrant and subareolar region of the
Less than 1% of All Breast Cancers • 95
Figure 2. Ultrasound 10/9/12 revealing a 6.5-cm complex mass with cystic and solid components.
Figure 1. Initial Outside Mammogram 3/5/12 revealing heterogeneously dense breasts with a 5.0-cm oval mass with partially obscured margins along the 10 o’clock axis at posterior depth.
right breast. Ultrasound of the palpable abnormality (Fig. 2) showed a 6.5 cm complex mass with cystic and solid components centered at 10 o’clock 2 cm from the nipple. Aspiration of the cystic component of the mass revealed a few small aggregates of atypical cells with enlarged nuclei and abundant vacuolated cytoplasm, possibly related to reactive changes; however, a residual intracystic papillary lesion could not be excluded. Based on these findings, the decision was made to perform a lumpectomy. The lumpectomy specimen was sectioned revealing a partially solid and partially cystic mass measuring
~8 9 7 9 3 cm. Histopathological analysis of the mass at low power showed a nonencapsulated lesion with both lobulated and papillary architectural features as well as cystic changes and necrosis. Highpower examination showed a biphasic population of both myoepithelial cells and ductal epithelial cells. There was a significant overgrowth of myoepithelial cells, which made identification of the ductal epithelial component very difficult. P63, CK903, CK5/6, and smooth muscle actin stains all highlighted the proliferation of myoepithelial cells, while a CK8 immunostain highlighted the epithelial component confirming this lesion as an adenomyoepithelioma. However, although adenomyoepitheliomas are typically benign lesions, they must be classified as malignant if they show cytologic atypia, a high mitotic index (greater than three mitosis per 10 high power field), and an infiltrative growth pattern. In view of this tumor showing all of these features, it was diagnosed as a malignant adenomyoepithelioma (Fig. 3). In light of this diagnosis, the patient returned to surgery for a simple mastectomy with sentinel node excision. The final pathology from the mastectomy showed a residual 2-mm microscopic focus of adenomyoepithelioma within the breast tissue; however, the two sentinel nodes and two additional axillary lymph nodes were all negative for malignancy. Although adenomyoepitheliomas are typically benign, rarely, malignant transformation can occur involving the epithelial component, the myoepithelial component, or both components.
96 • robinson et al.
(a)
(c)
(b)
(d)
Figure 3. (a) Low-power magnification (29) showing malignant adenomyoepithelioma with areas of necrosis and invasion into breast parenchyma. (b) High-power magnification (209) showing four mitosis. (c) Highpower magnification (209) showing invasive component of malignant adenomyoepithelioma with focal necrosis. (d) Low-power magnification (49) showing myoepithelial cells highlighted by p63 immunostain, within both the invasive and non-invasive areas of malignant adenomyoepithelioma.
involved by sparganosis. Clinical symptoms vary depending on the anatomic site involved. On biopsy, the features of Sparganosis are characteristic. Importantly, Spirometra must be distinguished from other cestodes recognized in clinical practice, such as Taenia solium causing Cysticerosis. The Cysticercus larva has a similar stroma, but also contains a scolex, hooks, and a surrounding fluid-filled cyst called a bladder. In addition, cysticerci do not display the longitudinal smooth muscle fibers that are characteristic of the sparganum. Finally, Cysticercosis often presents with multiple lesions and is classically associated with involvement of the brain, skeletal and cardiac muscle. The distinction between cysticercosis and sparganosis is relevant because the two cestodes have distinct modes of transmission and thus any required
public health measures in response to cases of infection would be best tailored with an accurate diagnosis. On clinical follow-up, no recent potential exposure to untreated water or snake meat was identified. The patient, however, provided a history of occasional frog meat consumption greater than 10 years ago while residing in the Philippines. It remained unclear how the frog meat was prepared, but it was presumed to be raw or undercooked, given that complete cooking kills the infective larvae. After subsequent clinical evaluation, no additional foci of Sparganosis were noted. In summary, we illustrate a unique case of Sparganosis with emphasis on the distinguishing morphologic features of the organism.
