(Radiographics. 1999;19:813-816.)
© RSNA, 1999
Cases of the Day1
Breast Imaging Case of the Day
Dvora Cyrlak, MD,
Philip M. Carpenter, MD and
Niraj B. Rawal, BS
1 From the Departments of Radiological Sciences (D.C.) and Pathology (P.M.C.), University of California, Irvine Medical Center (N.B.R.), 101 The City Drive, Orange, CA 92868-3298. From the 1998 RSNA scientific assembly. Received November 6, 1998; revision requested November 23 and received December 21; accepted December 22. Address reprint requests to D.C.
Index Terms: Breast neoplasms, 00.311, 00.329 • Fibroadenoma, 00.311
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HISTORY
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A 30-year-old woman had a newly palpable, 2-cm-diameter, circumscribed mass at the 3-o'clock position in the left breast. Fine-needle aspiration and mammography were performed.
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FINDINGS
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A mediolateral oblique mammogram showed a circumscribed mass with partially sharply defined, partially obscured borders (Fig 1a) that corresponded to the palpable mass. The mass was not seen on a craniocaudal mammogram (Fig 1b). Superior to the mass was a spiculated lesion (Fig 1a, 1b). The center of the lesion contained multiple circumscribed, rounded, translucent areas, which were best seen on a coned magnification mediolateral oblique mammogram (Fig 1c). The spicules were very long relative to the diameter of the center of the lesion and were distributed in a "sheaves of wheat" pattern with asymmetric clumping of the spicules. The results of fine-needle aspiration of the palpable mass were compatible with a fibroadenoma. Stereotactically guided core needle biopsy and subsequent wire localization and surgical biopsy were performed on the spiculated mass.
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Figure 1a. (a) Mediolateral oblique mammogram of the left breast shows a circumscribed mass (arrowhead) and an unsuspected spiculated lesion superior to it (arrow). (b) Craniocaudal mammogram does not clearly show the palpable mass but does show the spiculated lesion (arrow). (c) Coned magnification mediolateral oblique mammogram shows the translucent center of the spiculated lesion with asymmetric clumping of spicules.
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Figure 1b. (a) Mediolateral oblique mammogram of the left breast shows a circumscribed mass (arrowhead) and an unsuspected spiculated lesion superior to it (arrow). (b) Craniocaudal mammogram does not clearly show the palpable mass but does show the spiculated lesion (arrow). (c) Coned magnification mediolateral oblique mammogram shows the translucent center of the spiculated lesion with asymmetric clumping of spicules.
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Figure 1c. (a) Mediolateral oblique mammogram of the left breast shows a circumscribed mass (arrowhead) and an unsuspected spiculated lesion superior to it (arrow). (b) Craniocaudal mammogram does not clearly show the palpable mass but does show the spiculated lesion (arrow). (c) Coned magnification mediolateral oblique mammogram shows the translucent center of the spiculated lesion with asymmetric clumping of spicules.
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DIAGNOSIS: Tubular carcinoma and fibroadenoma.
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DISCUSSION
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Tubular carcinoma is an extremely well-differentiated invasive carcinoma (Fig 2a) that forms neoplastic tubules that mimic breast ductules (1). The tubules are typically lined with one layer of regularly shaped cells and are surrounded by fibrous stroma (1) (Fig 2b).
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Figure 2a. (a) Photomicrograph (original magnification, x5; hematoxylin-eosin stain) shows infiltrative growth of tubular carcinoma into adjacent fat; this growth pattern gives the lesion its spiculated appearance. (b) Photomicrograph (original magnification, x200; hematoxylin-eosin stain) shows tubules with patent lumina and angulated borders. The individual cells show low-grade cytologic features with little nuclear pleomorphism.
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Figure 2b. (a) Photomicrograph (original magnification, x5; hematoxylin-eosin stain) shows infiltrative growth of tubular carcinoma into adjacent fat; this growth pattern gives the lesion its spiculated appearance. (b) Photomicrograph (original magnification, x200; hematoxylin-eosin stain) shows tubules with patent lumina and angulated borders. The individual cells show low-grade cytologic features with little nuclear pleomorphism.
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Although invasive cancers containing tubular elements are not uncommon, pure tubular carcinoma is rare and accounts for less than 2% of all breast cancers (1). The minimum percentage of tubular elements required to make this diagnosis varies in different reports, ranging from 75% (1–4) to 80% (5) to 90% (6). Less pure tubular carcinomas are referred to as mixed tubular carcinomas. A third type is tubulolobular carcinoma, which has both tubular and infiltrating lobular elements (4).
