Stanford School of Medicine
 use browser back button to return

Surgical Pathology Criteria
http://surgpathcriteria.stanford.edu/

Metaplastic Carcinoma of the Breast

Definition

  • Breast carcinoma exhibiting either a mesenchymal (or other non-epithelial) component or squamous differentiation

Alternate / Historical Names

  • Adenosquamous carcinoma
  • Carcinosarcoma
  • Matrix producing carcinoma
  • Sarcomatoid carcinoma
  • Spindle cell carcinoma
  • Squamous cell carcinoma

Diagnostic Criteria

  • Must have a neoplastic component that is either squamous or non-epithelial
  • Carcinoma mixed with a mesenchymal or other non-epithelial component
    • May exhibit obviously malignant stroma
      • May resemble pleomorphic MFH or fibrosarcoma
      • May exhibit heterologous differentiation
        • Usually osteosarcoma or chondrosarcoma
        • Less commonly glioma, melanoma, rhabdomyosarcoma, angiosarcoma or liposarcoma
    • Stroma may be composed of bland spindle cells (spindle cell carcinoma)
      • p63 positive, often high molecular weight keratin positive
      • May contain fibroblasts and or myofibroblasts
      • May resemble nodular fasciitis or fibromatosis
    • Mesenchymal component may be keratin positive in about half of cases
      • High molecular weight keratin is most often positive
    • Epithelial component may be sparse
      • May be identified only by presence of keratin reactivity
        • Broad spectrum and high molecular weight keratins are useful
      • Squamous component may be cystic
  • Carcinomas with metaplastic squamous components
  • Most have a component of ductal carcinoma
    • There are rare reports of metaplastic carcinoma associated with lobular, medullary, mucinous and tubular carcinoma

Richard L Kempson MD
Robert V Rouse MD
Department of Pathology
Stanford University School of Medicine
Stanford CA 94305-5342

Original posting: May 1, 2006
Updates: January 21, 2009

Supplemental studies

Immunohistology

  • From a diagnostic standpoint the important distinction is from sarcoma
    • p63 and CK5/6 appear to be quite specific for this
    • Laminin 5 appears more sensitive but more data is needed regarding its specificity
    • It is important to be aware of significant smooth muscle actin and S100 reactivity
      • Their presence does not rule out carcinoma
Laminin 5 96%
p63 57-86%
CK5/6 50-86%
CD10 85%
Smooth muscle actin 60%
S100 45%
Squamous and mesenchymal elements and in most cases ductal elements all stained

Differential Diagnosis

 

  • Pure sarcoma should be diagnosed only after thorough sectioning and with negative stains for p63, broad spectrum keratin and high molecular weight keratin

 

Metaplastic Carcinoma Phyllodes Tumor
Spindled component may be positive for high molecular weight keratin or p63 Stromal component negative for high molecular weight keratin and p63
Epithelial component is malignant Epithelial component is benign
Squamous differentiation may be present No squamous differentiation

 

  • Nodular fasciitis is very rare in the breast and should be diagnosed only after thorough sectioning and with negative keratin stains (including high molecular weight keratin)

 

  • Fibromatosis is very rare in the breast and should be diagnosed only after thorough sectioning and with negative keratin stains (including high molecular weight keratin)

 

  • Pleomorphic adenoma is very rare in the breast and does not have infiltrating margins and the epithelial component is not malignant

 

Metaplastic Carcinoma of the Breast with Mesenchymal Differentiation Carcinoma of the Breast with Osteoclast-like Giant Cells
Sarcomatous (malignant) stroma Only giant cells, no neoplastic stroma
May form osteoid (osteosarcoma) No osteoid
Other metaplastic carcinomas with non-mesenchymal differentation would not be confused with carcinomas with osteoclast-like giant cells

 

Metaplastic Carcinoma Adenomyoepithelioma
Glandular component, if present, is histologically malignant, except in low grade spindle cell metaplastic carcinoma Epithelial component is histologically bland
Stromal component may be bland or histologically malignant Stroma is histologically bland
Stromal component may resemble a variety of sarcomas or low grade fibrous proliferation Stroma shows myoepithelial differentiation only
Squamous differentiation may be present No squamous differentiation

Clinical

  • Behavior is that of carcinoma rather than sarcoma
    • First metastases are to lymph nodes
    • Metastases are usually pure carcinoma
    • Recent studies have questioned this, finding sarcoma-like behavior (recurrence without nodal metastases but with hematologic metastases) in lesions with minimal or only focal evidence of typical carcinoma and bland fibrous stroma (spindle cell carcinoma)
  • 5 year survival reported as 47-68%

