Australian Society of CytologyCase of the Month
May 2004 - Answer and Discussion
Metastatic adenocarcinoma from a primary ductal carcinoma of the breast.
Answer
The smears show numerous malignant cells in large aggregates and balls with smooth external borders. Nuclei are enlarged and pleomorphic. The malignant cells have moderate amounts of cytoplasm.
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The cell block show numerous hollow malignant cell aggregates, but no papillary structures are seen.
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Concurrent peritoneal biopsies show irregular nests, cords and Indian-files of tumour cells which infiltrate the submesothelial connective tissue.
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Immunocytochemistry studies show strong positivity with CEA staining. There is strong nuclear staining with Oestrogen Receptor protein in approximately 70% of the tumour cells. Progesterone receptor staining was negative.
These results favour a metastatic breast adenocarcinoma.
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Subsequent Ascitic and Pleural fluid specimens showed identical aggregates of adenocarcinoma cells.
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Discussion
Up to 75% of all breast carcinomas are of a ductal type.
Ductal carcinomas often give rise to pleural effusions, in contrast to Lobular carcinomas which can involve the peritoneal cavity causing ascites.
Metastasis to the pleurae can occur many years after initial diagnosis.
In this case, the final photographs of tumour cells from the Ascitic and Pleural fluids (above) come from samples taken 3 years after the initial specimen from the Pouch of Douglas was received.
In serous fluids, the cells from a ductal carcinoma present in large numbers as 3 dimensional tumour balls or “proliferation spheres”. These spheres often have the hollow centers as seen above forming acinar structures with smooth external outlines, and may possess scanty amounts of mucin.
Malignant cells have a monotonous appearance with an increased N:C ratio. Nuclei are pleomorphic, hyperchromatic with coarse chromatin and prominent nucleoli.
References:
- Gray W,McKee G,Diagnostic Cytopathology, 2nd Edition,Churchill Livingstone 2003.
- Geisinger K,Raab S,Stanley M,Silverman J,Abati A, Modern Cytopathology, Churchill Livingstone 2004.
