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Table of Contents
Definition / general | Clinical features | Prognostic factors | Case reports | Clinical images | Gross description | Gross images | Microscopic (histologic) description | Microscopic (histologic) images | Cytology description | Cytology images | Positive stains | Negative stains | Molecular / cytogenetics description | Videos | Differential diagnosis | Additional referencesCite this page: Medullary carcinoma. PathologyOutlines.com website. http://www.pathologyoutlines.com/topic/breastmalignantmedullary.html. Accessed August 20th, 2017.
Definition / general
- Well circumscribed, composed of poorly differentiated cells in syncytia or large sheets, with prominent lymphoplasmacytic infiltrate, scant fibrous stroma, no glandular structures, minimal DCIS
- Considered a type of basal-like carcinoma (Breast Cancer Res 2007;9:R24, Am J Surg Pathol 2007;31:501)
- "Medulla" refers to soft structure of marrow (tumors are often soft)
Clinical features
- Uncommon, < 1% of invasive breast carcinomas
- Usually < 50 years old, often < 35 years old, common in Japanese, associated with BRCA1 mutations
- More activated cytotoxic lymphocytes than poorly differentiated ductal carcinomas (Mod Pathol 1999;12:1050, Mod Pathol 2008;21:1101)
Prognostic factors
- Slightly better prognosis than invasive ductal carcinoma NOS, even though high grade, aneuploid, ER / PR negative, p53 positive and high proliferation rates (Hum Pathol 1988;19:1340, Int J Radiat Oncol Biol Phys 2005;62:1040)
- Better prognosis may be due to prominent inflammation (Eur J Cancer 2009;45:1780, Mod Pathol 2010;23:1357)
Case reports
- 58 year old woman with synchronous bilateral medullary carcinoma (J Cancer Res Ther 2012;8:129)
Clinical images
Images hosted on PathOut server:
Mammogram, courtesy of Dr. Mark R. Wick
Gross description
- Well circumscribed, often large, resembles fibroadenoma but without whorls
- Soft, fleshy, tannish gray
- No desmoplasia
- Easy to cut, large areas of necrosis and hemorrhage
Gross images
Images hosted on PathOut server:
Courtesy of Dr. Mark R. Wick
Sharply defined margin
with internal nodularity
and bosselated surface
(AFIP)
Images hosted on other servers:
Well circumscribed partly cystic grey white
Atypical medullary carcinoma: primary and nodal metastases
Gray fleshy tumor
Tannish pink tumor with circumscribed margin
Tumor with extensive hemorrhage
Well circumscribed and may be partially cystic
Flickr images:
Locally advanced 7 cm tumor
Microscopic (histologic) description
- Indistinct cell borders (syncytial growth) making up 75%+ of tumor with large pleomorphic tumor cells containing large nuclei, prominent nucleoli, numerous mitotic figures; peripheral cells are more eosinophilic
- Prominent lymphoplasmacytic infiltrate at periphery composed of T cells and IgA plasma cells
- Pushing borders / well circumscribed
- Classify as medullary carcinoma if tumor has above three features
- Classify as atypical medullary carcinoma (or infiltrating ductal carcinoma) if tumor has only 2 of 3 features listed above (atypical medullary carcinoma has similar prognosis as ductal carcinoma NOS)
- Other features:
- Sparse stroma
- Variable spindle cell or squamous metaplasia, occasional bizarre tumor giant cells and extensive necrosis
- No / minimal glandular differentiation, no intraductal growth or DCIS, no mucin, no calcification
Microscopic (histologic) images
Scroll to see all images.
Images hosted on PathOut server:
AFIP images:
AFIP - Atypical medullary carcinoma:
Tumor invades fat; is not well circumscribed
Images hosted on other servers:
Flickr images:
Images hosted on PathOut server:
Courtesy of Dr. Mark R. Wick
AFIP images:
Tumor cells
A lobule with in situ carcinoma in some lobular units
Focal areas of squamous metaplasia with keratin pearls
AFIP - Atypical medullary carcinoma:
Medullary features
Images hosted on other servers:
More distinct cell borders
Clusters of sheets of syncytial cells with prominent lymphoplasmacytic infiltrate
Various images
High grade syncytial pattern
FISH and IHC show HER2 amplification
Atypical medullary
carcinoma because
no lymphoplasma-
cytic infiltrate
Flickr images:
ER negative
p63
p53
CISH, heterogeneous
expression of HER2,
various images
HER2 staining (usually is negative, in this case, is focally 3+ [see image on right])
Cytology description
- Cellular smears
- Tumor cells in loosely cohesive sheets and single cells
- Moderate / marked nuclear pleomorphism and nuclear irregularities, mixed with mononuclear inflammation (Diagn Cytopathol 2007;35:408, Acta Cytol 2009;53:165)
Cytology images
Images hosted on other servers:
Papanicolaou
Atypical medullary carcinoma
Negative stains
Molecular / cytogenetics description
- Microsatellite instability is uncommon, in contrast to medullary colonic tumors (Am J Clin Pathol 2001;115:823)
- Similar genetic alterations as basal-like carcinomas
- Usually aneuploid
- Associated with BRCA1 mutations
Videos
Histopathology Breast—Medullary carcinoma
Differential diagnosis
- Collision tumor of invasive ductal NOS and MALT lymphoma: see Arch Pathol Lab Med 2004;128:99
- Lymphoepithelioma-like carcinoma: has infiltrative borders
- Lymph node in axillary tail: not circumscribed and may not be syncytial
- Undifferentiated ductal carcinoma: lacks prominent lymphoplasmacytic infiltrate, has infiltrative borders
Additional references
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