10 May 2006 Case of the Week #45

 

These cases can also be accessed by clicking on the Case of the Week button on the left hand side of our Home Page at www.PathologyOutlines.com. This email is sent only to those who subscribe in writing or by email. To view the images or references, you must click on the links in blue.

 

To subscribe or unsubscribe, email info@PathologyOutlines.com, indicating subscribe or unsubscribe to Case of the Week. We do not sell, share or use your email address for any other purpose. We also maintain two other email lists: to receive a biweekly update of new jobs added to our Jobs page, and to receive a monthly update of changes made to the website. You must subscribe or unsubscribe separately to these email lists.

 

We are pleased to announce that Lippincott Williams & Wilkins (LWW) now offers visitors to PathologyOutlines.com a 10% discount on all products purchased at www.LWW.com, except for web-based products.  Just use promotion code W5ECA1ZZ.  Any purchases made through Lippincott with this code, or through Amazon.com after visiting our Books page help our website financially, at no additional charge to you.

 

We thank Dr. Ankur Sangoi, Stanford University Department of Pathology, Stanford, California (USA) for contributing this case. We invite you to contribute a Case of the Week by sending an email to NPernick@PathologyOutlines.com with microscopic images (any size, we will shrink if necessary) in JPG or GIF format, a short clinical history, your diagnosis and any other images (gross, immunostains, EM, etc.) that may be helpful or interesting. We will write the discussion (unless you want to), list you as the contributor, and send you a check for $35 (US) for your time after we send out the case. Please only send cases with a definitive diagnosis.

 

Case of the Week #45

 

Clinical history

 

A 72 year old woman with no prior history underwent a lumpectomy for calcifications on her mammogram.

 

Micro images: image1, image2, image3, image4, image5, image6, image7, image8

 

What is your diagnosis?

 

(scroll down to continue)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Diagnosis:

 

Low grade DCIS with neuroendocrine features

 

Discussion

 

An immunostain for synaptophysin confirmed the neuroendocrine nature of the tumor cells (image9, image10)

 

Neuroendocrine-type DCIS is a rare variant, that is also called intraductal papillary carcinoma. It typically occurs in women age 60 years or greater, and is often accompanied by a breast mass or nipple discharge. It is frequently associated with intraductal papilloma with pagetoid involvement by the tumor cells, and despite its low grade nature, may have an invasive component, which often has mucinous or endocrine features (AJSP 1995;19:1237, AJSP 1996;20:921)

 

Microscopically, the tumor has a solid growth pattern, or may have neuroendocrine-like festoons and rosettes and a prominent fibrovascular septa. The cells are polygonal, oval or spindled, with abundant granular eosinophilic cytoplasm and bland, oval nuclei. There may be accumulation of basophilic intracellular mucin. Stromal fibrosis is variable. There is usually no necrosis.

Cytologic smears show plasmacytoid tumor cells and arborizing papillary fronds (Cancer 2000;90:286)

 

Tumor cells are immunoreactive for neuroendocrine markers chromogranin, synaptophysin and neuron-specific enolase. They are usually ER+ and PR+, and negative for high molecular weight cytokeratin, p53, HER2 and Ki-67 (Histopathology 2004;45:343). Ultrastructural examination shows dense core neurosecretory granules and larger mucigen granules.

 

The differential diagnosis includes florid epithelial hyperplasia and papilloma, which can be distinguished based on the monomorphic cell population associated with DCIS or the neuroendocrine immunostains.

 

Additional references: Am Surg 2000;66:1163 (case report),

 

Nat Pernick, M.D.
PathologyOutlines.com, LLC
30100 Telegraph Road, Suite 404
Bingham Farms, Michigan (USA) 48025
Telephone: 248/646-0325
Fax: 248/646-1736
Email: NPernick@PathologyOutlines.com