|Year : 2015 | Volume
| Issue : 2 | Page : 94-96
Secretory carcinoma of breast mimicking an abscess: A diagnostic dilemma
K Bharathi, Naseem Noorunissa
Department of Pathology, Shri Satya Sai Medical College and Research Institute, Nellikuppam, Kancheepuram, Tamil Nadu, India
|Date of Web Publication||10-Apr-2015|
Department of Pathology, Shri Satya Sai Medical College and Research Institute, Nellikuppam, Kancheepuram - 603 108, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Secretory carcinoma is a rare type of breast carcinoma usually seen in the young females, and it is also called as "Juvenile carcinoma." We report here a case of secretory carcinoma in an elderly female with an unusual clinical presentation. She had a painful swelling in left breast of 6 cm × 5 cm size for the past 6 months. Skin over the swelling was inflamed and ulcerated. Mammogram findings favored a chronic infected hematoma/abscess. Fine needle aspirate (FNA) is a murky fluid admixed with blood and was reported as acute inflammatory lesion. 2 weeks later she developed nipple retraction and an increase in size of the swelling. Fine needle aspiration cytology (FNAC) was repeated again from firm areas and in multiple points of swelling. To our surprise, FNA smears revealed dysplastic ductal epithelial cells with minimal atypia. Modified radical mastectomy was planned. Histopathological examination confirmed the mass as secretory carcinoma, a rare variant of ductal carcinoma of the breast. Postoperative chemotherapy and radiotherapy was started. We report this case to emphasize that FNAC can be repeated in suspicious cases and should be correlated clinico-radiologically to give a preoperative diagnosis.
Keywords: Breast abscess, elderly age, fine needle aspiration cytology, rare tumor, secretory carcinoma
|How to cite this article:|
Bharathi K, Noorunissa N. Secretory carcinoma of breast mimicking an abscess: A diagnostic dilemma. Int J Health Allied Sci 2015;4:94-6
|How to cite this URL:|
Bharathi K, Noorunissa N. Secretory carcinoma of breast mimicking an abscess: A diagnostic dilemma. Int J Health Allied Sci [serial online] 2015 [cited 2020 Feb 22];4:94-6. Available from: http://www.ijhas.in/text.asp?2015/4/2/94/154909
| Introduction|| |
Secretory carcinoma of breast is a rare entity (<1%) with a favourable prognosis. Though it is once called as 'juvenile carcinoma', many cases are now reported in the wide range of age group (3-66 years). Few cases are reported in male children and male: female occurance ratio is 1:6. Secretory carcinoma is unique with a balanced gene translocation, t(12:15) that creates ETV6-NTRK3 gene translocation. It is difficult to diagnose this malignant tumor through FNAC because of minimal nuclear dysplasia and vacuolated cytoplasm. Core needle biopsy is helpful in such cases which may show stromal invasion. Modified radical mastectomy with axillary clearance is the treatment of choice.
| Case report|| |
A 50-year-old postmenopausal female presented with complaints of the painful lump in left breast for the past 6 months duration. Lump was measuring 6 cm × 5 cm size and subareolar in location. Skin over the swelling was inflamed and ulcerated [Figure 1]. Axillary lymphnodes were not palpable. Mammogram showed a complex cyst with solid hypodense areas. A provisional diagnosis of chronic hematoma/abscess was given [Figure 2].
|Figure 1: Photograph shows 6 cm × 5 cm left breast lump with nipple retraction and ulceration|
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|Figure 2: Mammogram shows the complex cystic appearance of the lump along with solid areas|
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Fine needle aspirate was a murky hemorrhagic fluid, which on microscopic examination showed only acute inflammatory cells suggesting an inflammatory pathology. 2 weeks later she developed nipple retraction with an increase in size of swelling. A clinical suspicion of breast carcinoma was raised. Hence, fine needle aspiration cytology was repeated from firm areas at multiple points. Now the Smears from the solid part of the mass showed ductal epithelial cells with mild atypia with vacuolated cytoplasm [Figure 3]. Bare nuclei were absent in the background. These features were suggestive of ductal carcinoma of the breast.
|Figure 3: Cytology smear shows groups of ductal epithelial cells having vacuolated cytoplasm and mild nuclear atypia (green arrow, H and E, ×400)|
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She underwent modified radical mastectomy with axillary lymphnode dissection. On gross examination, neoplasm showed a cavity filled with necrotic material and a solid component, which is gray white and friable.
