Coexistence of metaplastic carcinoma of the breast with tuberculous axillary lymphadenopathy: A rare occurrence

Raveendran Vishnu; Balakrishnan Gurushankari; Krishnaraj Balamourougan; Thirthar Palanivelu Elamurugan; Sathasivam Sureshkumar; Rajakannu Muthukumarassamy; Devi Prasad Mohapatra; Debdatta Basu; Vikram Kate

doi:10.4103/IJAMR.IJAMR_140_20

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Year : 2020 | Volume : 7 | Issue : 1 | Page : 35-38

Coexistence of metaplastic carcinoma of the breast with tuberculous axillary lymphadenopathy: A rare occurrence

Raveendran Vishnu¹, Balakrishnan Gurushankari¹, Krishnaraj Balamourougan¹, Thirthar Palanivelu Elamurugan¹, Sathasivam Sureshkumar¹, Rajakannu Muthukumarassamy¹, Devi Prasad Mohapatra², Debdatta Basu³, Vikram Kate¹
¹ Department of Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
² Department of Plastic Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
³ Department of Pathology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India

Date of Submission	18-Jun-2020
Date of Acceptance	28-Jun-2020
Date of Web Publication	18-Aug-2020

Correspondence Address:
Dr. Vikram Kate
Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry - 605 006
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/IJAMR.IJAMR_140_20

Abstract

Metaplastic breast carcinoma (MBC) is a rare malignant neoplasm of the breast which is highly aggressive and is known for its early recurrence and poor prognosis. Concurrent detection of a MBC and tuberculosis of the axillary lymph node is a rarity. To the best of our knowledge, there is no such case report in the literature. A 35-year-old premenopausal woman was diagnosed as a case of left carcinoma breast with a left axillary lymph node. Core-needle biopsy of the breast was suggestive of squamous cell carcinoma. The patient underwent modified radical mastectomy with a latissimus dorsi myocutaneous flap. The postoperative biopsy of the breast and axilla revealed MBC and tuberculous lymphadenitis of the axillary lymph node. The patient received antitubercular therapy and radiotherapy, followed by chemotherapy and had no recurrence on follow-up. This case report emphasizes that metaplastic carcinoma breast can coexist with tuberculous axillary lymphadenopathy.

Keywords: Antitubercular therapy, breast cancer, mastectomy, squamous cell carcinoma breast

How to cite this article:
Vishnu R, Gurushankari B, Balamourougan K, Elamurugan TP, Sureshkumar S, Muthukumarassamy R, Mohapatra DP, Basu D, Kate V. Coexistence of metaplastic carcinoma of the breast with tuberculous axillary lymphadenopathy: A rare occurrence. Int J Adv Med Health Res 2020;7:35-8

How to cite this URL:
Vishnu R, Gurushankari B, Balamourougan K, Elamurugan TP, Sureshkumar S, Muthukumarassamy R, Mohapatra DP, Basu D, Kate V. Coexistence of metaplastic carcinoma of the breast with tuberculous axillary lymphadenopathy: A rare occurrence. Int J Adv Med Health Res [serial online] 2020 [cited 2023 Apr 2];7:35-8. Available from: https://www.ijamhrjournal.org/text.asp?2020/7/1/35/292396

Introduction

Metaplastic breast carcinoma (MBC) is a rare, malignant neoplasm of the breast which accounts for 0.2%–5% of all breast cancers.^[1] They are highly malignant tumors known for their early recurrence and poor prognosis. Synchronous detection of tuberculosis and metaplastic variant of carcinoma breast is rare. Although there are a few reports on the coexistence of carcinoma breast and tuberculosis, to the best of our knowledge, there is no report of MBC with tuberculosis of axillary lymph node in the literature.^[2],[3] We report a unique case of MBC with tuberculosis of the axillary lymph nodes and discuss its management.

