Aspiration Cytodiagnosis of Breast Carcinoma in Pregnancy and Lactation With lmmunohistochemical and Electron Microscopic Study of an Unusual Mammary Malignancy With Pleomorphic Giant Cells Raj K. Gupta, M.D., F.I.A.c., St John Wakefield, Ph.D., Sharda Lallu, BSC., Robert Fauck, C.T. (I.A.C.), John Simpson, M.B., C.H.B., F.R.C.S., F.R.A.C.S., and Carl s. Dowle, M.B., C.H.B., F.R.A.C.S.

We have reviewed our experience with 8,706 needle aspiration cytology (NAC) of the breast which were done from January 1983 to June 1991. During our study we diagnosed four cases of breast carcinomas (three ductal type and one with pleomorphic giant cells) in pregnant or lactating women; in all of these the cytologic findings corresponded with the subsequent tissue diagnosis and cell blockpreparations. Considering that carcinoma of breast dur- ing pregnancy and lactation is rare and is second only to cervical cancer, it was felt that its diagnosis by NAC was useful for timely management. In the case in which pleomorphic giant cells were present as an integral component of the tumour, immunohisto- chemical and electron microscopic study was done. This is dis- cussed in view of our recent experience with this unusual tumour. Diagn Cytopathol 1992;8:352-356. 0 1992 WiIey-Liss, Inc.

Key Words: Needle aspiration cytology; Cell block preparation

The usefulness of needle aspiration cytology (NAC) of the breast has been shown in a number of recent studies. 1 ~ 9

We have reviewed our experience with NAC of breast at Wellington Hospital and diagnosed four cases of breast carcinoma in pregnant or lactating women. Since NAC is valuable in the workup of pregnant or lactating women with a clinically suspicious well- or ill-defined breast mass,

R.eceived July 30, 1991. Accepted November 7, 1991. From the Department of Pathology and Surgery, Wellington Hospital

Address reprint requests to Raj K. Gupta, M.D., F.I.A.C., Cytology and School of Medicine, Wellington, New Zealand.

Unit, Wellington Hospital, Wellington, New Zealand.

the diagnosis of ductal breast carcinoma (3 cases) and unusual pleomorphic carcinoma with giant cells (1 case) enabled a timely management. In the case with pleomor- phic giant cells, immunohistochemical and electron mi- croscopic study was done to ascertain the origin of malig- nant giant cells. This is discussed in view of our recent experience with this unusual carcinoma. lo, l 1

Materials and Methods A cytodiagnostic service for breast abnormalities was es- tablished at Wellington Hospital in January 1983. From January 1983 to June 1991, 8,706 needle aspirates from patients between the age of 15 to 96 years were cytologi- cally examined. All needle aspirates were obtained using a disposable 10 ml syringe and a 20 gauge disposable needle. Aspirations were performed using multiple passes in the lesion, maintaining negative pressure. The aspirated material was immediately washed in a cytology container in which 5 ml of 30% ethyl alcohol in physiologic saline was present. This was accomplished by withdrawing the 30% ethyl alcohol from the container in the syringe barrel and then gently flushing the contents back into the con- tainer. This procedure was repeated two or three times to ensure that all material from the syringe and needle was washed back into the container. The cytosieve method l2

using Schleicher and Schuell filters or Gelman filters with 5 pm pore size was used to prepare specimens in all cases and staining was done by a modified Papanicolaou me-

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thod. l 2 Additionally, cell block preparations from aspi- rate material were made.

In the case in which a diagnosis of pleomorphic giant cell carcinoma (PGC) of breast was made, cytospin prepa- rations, cell blocks from aspirate, and tissue were further utilised for immunoperoxidase study and histochemical study (high iron diamine alcian blue, aldehyde fuchsin alcian blue, and alcian blue stains). For electron micros- copy (EM), a portion of aspirate was centrifuged into a cell button and this was divided into 1 mm cubes, fixed in glutaraldehyde, post fixed in osmium tetroxide, passed through graded alcohols, embedded, sectioned, and stained with uranyl acetate and lead citrate.

In this study, although a review of results from NAC of the breast was done in all types of cases, a particular emphasis was placed on the NAC diagnosis of breast car- cinoma in pregnancy or lactation. Information on these cases was obtained by reviewing the charts for pertinent details of clinical, surgical, post surgical information, and other findings. These are summarised in Table 111.

