9 hours ago
49-Year-Old Patient's Pleomorphic Breast Relapse in Weeks
A 49-year-old woman with a history of bilateral breast cancer (right breast, cT2cN0M0, clinical stage IIA; left breast, cT2cN1M0, clinical stage IIB) presented with local recurrence in the right breast.
Following neoadjuvant chemotherapy, the patient achieved a partial pathologic response and underwent breast-conserving surgery with axillary lymph node dissection and radiotherapy.
After 6 years and 7 months, local recurrence in the right breast was identified, and the patient subsequently underwent mastectomy. However, 4 weeks later, metastasis to the contralateral breast was detected. An additional 13 weeks later, metastatic pleural tumours occupied approximately 70% of the thoracic cavity.
Only detailed pathologic analysis revealed the underlying diagnosis of pleomorphic breast carcinoma.
Nobuyuki Takemoto, MD, from the Department of Breast and Thyroid Surgery at Japan Medical Alliance East Saitama General Hospital in Satte, Japan, and colleagues documented the extremely rare case.
The Patient and Her History
The patient visited the hospital complaining of swelling and erosion of the right nipple. Her medical history included bilateral breast cancer diagnosed more than 6 years earlier. The right-sided tumour was the nonluminal type (oestrogen and progesterone receptor positive; HER2 3+; Ki-67, 31%), and the left-sided tumour was luminal A-like (oestrogen and progesterone receptor positive; HER2-; Ki-67, < 5%).
As neoadjuvant chemotherapy, four cycles of adriamycin and cyclophosphamide (60/600 mg/m²) every 3 weeks, followed by paclitaxel (80 mg/m²) and trastuzumab (loading dose 4 mg/kg, maintenance 2 mg/kg) weekly for 12 weeks, were administered. The patient achieved a clinical partial response on imaging.
Bilateral breast-conserving surgery and axillary lymph node dissection were performed. The pathologic evaluation of the therapeutic effect was grade 1 (right: ypT1bypN0M0, ypstageI; left: ypT1cypN0[i+]M0, ypstageI).
After radiotherapy (50 Gy in 25 fractions) of the residual mammary gland, trastuzumab (6 mg/kg) was administered. However, the patient requested to discontinue treatment after two courses. She was subsequently followed with endocrine therapy (tamoxifen).
Six years and 7 months after the initial operation, local recurrence occurred.
Findings and Diagnosis
On admission, all vital signs were within normal limits. Physical examination, including inspection, auscultation, palpation, and percussion, showed no abnormalities. Routine laboratory test results were unremarkable.
A CT revealed a swollen right nipple. and three stump cytology tests for erosion were negative, but the nipple itself showed a tendency to grow, so a core needle biopsy (CNB) was performed. Pathologic findings showed invasive carcinoma and suggested metaplastic carcinoma. As no metastases to other organs were found, a right mastectomy was performed. After chemotherapy with carboplatin, radiation therapy to the supraclavicular fossa was planned; however, 4 weeks after the operation, a round mass of approximately 1 cm was found in the left breast.
CNB revealed a suspicious malignant metaplastic carcinoma. It was determined that there was a high possibility of metastasis to the contralateral side, and a left mastectomy was performed. However, 12 weeks later, a left pleural tumour and a right chest wall mass appeared. After another 13 weeks, the left thoracic cavity was occupied by almost 70% of the pleural mass, and the right chest wall mass grew to 10 cm in size.
Furthermore, the white blood cell count rose rapidly to 98.8 × 103/µL, with 94.8% neutrophils, 2.5% lymphocytes, and 1.8% monocytes. Bone marrow metastasis was suspected, but bone marrow aspiration could not be performed due to the patient's poor general condition. The patient died 25 weeks after the diagnosis of local recurrence.
Pathologic examination revealed a pleomorphic carcinoma (PC) transitioning from ductal carcinoma, with a subtype of triple-negative breast cancer. Immunohistochemical staining showed positive expression of AE1/3 (anti-pan cytokeratin), beta-catenin, E-cadherin, and vimentin. Staining was negative for CAM5.2 (cytokeratin), HMB45 (human melanoma black 45), and LCA (leukocyte common antigen).
Discussion
'When a rapidly growing breast mass is encountered, it is necessary to consider PC as one of diagnostic candidate. Little research has been done on PC, particularly on diagnosis and therapy. Thus, further case accumulation and analyses are awaited to gain more insight on the characteristics of PC,' the authors wrote.