Differentiation between pure and mixed tubular carcinomas is important because it affects the prognosis. As the percentage of nontubular elements in a tumor increases, so does the likelihood of lymph node and metastatic spread and multifocality (1,2,4,5,7,8). The frequency of lymph node metastasis in mixed tubular carcinoma is comparable with that in infiltrating ductal carcinoma (5).
Tubular carcinoma is most common in women aged 40–60 years (2,3,6,7). The median age is the middle to late 40s, slightly younger than for breast cancer in general (1). Although tubular carcinoma may be discovered as a palpable mass, it is usually detected at screening mammography when the mass is less than 1 cm in diameter (2,3,5,6). Typically, tubular carcinoma appears on mammograms as a small, spiculated mass indistinguishable from other invasive cancers (2,7,9). The spicules seen at mammography are due to malignant cells and fibrous stroma (2). Uncommonly, microcalcifications are present (2,5,6).
The mammographic appearance of the tubular carcinoma in our patient suggested the possibility of a radial scar, which is a benign sclerosing lesion. Specifically, the following mammographic features described by Tabár and Dean (10) as favoring the diagnosis of radial scar were present (Fig 1): "translucent, oval or circular areas at the center of the radiating structure" and "long, thin spicules as well as spicules clumped together in thick aggregates."
In a study of 40 lesions suggestive of radial scars at mammography, Frouge et al (11) found 20 radial scars, 12 solitary carcinomas (including four tubular carcinomas), and eight carcinomas associated with a radial scar (seven tubular carcinomas and one infiltrating ductal carcinoma). They found no mammographic difference "between benign and malignant lesions according to size and shape of the spicules, size of the central core, and the presence of calcifications." According to our pathologist (P.M.C.), there was no histologic evidence of an associated radial scar in the tubular carcinoma found in our patient.
It is generally agreed that a tissue diagnosis is needed to distinguish carcinoma and benign spiculated lesions such as radial scars. Initially, stereotactically guided core needle biopsy was performed in our patient with both a prospective and retrospective histologic diagnosis of "sclerosing adenosis and fibrosis." This diagnosis necessitated excisional biopsy of the entire lesion (11,12).
There is controversy as to whether tubular carcinoma arises from a radial scar or is just an associated finding. On the basis of histopathologic studies, Linell et al (13) reached the following conclusions: "Our investigation of several hundred radial scars revealed many pictures of transitional stages (borderline cases) ranging up to frank tubular carcinomas and convinced us that tubular carcinoma always starts in a radial scar. Remnants of radial scars can be found in all tubular carcinomas. Since radial scars are much more common than carcinoma, it is improbable that they all develop into carcinomas."
In contrast, Andersen and Gram (14) performed long-term follow-up of 32 cases of radial scar and concluded that there is no increased frequency of breast carcinoma in patients with this history. A subsequent autopsy study showed that radial scars do not have increased malignant potential unless they contain high-risk lesions such as atypical hyperplasia or carcinoma in situ (15).
Aside from radial scar, other entities that have been found in association with tubular carcinoma include lobular proliferative lesions and ductal carcinoma in situ. Ductal carcinoma in situ is found in association with the majority of tubular carcinomas and is usually papillary, cribriform, or both (1,3). The presence of a fibroadenoma in the same breast as a tubular carcinoma in our patient is thought to be coincidental. Contralateral cancers, usually infiltrating ductal tumors, have been reported in 10% of patients with tubular carcinoma (1).
The prognosis for pure tubular carcinoma is excellent with low frequencies of axillary lymph node involvement and metastatic disease. Feig et al (5) found no axillary lymph node involvement in 17 cases of at least 80% pure tubular carcinoma. Leibman et al (6) reported that the prognosis for 90% or greater pure tubular carcinoma is so favorable that only wide local excision was recommended. In contrast, Elson et al (2) found a 29% frequency of axillary lymph node metastases in a series of patients with 75% or greater pure tubular carcinoma and recommended continuation of axillary lymph node dissection. Although tubular carcinoma is usually a unicentric lesion, decision making in regard to conservation therapy may be complicated by the presence of multifocality in about 20% of cases of pure tubular carcinoma. Multifocality or multicentricity is encountered in 30% or more of mixed tubular or tubulolobular carcinomas (1,4,16).
Our patient was treated with lumpectomy and radiation therapy. She was lost to follow-up after 1 year.
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References
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HISTORY
FINDINGS
