Gupta, Lilly S, Josephine, and Gali: Mixed mucinous carcinoma of breast – A case report


Introduction

Mucinous Carcinoma (MC) approximately accounts for 1-7% of breast carcinomas. It is most commonly seen in perimenopausal and postmenopausal women.1, 2 Pure Mucinous Carcinoma (PMC) has a better prognosis as compared to ductal or lobular variants of breast cancer and Mixed Mucinous Carcinoma (MMC) has unfavourable prognosis with early nodal metastases.3 Hence it is important to differentiate between the two variants of mucinous carcinoma.

Case History

We present a case of 70 year old female who came with the complaints of lump in the right breast since 2 months with no family history of breast cancer. On clinical examination, an irregular swelling of 2x1 cm was noted in upper outer quadrant and right axilla had a palpable swelling of 1x1cm. Ultrasound showed a well defined heterogenous lesion with few specks of calcification measuring 2.1x1.4cm at 10-12`o clock position involving the retroareolar region was seen and a BIRADS V score was given. Fine Needle Aspiration Cytology (FNAC) examination of breast was done and it was positive for malignant cells.

The patient underwent Right Modified mastectomy with right axillary dissection. On gross examination, a whitish hard tumour beneath Nipple Areolar Complex measuring 2x1cm with fibrous area and specks of calcification was noted. On Microscopic Examination, Sections from the tumour studied show a neoplasm composed of islands of tumour cells suspended in extracellular mucin (<30%) separated by thick fibrous septae – Capella Type B. Focal areas showing tumour cells arranged in solid nests. Individual tumour cells are oval with moderate eosinophilic cytoplasm and round to oval vesicular nuclei, mitosis is rare. Ductular formation is scanty. Multiple foci of intraductal carcinoma, solid type, cribriform type and comedo types seen. 3/13 lymph nodes were positive and margins were free of tumour.

Immunohistochemistry was done –

ER, PR, Synaptophysin were positive and

Her2neu was negative.

Figure 1

Scanner view showing fatty tissue with islands of tumour cells suspended in extracellular mucin

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Figure 2

Low power view of tumour cells suspended in extracellular mucin

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Figure 3

High power view of individual oval tumour cells with eosinophilic cytoplasm and vesicular nuclei

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Figure 4

Low power view of lymph node showing tumour deposits surrounded by perineural fat

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Figure 5

High power view showing positivity for ER

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Figure 6

High power view showing positivity for PR

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Figure 7

High power view showing positivity for synaptophysin

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Figure 8

High power view showing negativity for Her2neu

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Discussion

In our Institution, during last 3 years 50 cases of breast carcinoma were reported out of which only 3 cases i.e., 6% were mucinous adenocarcinoma of breast. FNAC was done in this case which was positive for malignancy.

MC is a relatively rare histological subtype that is characterized by neoplastic cells that are arranged in sheets or clusters and are suspended in extracellular mucin. In PMC, mucinous component is >90% consisting of solely of tumor tissue with extracellular mucin production.1 MMC has 10-90% of mucin along with invasive ductal epithelial component. Based on the cellularity and endocrine differentiation, two types of MC has been suggested. Capella type A shows scattered small epithelial clusters, strips or cribriform structures floating in pools of extracellular mucin. Capella type B shows large sheets of tumor cells with mucin production and neuroendocrine features which was confirmed by Synaptophysin IHC in this case.4, 5 Most of the MC cases are ER, PR Positive and Her2neu negative. MMC have higher rate of nodal involvement.6

It is important to differentiate MC from non-neoplastic mucocele like lesions.7 The absence of cytological atypia in epithelial lining of mucin filled ducts and presence of myoepithelial cells in pools of mucin which are extravasated in stroma due to rupture of cystically dilated mucin filled are features of mucocele like lesions.

Conclusion

In view of nodal involvement, it is important to differentiate between PMC and MMC. PMC usually shows a better prognosis and a lower lymph node metastatic rate compared to MMC.8 Adjuvant endocrine therapy is indicated for hormone responsive tumors as most of mucinous carcinomas are positive for estrogen receptor and/or progesterone-receptor. 9, 7

Abbreviations

IHC – Immunohistochemistry; MC - Mucinous carcinoma; PMC - Pure Mucinous Carcinoma; MMC - Mixed Mucinous Carcinoma; FNAC - Fine Needle Aspiration Cytology; BIRADS - Breast Imaging-Reporting and Data System; ER – Estrogen Receptor; PR – Progesterone Receptor

Source of Funding

None.

Conflict of Interest

The authors declare no conflict of interest.

References

1 

P Sun Z Zhong Q Lu M Li X Chao D Chen Mucinous carcinoma with micropapillary features is morphologically, clinically and genetically distinct from pure mucinous carcinoma of breastModern Pathol20203310194560

2 

HA Haddad Awadia Awadallah MA Hadi Mucinous breast carcinoma: Report of four cases and review of the literatureClin Diagn Pathol20171410.15761/CDP.1000120

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CI Li Risk of mortality by histologic type of breast cancer in the United StatesHorm Cancer2010131566510.1007/s12672-010-0016-8

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S Park J Koo JH Kim WI Yang BW Park KS Lee Clinicopathological characteristics of mucinous carcinoma of the breast in Korea: comparison with invasive ductal carcinoma-not otherwise specifiedJ Korean Med Sci20102533618

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B Weigelt FC Geyer HM Horlings B Kreike H Halfwerk JS Reis-Filho Mucinous and neuroendocrine breast carcinomas are transcriptionally distinct from invasive ductal carcinomas of no special typeModern Pathology20092211140114

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JC Paramo C Wilson D Velarde J Giraldo RJ Poppiti TW Mesko Pure mucinous carcinoma of the breast: is axillary staging necessary?Ann Surg Oncol2002921614

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T Nakagawa K Sato M Moriwaki R Wada A Arakawa M Saito Successful endocrine therapy for locally advanced mucinous carcinoma of the breastBreast J20121866323

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P Skotnicki B Sas-Korczynska L Strzepek J Jakubowicz P Blecharz M Reinfuss Pure and mixed mucinous carcinoma of the breast: a comparison of clinical outcomes and treatment resultsBreast J201622552934

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A Ranade R Batra G Sandhu R A Chitale J Balderacchi Clinicopathological evaluation of 100 cases of mucinous carcinoma of breast with emphasis on axillary staging and special reference to a micropapillary patternJournal of clinical pathology2010631210431050



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Article History

Received : 17-08-2021

Accepted : 14-09-2021

Available online : 23-11-2021


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https://doi.org/10.18231/j.ijpo.2021.108


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