BREAST IMAGES
Primary Neuroendocrine Tumor of the Breast Santiago Sherwell-Cabello, MD, Antonio Maffuz-Aziz, MD, Betsabe Hern andez-Hern andez, MD, Ver onica Bautista-Pe~ na, MD, and Sergio Rodrıguez-Cuevas, MD Instituto de Enfermedades de la Mama, FUCAM AC, Mexico City, Mexico
A
60-year-old postmenopausal woman with no remarkable history was seen in 2011 due to the presence of fibroadenoma in the left breast. Two years later, she presented at our institution with a 5.5 cm tumor in the right breast with palpable axillary nodes, which was not seen on previous mammograms (Fig. 1). A percutaneous biopsy showed a poorly differentiated neuroendsocrine tumor. Clinical stage IIIA (T3N1 M0). No morphological changes were found in the fibroadenoma in the left breast. A 68Ga-DOTATATOC PET-CT was carried out to rule out other primary sites. No functional zones outside the breast and axilla were found (Fig. 2).
In the tumor board session, the patient was considered a candidate for a modified radical mastectomy. The definitive histopathological result showed a 6 cm (a)
(b)
(c)
Figure 2. 68Ga-DOTATATOC PET-CT confirming primary breast origin. (a) No functional zones outside the zones outside the breast and axilla were found. (b) Image of the breast tumor. (c) Axillary lymph nodes.
Figure 1. BI-RADS 5 CC-Mammography showing the right breast tumor. Address correspondence and reprint requests to: Santiago SherwellCabello, MD, Instituto de Enfermedades de la Mama, FUCAM AC Breast Surgical Oncology, Bordo 100 Sta Ursula Coapa Coyoacan, Mexico City 04980, Mexico, or e-mail: [email protected] DOI: 10.1111/tbj.12413 © 2015 Wiley Periodicals, Inc., 1075-122X/15 The Breast Journal, 2015 1–2
Figure 3. Section of the breast showing a 6 cm tumor with hemorrhagic areas.
2 • sherwell-cabello et al.
(a)
(b)
(c)
Figure 4. (a) Panoramic view, H-E 59; solid growth pattern with extensive necrotic areas. (b) Round–oval shaped cells with granular cromatine and multiple mitosis were identified. (c) Positive for synaptophysin.
light brown nodular tumor, with hemorrhagic and necrotic areas. No tumor cells were found in surgical margins (Fig. 3). A neoplasm with a solid growth pattern and necrotic areas was observed in histologic sections (Fig. 4a). Round to oval small cells, fine granular chromatin and scant cytoplasm were observed (Fig. 4b). Cells with multiple mitosis were found (19 in 10 HPF). Lymphatic invasion was identified, and metastatic activity was found in a 4 cm axillary cluster and in 11 of 15 lymph nodes, 6 of them with capsule rupture. A immunohistochemistry panel was performed and resulted positive for synaptophysin (Fig. 4c), focally for CK7 and mammaglobine, and negative for TTF-1, E, chromogranin, CK20, CD99, estrogen and progesterone receptors, Her2-neu, somatostatin, GH, ACTH, and calcitonin. Ki-67 was defined as 70%. Based on the 2012 Breast Cancer Guidelines of the AJCC/ TNM, a pathologic stage III C (pT3 pN3aM0) was determined. Chemotherapy with carboplatin and etoposide was indicated. Subsequently, radiotherapy was administered at a dose of 60 Gy to the thoracic wall and axillary and
supraclavicular areas. No surgical complications were found. A 6-month follow-up is reported, in which no local or distant recurrence was detected. Primary breast neuroendocrine tumors were initially described by Feyrter in 1963. The majority of neuroendocrine carcinomas develop in the gastrointestinal or respiratory tracts, less than 1% arise in the breast tissue. Primary neuroendocrine tumors of the breast are defined as a subtype of invasive carcinoma in which more than 50% of the neoplastic cells express neuroendocrine markers, being chromogranin and synaptophysin the most sensitive markers for breast origin. In addition, radiolabeled octreotide imaging studies represent a useful tool to rule out other more common primary sites. There is no consensus on the management of primary breast neuroendocrine tumors. Modified radical mastectomy has been proposed as the standard surgical approach. Carboplatin and etoposide therapy has been described as firstline treatment for neuroendocrine tumors. The use of radiation therapy and hormone therapy should be used under the same indications for other breast tumors.