Case Report

A 35-year-old premenopausal woman presented with a lump in the left breast for the past 4 months with a history of ulceration for the past month. The patient had no history of any skin, oral, pharyngeal, or perianal lesions. On examination, a mass of size 20 cm × 15 cm with variegated consistency occupying the upper quadrants of the left breast was noted with skin ulceration [Figure 1]a and b]. Multiple matted lymph nodes were noted in the central group of the left axilla. A wedge biopsy from the ulcerated area showed features suggestive of squamous cell carcinoma of the breast [Figure 2]a. Metastasis to the breast from a primary tumor in the skin, esophagus, lung, ear, nose, throat, cervix, or anal canal was ruled out by doing ultrasonography of the contralateral breast and abdomen, chest radiograph, panendoscopy, gynecological examination, and proctoscopy. A bone scan was done, which was normal. The diagnosis of a primary squamous cell carcinoma of the breast was made.

Figure 1: Clinical images of the metaplastic carcinoma of the breast; (a) Anterior view of the ulcerated breast lump; (b) Lateral view of the ulcerated breast lump

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Figure 2: Histopathological images of metaplastic carcinoma of the breast; (a) Core-needle biopsy from the breast depicting keratin pearls suggestive of squamous cell carcinoma (H and E; ×100); (b) Postoperative biopsy of the breast depicting glandular pattern suggestive of adenocarcinoma (H and E; ×10)

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A left modified radical mastectomy with a latissimus dorsi myocutaneous flap was performed. On histopathological examination, the tumor was involving the superior and lateral quadrants of the breast. The superior, inferior, medial, and lateral margins were 0.7 cm, 4.5 cm, 8 cm, and 3 cm, respectively, from the tumor, and the deep resected margin was 0.1 cm away from the tumor. Axillary pad of fat had 19 lymph nodes with the largest measuring 1.8 cm × 1 cm × 0.5 cm. Microscopic examination revealed predominant areas of squamous cell carcinoma pattern with areas of adenocarcinoma [Figure 2]b. The lactiferous duct showed evidence of squamous metaplasia with carcinoma in situ changes. No lymphovascular embolus was noted. On immunohistochemistry, the tumor was triple negative with epithelial membrane antigen positivity. The final diagnosis of MBC was made. The isolated lymph nodes showed caseating tuberculous lymphadenitis with acid-fast bacilli. No evidence of metastasis was found in the isolated lymph nodes [Figure 3]a and [Figure 3]b.

Figure 3: Histopathological images of tuberculosis of the axillary lymph node; (a) Biopsy from the axillary lymph node depicting multiple epithelioid granulomas (H and E; ×10); (b) Biopsy from the axillary lymph node depicting Langhans giant cells (H and E; ×100)

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Postoperatively, the patient received 25 fractions of teleradiotherapy over 5 weeks. Antitubercular drugs (antitubercular therapy [ATT]) were started according to the national protocol, Revised National Tuberculosis Control Programme, category I.

After the completion of radiotherapy, the patient received six cycles of chemotherapy with cyclophosphamide, adriamycin, and 5-fluorouracil, 3-weekly. The patient was regularly followed up for 3 years postoperatively and showed no evidence of recurrence.

Discussion

MBC is a rare variety of breast cancer with an incidence of 0.2%–5%.^[1] It has a heterogenous histology with five different subgroups as per the WHO classification; low-grade adenosquamous carcinoma, fibromatosis-like metaplastic carcinoma, squamous cell carcinoma, metaplastic carcinoma with mesenchymal differentiation (chondroid, osseous, other types of mesenchymal differentiation), and spindle cell carcinoma.^[4],[5],[6] The median age of presentation of MBC in a series of 35 patients was 47.4 years, in a case series with 12 patients was 46.5 years, and 54 years in another series of 38 cases.^[7],[8],[9] The present case was a 35-year-old premenopausal woman with no history of any comorbidities.

