A 58 year old asymptomatic female presented for annual mammogram.
Mammography (Figure 1 a-d) demonstrated a persistent focal asymmetry with associated amorphous, indistinct and coarse, heterogeneous calcifications spanning approximately 5.0 cm in maximum length in the left breast lower inner quadrant. There were additional coarse heterogeneous calcifications in the immediate left retroareolar region spaced approximately 5.0 cm from the anterior margin of the focal asymmetry.
Breast ultrasound (Figure 2 a-c) showed a 1.0 x 0.8 x 0.7 cm irregular, spiculated, hypoechoic mass in the left breast at 8 o'clock axis, 8.0 cm from the nipple, in the area of focal asymmetry on mammogram.
Ultrasound guided core needle biopsy was performed and the results showed well- differentiated neuroendocrine carcinoma (Figure 3). Immunohistochemistry showed tumor cells to be positive for E-cadherin, ER, PR, GCDFP-15, CK7, chromogranin, and synaptophysin (Figure 4 a-e). Immunohistochemistry was negative for CK20 and HER2.
The patient then underwent pre-surgical breast magnetic resonance imaging (MRI) (Figure 5 a-d) which demonstrated two confluent spiculated enhancing masses with rapid wash-in and delayed wash-out enhancement (progressive kinetics) and heterogeneous T2 signal intensity and isointense T1 signal located in the left lower inner quadrant, corresponding to area of mammographic and ultrasound findings. There was a focus of signal void artifact corresponding to biopsy clip adjacent to the most posterior mass. There were several associated adjacent small sub centimeter enhancing satellite lesions. The entire area of abnormality on breast MRI measured approximately 5.5 x 3.5 x 2.5 cm.
Subsequently, the patient underwent a left breast lumpectomy with sentinel lymph node biopsy. The final pathology (Figure 6 a-c) revealed two different foci of well differentiated primary neuroendocrine carcinoma of the breast measuring 15 mm and 8 mm in greatest microscopic dimension without margin involvement and negative sentinel nodes (stage: pT1cN0M0).
Imaging features of primary neuroendocrine carcinoma of the breast are suspicious for malignancy, but are not specific, precluding the possibility of arriving at the diagnosis solely based on imaging characteristics. The diagnosis requires biopsy showing expression of neuroendocrine markers in more than 50% of the cell population, the presence of ductal carcinoma in situ, and the absence of clinical evidence of concurrent primary neuroendocrine carcinoma of any other organ.
Saturday, 13 February 2016
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