Primary Neuroendocrine Tumor of the Breast Santiago Sherwell-Cabello, MD, Antonio Maffuz-Aziz, MD, Betsabe Hern andez-Hern andez, MD, Ver onica Bautista-Pe~ na, MD, and Sergio Rodrıguez-Cuevas, MD Instituto de Enfermedades de la Mama, FUCAM AC, Mexico City, Mexico
A
60-year-old postmenopausal woman with no remarkable history was seen in 2011 due to the presence of fibroadenoma in the left breast. Two years later, she presented at our institution with a 5.5 cm tumor in the right breast with palpable axillary nodes, which was not seen on previous mammograms (Fig. 1). A percutaneous biopsy showed a poorly differentiated neuroendsocrine tumor. Clinical stage IIIA (T3N1 M0). No morphological changes were found in the fibroadenoma in the left breast. A 68Ga-DOTATATOC PET-CT was carried out to rule out other primary sites. No functional zones outside the breast and axilla were found (Fig. 2).
In the tumor board session, the patient was considered a candidate for a modified radical mastectomy. The definitive histopathological result showed a 6 cm (a)
(b)
(c)
Figure 2. 68Ga-DOTATATOC PET-CT confirming primary breast origin. (a) No functional zones outside the zones outside the breast and axilla were found. (b) Image of the breast tumor. (c) Axillary lymph nodes.
Figure 1. BI-RADS 5 CC-Mammography showing the right breast tumor. Address correspondence and reprint requests to: Santiago SherwellCabello, MD, Instituto de Enfermedades de la Mama, FUCAM AC Breast Surgical Oncology, Bordo 100 Sta Ursula Coapa Coyoacan, Mexico City 04980, Mexico, or e-mail: [email protected] DOI: 10.1111/tbj.12413 © 2015 Wiley Periodicals, Inc., 1075-122X/15 The Breast Journal, 2015 1–2
Figure 3. Section of the breast showing a 6 cm tumor with hemorrhagic areas.
2 • sherwell-cabello et al.
(a)
(b)
(c)
Figure 4. (a) Panoramic view, H-E 59; solid growth pattern with extensive necrotic areas. (b) Round–oval shaped cells with granular cromatine and multiple mitosis were identified. (c) Positive for synaptophysin.
light brown nodular tumor, with hemorrhagic and necrotic areas. No tumor cells were found in surgical margins (Fig. 3). A neoplasm with a solid growth pattern and necrotic areas was observed in histologic sections (Fig. 4a). Round to oval small cells, fine granular chromatin and scant cytoplasm were observed (Fig. 4b). Cells with multiple mitosis were found (19 in 10 HPF). Lymphatic invasion was identified, and metastatic activity was found in a 4 cm axillary cluster and in 11 of 15 lymph nodes, 6 of them with capsule rupture. A immunohistochemistry panel was performed and resulted positive for synaptophysin (Fig. 4c), focally for CK7 and mammaglobine, and negative for TTF-1, E, chromogranin, CK20, CD99, estrogen and progesterone receptors, Her2-neu, somatostatin, GH, ACTH, and calcitonin. Ki-67 was defined as 70%. Based on the 2012 Breast Cancer Guidelines of the AJCC/ TNM, a pathologic stage III C (pT3 pN3aM0) was determined. Chemotherapy with carboplatin and etoposide was indicated. Subsequently, radiotherapy was administered at a dose of 60 Gy to the thoracic wall and axillary and
supraclavicular areas. No surgical complications were found. A 6-month follow-up is reported, in which no local or distant recurrence was detected. Primary breast neuroendocrine tumors were initially described by Feyrter in 1963. The majority of neuroendocrine carcinomas develop in the gastrointestinal or respiratory tracts, less than 1% arise in the breast tissue. Primary neuroendocrine tumors of the breast are defined as a subtype of invasive carcinoma in which more than 50% of the neoplastic cells express neuroendocrine markers, being chromogranin and synaptophysin the most sensitive markers for breast origin. In addition, radiolabeled octreotide imaging studies represent a useful tool to rule out other more common primary sites. There is no consensus on the management of primary breast neuroendocrine tumors. Modified radical mastectomy has been proposed as the standard surgical approach. Carboplatin and etoposide therapy has been described as firstline treatment for neuroendocrine tumors. The use of radiation therapy and hormone therapy should be used under the same indications for other breast tumors.