MBC is usually an aggressive form of breast cancer associated with large size, high-grade, triple negativity, poor outcome, high incidence of local recurrence, low tendency for nodal metastasis, and pulmonary metastasis.^[9],[10] The size of the tumor has shown a correlation with recurrence and survival rates.^[11] In the present case, the tumor size was 20 cm × 15 cm and had developed skin ulceration within a short time of 4 months, which shows the aggressive behavior of the tumor. However, some forms of metaplastic carcinoma are not that aggressive, such as low-grade adenosquamous variant and fibromatosis-like variant, which have a good prognosis.

Preoperative diagnosis is difficult to establish on the basis of clinical, radiological, and histopathological examination since the representative specimen is difficult to obtain by a core-needle biopsy. An excisional biopsy is considered to be the gold standard for diagnosis but is seldom practiced due to the rarity of MBC.^[9] In the present case, preoperative biopsy showed only the features of squamous cell component not the adenomatous. Hence, the initial diagnosis was of a squamous cell carcinoma of the breast. The histogenesis of this rare malignancy is unclear. Theories include malignant growth of intrinsic epidermal elements and metaplasia from breast parenchyma.^[1] In the present case, the final paraffin section of the mastectomy specimen revealed squamous metaplasia in the ducts.

There is no clear consensus regarding the management and follow-up of the patients with MBC due to scant data available in the literature. Most patients have undergone mastectomy with or without chemotherapy and radiotherapy. The axillary node involvement rate of MBC tended to be lower than that of infiltrating ductal carcinoma of the breast.^[9],[12] In a retrospective study, only two of the 19 women with axillary dissection had metastases, but one woman had a positive supraclavicular lymph node in the presence of negative axillary nodes.^[11] All metastases were squamous carcinoma. Prophylactic postoperative radiation therapy and radiation for lymph node metastases at initial surgery did not prolong survival as four of the five recipients died from the tumor. Hormonal therapy has no role in the management of MBC as most of them are triple-negative tumors.^[13] In the present case, the patient underwent modified radical mastectomy, followed by a latissimus dorsi myocutaneous flap cover because of the large size of the tumor. She received radiotherapy since the tumor was found to involve the deep resected margin. She received six cycles of chemotherapy with cyclophosphamide, adriamycin, and 5-fluorouracil.

Although the tuberculous involvement of the axillary lymph nodes in a case of carcinoma of the breast has been reported, no proven association exists between tuberculosis and carcinoma of the breast.^{[3],[14],[15]} In a review, 29 cases of coexistence of breast carcinoma and tuberculosis of the breast or axillary lymph nodes were reported.^[14] Many factors have been attributed for the co-occurrence of tuberculosis in cancer patients, which include suppression of the immune system by malignancy and endemicity. Tuberculous lymphadenitis is the most common form of extrapulmonary tuberculosis. In an endemic country, the axillary lymph nodes of breast malignancy patient should be carefully examined as they can be of a tuberculous origin. They are mostly an incidental diagnosis, similar to the present case. A preoperative diagnosis of the coexistence of breast cancer with axillary tuberculosis aids in reducing the complications secondary to tuberculosis, eases the axillary dissection post-ATT, and prevents overstaging of the breast cancer. There is no clear consensus regarding the treatment policies in cases where these two conditions coexist. There are studies which suggest starting ATT along with chemotherapy or radiotherapy postdefinitive surgery.^[9] There are no reports describing the coexistence of MBC and tuberculosis of the axillary lymph node in the literature. In the present case, besides the absence of metastasis, there was granuloma formation with caseation necrosis and acid-fast bacilli in the axillary lymph nodes. Further research is required in order to understand and manage this condition.

Conclusion

MBC is one of the rare types of breast malignancy and its coexistence with tuberculosis of the axillary lymph nodes is rare. Preoperative diagnosis is usually difficult. The management protocol is evolving as reports on MBC are limited and none if tuberculosis and MBC coexist. Chemotherapy and radiotherapy along with surgery is the mainstay of treatment. Tuberculous lymphadenopathy, when associated with a primary breast malignancy, is to be managed as per usual treatment protocol. This case report emphasizes that metaplastic carcinoma breast can coexist with tuberculous axillary lymphadenopathy, and both these conditions need to be treated separately.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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