Grading / Staging / Report

Grading

  • Bloom-Scarff-Richardson grading is not applicable to metaplastic carcinomas

Staging

  • TNM staging is the most widely used scheme for breast carcinomas but is not universally employed
  • Critical staging criteria for regional lymph nodes
    • Isolated tumor cell clusters
      • Usually identified by immunohistochemistry
        • Term also applies if cells identified by close examination of H&E stain
      • No cluster may be greater than 0.2 mm
      • Multiple such clusters may be present in the same or other nodes
    • Micrometastasis
        • Greater than 0.2 mm, none greater than 2.0 mm
    • Metastasis
      • At least one carcinoma focus over 2.0 mm
        • If one node qualifies as >2.0 mm, count all other nodes even with smaller foci as involved
      • Critical numbers of involved nodes: 1-3, 4-9 and 10 and over
    • Note extranodal extension

Report

  • Excisions: the following are important elements that must be addressed in the report for infiltrative breast carcinomas
    • Grade
      • Not generally applicable
    • Size of neoplasm
      • Give 3 dimensions or greatest dimension
      • Critical cutoffs occur at 0.5 cm and at 2 cm
    • Margins of resection
      • Measure and report the actual distance of both invasive and in situ carcinoma
    • Angiolymphatic invasion
      • Indicate if confined to tumor mass, outside tumor mass or in dermis
    • (Extensive DCIS is not currently felt to be a significant predictor of behavior)
    • Results of special studies performed for diagnosis
    • Results of prognostic special studies performed
      • ER, PR, Proliferation marker, Her2neu
      • If studies were performed on a prior specimen, refer to that report and give results
  • Needle or core biopsies
    • Presence of absence of angiolymphatic invasion
    • Results of special studies performed for diagnosis
    • Results of prognostic special studies if performed
      • ER, PR, Proliferation marker, Her2neu
      • State if studies are deferred for a later excision specimen
  • Regional lymph nodes
    • Report findings as described above

