Metaplastic carcinoma of the right breast and simultaneous giant ovarian teratoma: a case report
A 55-year-old woman (married, having 3 children) presented with a painless mass in the right breast discovered by self-examination one year before reporting it. She had no other symptoms or previous breast problems and no family history of breast cancer.\nOn clinical examination, palpation of the right breast revealed a painless, mobile, hard mass at the 1-o'clock position (upper inner quadrant) that measured 5.0 cm in width and 4.0 cm in height. There was no tethering of the skin or peau d' orange, and there were no enlarged lymph nodes in the axillary region. The opposite breast and the axilla were normal. Hematological investigation results were within normal limits, and chest X-ray, electrocardiogram showed the heart and lung functions were normal. A large mass was also noted in the mid-lower right part of the abdomen. Clinical diagnosis of the right breast mass and abdominal mass was ambiguous.\nUltrasound scan of the breast showed a hypoechoic area measuring approximately 28 cm in anteroposterior diameter in the upper half of right breast. Meanwhile, it was demonstrated that a relatively circumscribed complex echoic mass with posterior enhancement and uneven density and abundant vessels existed in this area. Calcifications were found focusing in the breast lesion, and several axillary lymph nodes were highly suspicious of metastasis. There were no other focal lesions noted on the scan. Mammography demonstrated an increased density with smooth contour corresponding to the palpable mass. The patient had also undergone an initial computed tomography scan, which revealed a spherical multicystic mass in the right abdomen that measured 259 mm in length, 170 mm in width, and 106 mm in height.\nFine-needle aspiration cytology and intraoperative frozen sections demonstrated and confirmed the malignancy of the mass in the right breast as infiltrating ductal carcinoma (IDC). Upon review of the biopsy specimen from the breast tissue at a multidisciplinary meeting, the diagnosis was reclassified as granulocytic sarcoma.\nThe patient underwent modified radical mastectomy of the right breast and laparoscopic excision of the abdominal mass in the lower right quadrant 15 days after gynecology consultation. The histology of both lesions was reviewed. No residual tumor was found in the surgical margin of the breast specimen. Having underwent 6 courses of chemotherapy, the patient is now under follow-up, and she has no relapsed disease.\nGross pathologic examination of the right breast specimen revealed a tumor that measured 4.5 cm in length, 3.0 cm in width, and 3.0 cm in height. A gray nodule was seen on gross section with punctiform necrosis. Microscopically, the right breast tumor exhibited a biphasic pattern consisting of epithelial and mesenchymal components of carcinosarcoma. The epithelial components were formed by poorly differentiated carcinoma that exhibited glandular tubiform and screen-form or nest-form patterns. The mesenchymal components contained connective tissue cells, spindle cells, osteoblastic cells, and bone matrix. Mesenchymal fibrous tissue was hyperplastic, and some mesenchymal cells had obvious heteromorphism. Cell nuclei were large and undergoing anachromasis. Mitotic activity within these cells was extremely high (). Bone matrix was present outside of these cells in some areas. No metastasis was found in 25 lymph nodes.\nGross pathologic examination of the mass from the lower right quadrant of the abdomen showed a tumor measuring 14.0 cm in length, 12.0 cm in width, and 7.0 cm in height with gray capsule wall. The thickness of the capsule wall was 0.2–0.5 cm. Fatty tissues and hairs were prevalent in the tumor. Microscopically, the capsule wall contained squamous epithelium. Skin appendages such as sweat and sebaceous glands were found under the epithelium. There were also some ovarian tissues. Keratinized tissues, which were stained in red, were apparent in the capsular space ().\nImmunohistochemical studies of the breast tumor showed that the epithelial components were positive for c-erbB2 but negative for estrogen receptor (ER), progesterone receptor (PR), vimentin, and cytokeratin 5/6 (CK5/6). In contrast, the mesenchymal components were positive for vimentin and negative for ER, PR, and c-erbB2. In addition, epithelial membrane antigen (EMA), smooth muscle antigen (SMA), S-100 protein, and P63 were not expressed in either the epithelial or mesenchymal component of the breast tumor ().