10 May 2006 Case of the Week #45


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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?


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Low grade DCIS with neuroendocrine features




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.
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