Histopathological examination showed many microcysts and macrocysts filled with periodic acid-Schiff (PAS) positive diastase resistant secretions [Figure 4]. Neoplasm has a pushing border. Cysts were lined by malignant ductal epithelial cells with vesicular nucleus and vacuolated cytoplasm [Figure 4]. Some of the cells showed apocrine changes also. These features were in favor of secretory carcinoma of the breast, a rare variant of ductal carcinoma of the breast. Five lymphnodes were dissected out from axillary pad of fat. They do not show any metastatic deposits.
|Figure 4: Photomicrograph shows cystic spaces filled with secretions and are lined by cuboidal epithelial cells with atypical vesicular nucleus (black arrow, H and E, ×400)|
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Postoperative chemotherapy of cyclophosphamide, methotrexate and 5-flurouracil (CMF) was given. Tamoxifen 10 mg/day was also started. 1-year of follow-up till now showed no recurrence. In our case, secretory carcinoma caused a diagnostic dilemma by mimicking like breast abscess/chronic infected hematoma. We report this case for its unusual clinical presentation and rare histology.
| Discussion|| |
Secretory carcinoma also called as "Juvenile carcinoma" can occur in any age group. Few cases are reported in young males. Usually asymptomatic but can present with nipple discharge. It is an indolent neoplasm with a good prognosis.  Secretory carcinoma occurring in the elderly age group is often aggressive with axillary lymphnode metastasis. ,
Grossly neoplasm is well-circumscribed solid and cystic, small with pushing margins. Usually subareolar in location. It is the only epithelial tumor of the breast with a balanced translocation t (12:15), that creates an ETV6-NTRK3 gene translocation.  Mammogram findings are variable ranging from a complex cyst to completely solid hypodense tumor. Cytology literature on secretory carcinoma is very sparse. Cytologically it is very difficult to diagnose secretory carcinoma because of the mild atypia in the nucleus and vacuolated cytoplasm mimicking like lactational changes. It often mimics benign epithelial proliferative lesions cytologically. 
Microscopic appearance is distinct. The malignant ductal epithelial cells are arranged in tubules, solid sheets, follicular pattern (thyroid like) forming microcysts and macrocysts containing PAS positive, diastase resistant secretions in the lumen. Margins are of pushing type. Prominent hyalinization can be present. Tubular and papillary pattern is predominant.  Cells characteristically have vacuolated cytoplasm, a bland uniform nucleus and rare mitotic figures. Tavassoli and Norris reported that three features of secretory carcinoma (tumors <2 cm, well-circumscribed margins and age <20 years) indicate a favorable prognosis. 
Immunohistochemically malignant cells show strong positivity for alpha-lactalbumin, lysozyme salivary type amylase, epithelial membrane antigen, S-100 protein, accompanied by the variable expression of gross cystic disease fluid protein-15, and carcinoembryonic antigen.  Estrogen receptor and progesterone receptor status is variable.
Treatment recommendations are wide excision or quandrectomy with low axillary dissection in young patients. Surgery in the form of modified radical mastectomy with axillary clearance is the treatment of choice for elderly people. Postoperative chemotherapy using CMF regimen and radiotherapy is given to increase the survival rate. Cases have been reported regarding its resistance to chemotherapy. 
Though considered an indolent neoplasm, secondary metastatic deposits and recurrence does occur.  Axillary lymphnode metastasis is seen in 15% of the cases. Overall prognosis is excellent and the 5 years survival rate is nearly 100%.
| Conclusion|| |
Secretory carcinoma of the breast, a rare variant of ductal carcinoma occurs even in the young adults. Prognosis is excellent in younger age group but seems slightly less favorable in older patients. It is the only epithelial tumor of the breast with ETV6-NTRK3 gene translocation. We report a rare case of secretory carcinoma in a postmenopausal female mimicking like an abscess clinically and radiologically. In such cases, a high index of suspicion is needed.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]