Centrally necrotizing breast carcinoma: a rare histological subtype, which was cause of misdiagnosis in an evident clinical local recurrence
Centrally necrotizing carcinoma is a rare subtype of breast carcinoma, which is characterized by an extensive central necrotic zone accounting for at least 70% of the cross-sectional area of the neoplasm. This central necrotic zone, in turn, is surrounded by a narrow rim of proliferative viable tumor cells. We report an unusual clinical situation in which a patient whose evident breast mass suggested an ipsilateral local recurrence and for which numerous attempts to confirm the histological diagnosis had failed. The patient was treated with a radical mastectomy based on clinical suspicion of breast cancer recurrence after an undesirable delay. In this case, the narrow rim of viable malignant tissue had a thickness of 0.5 to 8 mm, and the centrally necrotizing carcinoma had a central zone with a predominance of fibrosis. The special features of this case led to a misdiagnosis and to an evident clinical local recurrence.
KeywordsCentrally necrotizing carcinoma Triple-negative breast cancer Misdiagnosis
α-smooth muscle protein
Centrally necrotizing carcinoma
Glial fibrillary acidic protein
Magnetic resonance imaging
Transverse Rectus Abdominis Myocutaneous.
Today, in most patients suffering from breast cancer, treatment is implemented with a histologically confirmed diagnosis and without a diagnostic surgical procedure because a representative sample of the tumor is usually obtained by current radiologic technology. However, in this case, a patient presented with a large breast mass as a clinical form of a breast cancer recurrence and underwent a radical mastectomy based on clinical suspicion of breast cancer recurrence without microscopic confirmation. Subsequently, the mass was diagnosed as a special subtype of invasive ductal carcinoma also termed ‘centrally necrotizing carcinoma’ (CNC) . The special macroscopic characteristics of this tumor subtype could explain why we did not diagnose cancer recurrence despite the numerous attempts that were carried out to obtain some malignant tissue.
A 53-year-old white woman diagnosed with a triple-negative basal-like invasive ductal carcinoma located at the intersection of upper quadrants of the right breast was treated with breast-conserving surgery having free surgical margins (>1.5 cm) and sentinel lymph node biopsy. Pathologic stage of the tumor was pT1N0M0. Adjuvant chemotherapy and radiotherapy were given.
Seventeen months after the end of the radiotherapy, she presented with a painful mass in her right breast at the surgical bed. There were neither palpable axillary lymph nodes nor elevation of tumor markers. The imaging study with mammography and magnetic resonance imaging (MRI) showed a right breast mass whose pathological study comprising seven breast tissue fragments obtained by vacuum-assisted percutaneous biopsy revealed fat necrosis and fibrosis. These findings were interpreted as sequelae of breast-conserving treatment. Anti-inflammatory treatment was given and close follow-up was recommended.
Right breast with a segment of skin weighing 1044 g and measuring 14 × 14 × 7 cm exhibited a retroareolar, well-circumscribed, grayish-white nodular mass with moderate consistency on a cut surface. The mass was 6 cm in size. Microscopically, the tumor was composed of an extensive central acellular hyaline and a necrotic area with some 'ghost’ cells and nuclear debris. This central area occupied more than 70% of the tumor mass and was surrounded by a narrow rim of viable infiltrating ductal carcinoma, poorly differentiated showing lack of tubule lumen formation and high nuclear grade. The thickness of the rim varied from 0.5 to 0.8 cm. Margins were free of malignancy at 1.5 cm minimal distance from the pectoral major muscle.
CNC is an uncommon subtype of breast carcinoma which displays the following histological characteristics: it comprises a well-circumscribed unicentric nodule, having an extensive central necrotic zone accounting for at least 70% of the cross-sectional area of the neoplasm; the central zone is surrounded by a narrow rim of proliferative viable tumor cells; and the residual tumor cells show high-grade infiltrating ductal carcinoma, usually accompanied by the component of ductal carcinoma in situ. Immunostaining profile can show a myoepithelial immunophenotype characterized by the expression of S100 protein, α-smooth muscle protein (α-SMA) and keratin markers [1–3].
The central necrotic zone can show three histological features: a) predominance of tumor coagulative necrosis with variable degrees of fibrosis and hyaline material, b) predominance of fibrotic or scar-like tissue with a small amount of necrotic tumor debris and c) infarction.
The CNC special characteristics and, particularly in this case, the central zone pattern with predominance of fibrosis and adiponecrosis, together with the minimal width of the viable tumor rim (0.5 to 0.8 cm) were the cause of the failure to obtain a sample of viable tumor cells in the numerous biopsies that were carried out.
This is the second CNC case published arising in the surgical bed in a patient who had undergone a lumpectomy and radiotherapy. Despite showing all defined clinical and CNC histological characteristics, features of the case contributed to difficulties in diagnosis. The other case was published by Jimenez RE (1) in a series of 34 patients.
Written informed consent was obtained from the patient for publication of this report and any accompanying images.
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