Results The cytologic findings, sensitivity, specificity, and predic- tive value in all the cases are summarised in Table I and Table 11. In this series, there were 741 cases of cracinoma of breast and 4 of these cases were from pregnant or

Table I. Needle Aspiration Cytodiagnosis in 8,706 Cases

Number of Diagnosis (NAC) Cases

Non-specific (benign) 1,690 Inadequate sample 891 Cysts 1,941 Fibrocystic conditionsa 2,093 Fibroadenoma 677 Inflammatory 493 Suspiciousb 180 Carcinoma 74 1

%

19.41 10.23 22.29 24.04

7.77 5.66 2.06 8.51

~

(4/741 were carcinomas in pregnant or lactating women) (0.53)

Total 8.706 100.00

““Fibrocystic conditions” includes cases in which mild or moderate atypia was present as part of the spectrum of mammary dysplasia. All carcinomas were confirmed on histology. All cases with a benign diagno- sis were followed for a period of 1.5 to 5.5 years; in none of these was any evidence of carcinoma found. ’On biopsy, 9 of 180 were carcinoma in situ, 137 were ductal carcinoma, and 34 showed fibrocystic conditions.

Table 11. Aspiration Cytodiagnosis of Breast Disease

Sensitivity, Specificity, and Predictive Values of the

%

Sensitivity Specificity Positive predictive value Negative predictive value

100.0 99.6 96.2

100.0

lactating women. In 3 of these, the typical pattern of an infiltrating ductal carcinoma of the breast was found while in one case cytodiagnosis of unusual pleomorphic giant cell carcinoma (PGC) of the breast was made (Table 111). The PGC was further studied in view of its rarity and the results were as follows.

Cytohistologic Findings in PGC Papanicolaou stained Schleicher and Schuell filters prepa- rations, cytospin preparations, and hematoxylin-eosin stained preparations showed a high cellularity with nu- merous malignant cells with moderate cytoplasm, ovoid to angulated or lobulated nuclei, coarse chromatin, irregular nuclear membrane, and prominent irregular nucleoli. Ad- ditionally, many bizarre mononucleated and multinuclea- ted malignant giant cells were present, forming an integral component of the tumour. The multinucleated giant cells showed a wide variation in size and shape with numerous abnormal nuclei, coarse chromatin, and an irregular nu- clear membrane while the mononucleated forms were rea- sonably uniform in size and shape with a variable amount of cytoplasm. The cytologic findings are shown in Figure lA, B and the histologic findings are shown in (Fig. 2A-C).

Immunohistochemical Findings In all four cases, immunostaining for CEA, lysozyme, alpha-1 antitrypsin, HCG, desmin, S-100, factor VIII,

Fig. 1. Filter preparation showing two fields (A,B) with pleomorphic malignant giant cells in PGC (Papanicolaou stain x 550).

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Table 111. Summary of Findings in Four Cases of Breast Malignancies in Pregnancy or Lactationa

- Age,

Case years Pertinent clinical findings Cytology Managem ent Histoloav Follow u p

1 35 2 x 1.5 cm firm mass in right upper outer quadrant of breast of 2 week duration

Bone scans at time of clinical presentation normal; pregnant 36/40, delivery normal at term

mass left breast close to nipple

In May 1989, diffuse firm right breast enlargement; 5 months pregnant

Pregnancy terminated; within few weeks of diagnosis of carcinoma, pleural effusion and cerebral signs were found and pleural fluid and CSF showed cells from a metastatic carcinoma of breast

3 41 pregnant 35/40; right-sided 2.5 X 2 cm breast mass inferior to nipple; normal delivery by caesarean

4 36 4 X 3.5 cm hard irregular mass in left upper outer quadrant of breast; patient breast feeding following normal delivery

2 35 In May 1984, 3 cm hard

D C Right mastectomy with axillary dissection followed by adjuvant chemotherapy; few months after operation repeat bone scan showed metastatic disease in several bones

1984-DC 1984-Mastectomy with 1989-DC axillary dissection

followed by radiotherapy

axillary dissection followed by radiotherapy and adjuvant chemotherapy

1989-Mastectomy with

D C Mastectomy with axillary dissection followed by chemotherapy and radiotherapy

dissection followed by radiotherapy and adjuvant chemotherapy

PGC Mastectomy with axillary

DC; metastasis in 16/20 lymph nodes

Progressively deteriorating with metastatic disease 13 months since diagnosis

1984-DC; no lymph nodes metastasis

1989-Lobular carcinoma metastasis in 10/10 lymph nodes

D C no lymph nodes metastasis

Breast carcinoma with several malignant giant cells

No lymph node metastasis

Died within 2 months of the diagnosis of carcinoma of right breast

No autopsy was done

Alive and disease free for 5 years since diagnosis

Alive and disease free for 2 months since diagnosis

aPGC = pleomorphic giant cell carcinoma; D C = ductal carcinoma.