Malignant Adenomyoepithelioma: A Rare Entity Angelica Robinson, MD,* Jennifer Mayne, MD,* Nahal Boroumand, MD,† H. Colleen Silva, MD, FACS,‡ Mahmoud Eltorky, MD, PhD,† and Joshua Mayne, MD† *Department of Radiology, Medical Branch, University of Texas, Galveston, Texas; †Department of Pathology, Medical Branch, University of Texas, Galveston, Texas; ‡Department of Surgery, Medical Branch, University of Texas, Galveston, Texas
I
n August 2012, a 49-year-old female presented to our breast center requesting a second opinion. At that time, she stated that her symptoms of right breast enlargement, discomfort, and yellow nipple discharge had begun in September 2011. By March 2012, the nipple discharge had become spontaneous and bloody. Subsequently, between March 2012 and August 2012, she received various diagnostic studies and interventional procedures (at an outside institution), which included at least two vacuum-assisted ultrasound-guided core biopsies and two surgical excisional biopsies. The pathology from these biopsies revealed no atypia or malignancy; Address correspondence and reprint requests to: Jennifer Mayne, Department of Radiology, Medical Branch, University of Texas, Galveston, TX, USA, or e-mail: [email protected] DOI: 10.1111/tbj.12214 © 2013 Wiley Periodicals, Inc., 1075-122X/14 The Breast Journal, Volume 20 Number 1, 2014 94–96
however, benign findings such as papillomatosis, ductal hyperplasia, and sclerosing adenosis were reported. Following the second excisional biopsy, the patient experienced no additional nipple discharge. On our initial physical examination in August 2012, no dominant breast masses were palpated. Review of the patient’s initial outside facility mammogram (Fig. 1) showed heterogeneously dense breasts with a 5-cm oval mass with partially obscured margins at 10 o’clock posterior depth, which had subsequently been excised. No additional imaging or intervention was performed, and a period of healing was advised, given her recent history of multiple right breast interventions. In October 2012, the patient followed up at our facility complaining of a recurrence of her palpable right breast mass. Physical examination now revealed a 7 9 7 cm palpable mass encompassing most of the upper outer quadrant and subareolar region of the
Less than 1% of All Breast Cancers • 95
Figure 2. Ultrasound 10/9/12 revealing a 6.5-cm complex mass with cystic and solid components.
Figure 1. Initial Outside Mammogram 3/5/12 revealing heterogeneously dense breasts with a 5.0-cm oval mass with partially obscured margins along the 10 o’clock axis at posterior depth.
right breast. Ultrasound of the palpable abnormality (Fig. 2) showed a 6.5 cm complex mass with cystic and solid components centered at 10 o’clock 2 cm from the nipple. Aspiration of the cystic component of the mass revealed a few small aggregates of atypical cells with enlarged nuclei and abundant vacuolated cytoplasm, possibly related to reactive changes; however, a residual intracystic papillary lesion could not be excluded. Based on these findings, the decision was made to perform a lumpectomy. The lumpectomy specimen was sectioned revealing a partially solid and partially cystic mass measuring
~8 9 7 9 3 cm. Histopathological analysis of the mass at low power showed a nonencapsulated lesion with both lobulated and papillary architectural features as well as cystic changes and necrosis. Highpower examination showed a biphasic population of both myoepithelial cells and ductal epithelial cells. There was a significant overgrowth of myoepithelial cells, which made identification of the ductal epithelial component very difficult. P63, CK903, CK5/6, and smooth muscle actin stains all highlighted the proliferation of myoepithelial cells, while a CK8 immunostain highlighted the epithelial component confirming this lesion as an adenomyoepithelioma. However, although adenomyoepitheliomas are typically benign lesions, they must be classified as malignant if they show cytologic atypia, a high mitotic index (greater than three mitosis per 10 high power field), and an infiltrative growth pattern. In view of this tumor showing all of these features, it was diagnosed as a malignant adenomyoepithelioma (Fig. 3). In light of this diagnosis, the patient returned to surgery for a simple mastectomy with sentinel node excision. The final pathology from the mastectomy showed a residual 2-mm microscopic focus of adenomyoepithelioma within the breast tissue; however, the two sentinel nodes and two additional axillary lymph nodes were all negative for malignancy. Although adenomyoepitheliomas are typically benign, rarely, malignant transformation can occur involving the epithelial component, the myoepithelial component, or both components.
96 • robinson et al.
(a)
(c)
(b)
(d)
Figure 3. (a) Low-power magnification (29) showing malignant adenomyoepithelioma with areas of necrosis and invasion into breast parenchyma. (b) High-power magnification (209) showing four mitosis. (c) Highpower magnification (209) showing invasive component of malignant adenomyoepithelioma with focal necrosis. (d) Low-power magnification (49) showing myoepithelial cells highlighted by p63 immunostain, within both the invasive and non-invasive areas of malignant adenomyoepithelioma.