Lists

Infiltrating Breast Carcinomas

Bibliography

  • Rosen PP, Oberman HA . Tumors of the Mammary Gland, Atlas of Tumor Pathology, AFIP Third Series, Fascicle 7, 1993
  • Elston CW, Ellis IO. Pathological prognostic factors in breast cancer. I. The value of histological grade in breast cancer: experience from a large study with long-term follow-up. Histopathology. 1991 Nov;19(5):403-10.
  • Chu PG, Weiss LM. Keratin expression in human tissues and neoplasms. Histopathology. 2002 May;40(5):403-39.
  • Wick MR, Lillemoe TJ, Copland GT, Swanson PE, Manivel JC, Kiang DT. Gross cystic disease fluid protein-15 as a marker for breast cancer: immunohistochemical analysis of 690 human neoplasms and comparison with alpha-lactalbumin. Hum Pathol. 1989 Mar;20(3):281-7.
  • Huvos AG, Lucas JC Jr, Foote FW Jr. Metaplastic breast carcinoma. Rare form of mammary cancer. N Y State J Med. 1973 May 1;73(9):1078-82.
  • Koker MM, Kleer CG. p63 expression in breast cancer: a highly sensitive and specific marker of metaplastic carcinoma. Am J Surg Pathol. 2004 Nov;28(11):1506-12.
  • Kaufman MW, Marti JR, Gallager HS, Hoehn JL. Carcinoma of the breast with pseudosarcomatous metaplasia. Cancer. 1984 May 1;53(9):1908-17.
  • Golshan M, Kuten A, William J, Richardson A, Modarressi A, Matulonis U. Metaplastic carcinoma of the breast with neuroglial differentiation. Breast. 2005 Oct 24.
  • Davis WG, Hennessy B, Babiera G, Hunt K, Valero V, Buchholz TA, Sneige N, Gilcrease MZ. Metaplastic Sarcomatoid Carcinoma of the Breast With Absent or Minimal Overt Invasive Carcinomatous Component: A Misnomer. Am J Surg Pathol. 2005 Nov;29(11):1456-1463.
  • Yang GC, Yee HT, Waisman J. Metaplastic carcinoma of the breast with rhabdomyosarcomatous element: aspiration cytology with histological, immunohistochemical, and ultrastructural correlations. Diagn Cytopathol. 2003 Mar;28(3):153-8.
  • Gobbi H, Simpson JF, Borowsky A, Jensen RA, Page DL. Metaplastic breast tumors with a dominant fibromatosis-like phenotype have a high risk of local recurrence. Cancer. 1999 May 15;85(10):2170-82.
  • Chhieng C, Cranor M, Lesser ME, Rosen PP. Metaplastic carcinoma of the breast with osteocartilaginous heterologous elements. Am J Surg Pathol. 1998 Feb;22(2):188-94.
  • Ruffolo EF, Koerner FC, Maluf HM. Metaplastic carcinoma of the breast with melanocytic differentiation. Mod Pathol. 1997 Jun;10(6):592-6.
  • Eggers JW, Chesney TM. Squamous cell carcinoma of the breast: a clinicopathologic analysis of eight cases and review of the literature. Hum Pathol. 1984 Jun;15(6):526-31.
  • Fisher ER, Palekar AS, Gregorio RM, Paulson JD. Mucoepidermoid and squamous cell carcinomas of breast with reference to squamous metaplasia and giant cell tumors. Am J Surg Pathol. 1983 Jan;7(1):15-27.
  • Gersell DJ, Katzenstein AL. Spindle cell carcinoma of the breast. A clinocopathologic and ultrastructural study. Hum Pathol. 1981 Jun;12(6):550-61.
  • Pitts WC, Rojas VA, Gaffey MJ, Rouse RV, Esteban J, Frierson HF, Kempson RL, Weiss LM. Carcinomas with metaplasia and sarcomas of the breast. Am J Clin Pathol. 1991 May;95(5):623-32.
  • Reddick RL, Jennette JC, Askin FB. Squamous metaplasia of the breast. An ultrastructural and immunologic evaluation. Am J Clin Pathol. 1985 Oct;84(4):530-3.
  • Santeusanio G, Pascal RR, Bisceglia M, Costantino AM, Bosman C. Metaplastic breast carcinoma with epithelial phenotype of pseudosarcomatous components. Arch Pathol Lab Med. 1988 Jan;112(1):82-5.
  • Shousha S, James AH, Fernandez MD, Bull TB. Squamous cell carcinoma of the breast. Arch Pathol Lab Med. 1984 Nov;108(11):893-6.
  • Toikkanen S. Primary squamous cell carcinoma of the breast. Cancer. 1981 Oct 1;48(7):1629-32.
  • Wargotz ES, Norris HJ. Metaplastic carcinomas of the breast: V. Metaplastic carcinoma with osteoclastic giant cells. Hum Pathol. 1990 Nov;21(11):1142-50.
  • Wargotz ES, Norris HJ. Metaplastic carcinomas of the breast. IV. Squamous cell carcinoma of ductal origin. Cancer. 1990 Jan 15;65(2):272-6.
  • Wargotz ES, Norris HJ. Metaplastic carcinomas of the breast. III. Carcinosarcoma. Cancer. 1989 Oct 1;64(7):1490-9.
  • Wargotz ES, Deos PH, Norris HJ. Metaplastic carcinomas of the breast. II. Spindle cell carcinoma. Hum Pathol. 1989 Aug;20(8):732-40.
  • Wargotz ES, Norris HJ. Metaplastic carcinomas of the breast. I. Matrix-producing carcinoma. Hum Pathol. 1989 Jul;20(7):628-35.
  • Leibl S, Gogg-Kammerer M, Sommersacher A, Denk H, Moinfar F. Metaplastic breast carcinomas: are they of myoepithelial differentiation?: immunohistochemical profile of the sarcomatoid subtype using novel myoepithelial markers. Am J Surg Pathol. 2005 Mar;29(3):347-53.
  • Rosen PP, Ernsberger D. Low-grade adenosquamous carcinoma. A variant of metaplastic mammary carcinoma. Am J Surg Pathol. 1987 May;11(5):351-8.
  • Drudis T, Arroyo C, Van Hoeven K, Cordon-Cardo C, Rosen PP. The pathology of low-grade adenosquamous carcinoma of the breast. An immunohistochemical study. Pathol Annu. 1994;29 ( Pt 2):181-97.
  • Van Hoeven KH, Drudis T, Cranor ML, Erlandson RA, Rosen PP. Low-grade adenosquamous carcinoma of the breast. A clinocopathologic study of 32 cases with ultrastructural analysis. Am J Surg Pathol. 1993 Mar;17(3):248-58.
  • Carpenter PM, Wang-Rodriguez J, Chan OT, Wilczynski SP. Laminin 5 expression in metaplastic breast carcinomas. Am J Surg Pathol. 2008 Mar;32(3):345-53.
Printed from Surgical Pathology Criteria: http://surgpathcriteria.stanford.edu/
© 2005  Stanford University School of Medicine