B72.3, vimentin, cytokeratin, HMB 45, and EMA were performed utilizing commercially available kits for im- munoperoxidase methods (CAM 5.2 for cytokeratin, sup- plied by Becton Dickinson; RPN 1 130 and 1 132 for EMA and HCG supplied by Amersham International; M 724 for desmin, M 725 for vimentin, A 082 for factor VIII, A 115 for CEA, A 099 for lysozyme, A 012 for alpha-1 antitrypsin, 231 1 for S-100, all supplied by Dako; BT 620 for B 72.3, supplied by Bio Med; and MA 001-5C for HMB 45, supplied by Bio Genex Labs).

In the case of PGC, the immunostaining for cytokeratin and EMA showed a strong brown diffuse positive reaction in tumour giant cells and carcinoma cells, while staining for B 72.3 and CEA was found as focal traces in carci- noma cells but was negative in tumour giaDt cells (Fig. 3A, B). In the three cases of ductal carcinoma, staining for EMA was found to be positive in carcinoma cells, while the staining for B 72.3, CEA, and cytokeratin was seen focally. A uniformly negative staining was found for all other markers and histochemical stains in all the four

cases. Known positive controls were used during all the procedures.

Electron Microscopy of PGC Because of the fast growing nature of this tumour the cells obtained for electron microscopy were somewhat necrotic. Despite this, their epithelial origin was evident. The cells were large, pleomorphic, and multinucleate. The nuclei had a convoluted nuclear membrane, marginated chroma- tin, and prominent nucleoli. Cytoplasmic vesicles were present in most of the cells and desmosomes were common (Fig. 4).

Discussion The association of breast malignancy in pregnancy or lac- tation is quite rare. 13-16 Also, breast carcinoma in these females is believed to disseminate rapidly and generally has a poor prognosis. 17-20 The incidence is about three in 10,000 pregnancies and the average age of the patient is about 35 years. 21-25 The rapidity of growth, early axillary

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Fig. 3. Cytospin preparations showing (A) positive staining for cytokera- tin in malignant giant cells and (B) positive staining for EMA in the malignant cells and giant cells in the case of PGC ( X 550).

Fig. 2. Cell block preparation of above case showing histologic features of PGC. (A) Low power view. (B,C) Two fields showing high power appearances of pleomorphic giant cells (hematoxylin eosin stain; A x250, B,C xSS0).

metastasis, and inoperability in a number of patients has been ascribed to certain factors which seem to result in an altered physiology during pregnancy and lactation; and these factors are said to be responsible for breast enlarge- ment, increased vascularity, and lymphatic permeability due to the changes in the hormonal environment.

In our opinion an investigation by NAC in pregnant and lactating women with a suspected breast pathology is quite important over and above the existing methods such as careful and frequent physical examination, since these women constitute a subgroup of patients with an above- average physician contact for ante natal and post natal care. Based on our findings we also feel that it is important that breast cancer during pregnancy or lactation be diag- nosed without delay. We also believe that the ‘‘liberal’’ surgical biopsy policy in these women is not desirable since with such a policy a number of these women with benign breast lesions would be subjected to unnecessary biopsies. In our practice we have used NAC as a first line

Fig. 4. Low magnification electron micrograph of multinucleated tu- mour cell showing convoluted nuclear membrane, marginated chroma- tin and cytoplasmic vesicles (X4,SOO). In the “inset,” part of two tumour cells is shown with desmosome junctions ( ~ 3 5 , 0 0 0 ) .

of investigation in all women presenting with breast dis- ease and have performed “open biopsy” only in those women in which NAC suggested marked atypia without features of a carcinoma on repeated aspirations. All women with an NAC diagnosis of malignancy have al- ways been directly treated.

A few interesting points deserve mention about the four cases described here and these pertain to the cytohis- tologic features of the malignancies. While in three of the cases the cytohistologic findings were of ductal carcino- ma, * in one case the breast malignancy showed features of

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PGC. This carcinoma is of an unusual type in which the pleomorphic malignant giant cells constitute the main component of the tumour. Recently, we have diagnosed this tumour in the breast and have described its featu- res."!" In the case described here, we also used im- munohistochemistry and electron microscopy, and our findings further supported our belief that the bizarre ma- lignant cells in PGC are most likely of malignant epithelial type rather than the stromal type. 'O,"

I n conclusion, we suggest that NAC is an effective method in the diagnosis of carcinomas of breast in women during pregnancy or lactation and is an important means of avoiding unnecessary surgery for benign disease in these patients.

Acknowledgments The authors gratefully acknowledge the technical help of Andy McHutchison and Caroline Hope. The photo- graphic assistance of Louise Goossens from the Audio- visual Unit is also acknowledged.

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