Neuroendocrine Tumor Metastases to the Breast: A Case Report and Review of the Literature

Breast metastases from neuroendocrine neoplasms (NENs) are considered infrequent. We report a case of a patient with ileocecal neuroendocrine tumor (NET) metastases to both breasts, for whom the initial clinical presentation was chronic diarrhea. Breast metastasis was initially suspected by a 68-Gallium DOTANOC positron emission tomography (PET)/CT and was confirmed by histopathology. We also performed a literature review in which we identified 116 cases of NENs metastatic to the breast reported so far. Most cases occurred in older women, were caused by NETs, and had the gastrointestinal tract as the primary site.

Invasive ductal carcinoma of breast with neuroendocrine differentiation: A case report

Primary invasive breast carcinoma with neuroendocrine differentiation is an uncommon presentation. We hereby report a case diagnosed as invasive ductal carcinoma with neuroendocrine differentiation in a 52‐year‐old female patient who presented with a painless right breast lump.

Primary invasive breast carcinoma with neuroendocrine differentiation is an uncommon presentation. We hereby report a case of invasive ductal carcinoma with neuroendocrine differentiation who presented with a painless right breast lump. The patient was evaluated with mammography, ultrasound‐guided tru‐cut biopsy, and CT scan of the chest. Later right mastectomy with frozen section examination of right axillary sentinel lymph node was performed. Finally, a diagnosis of invasive ductal carcinoma with neuroendocrine differentiation was made with the help of the histomorphological evaluation and immunohistochemical study using neuroendocrine markers like CD56 and INSM1. To the best of our knowledge, this is the first case of invasive breast carcinoma with neuroendocrine differentiation reported from Nepal and can help better understand the clinical entity, diagnosis, treatment, and prognosis of this rare tumor.

Primary Neuroendocrine Tumor of the Breast: Current Understanding and Future Perspectives

Primary neuroendocrine carcinoma of the breast (NECB) is characterized with heterogeneity, rarity, and poor differentiation, which is probably an underestimated subtype of breast cancer, including small cell NECs and large cell NECs. The diagnostic criteria for NECB have been constantly updated as the disease changes and the understanding increases. According to the latest WHO Classification, primary neuroendocrine neoplasm (NEN) of the breast consists of well-differentiated neuroendocrine tumors (NET), extremely aggressive neuroendocrine carcinomas (NEC) as well as invasive breast cancers of no special type (IBCs-NST) with neuroendocrine differentiation. The accurate diagnosis of NECB remains a challenge for its low incidence, which needs multi-disciplinary methods. For the rarity of the disease, there is a lack of large samples and prospective clinical research. For these invasive tumors, there are no standardized therapeutic guidelines or norms, and the treatment often refers to nonspecific breast cancer. In addition, the prognosis of such patients remains unknown. In 2003, the World Health Organization (WHO) listed NECB as an independent entity for the first time, while few features of NECB were clarified. In this review, it presents the WHO Classification, clinicopathologic characteristics, diagnosis, treatment, and prognosis of these patients. In addition, it summarizes the latest studies on molecular features of NECB, aiming to provide new therapeutic perspectives for the disease.

Metastatic non-Hematopoietic Neoplasms to the Breast: A Study of 238 Cases

AIMS

The aim of this study was to review the clinicopathologic characteristics of metastatic non-hematopoietic malignancies to the breast, in order to identify salient features for practicing pathologist that are useful in distinguishing metastatic lesions from primary breast neoplasms.

METHODS AND RESULTS

A total of 238 cases were identified during the period from January 2005 to January 2015. Clinicopathologic features of these cases were retrospectively reviewed. Primary tumors included melanoma (99, 42%), serous carcinoma (35, 15%), neuroendocrine neoplasm (32, 13%), sarcoma (23, 10%), and adenocarcinoma from various organs (47, 20%), among others. Most metastases were unilateral (223, 94%) and unifocal (206, 87%), and were detected radiographically (167, 70%). Concurrent ipsilateral axillary metastasis occurred in 33 (14%) patients. Among 238 cases, 41 had metastatic disease to the breast concurrently or preceding the primary cancer diagnosis. Notable, in 39 (16%) cases, breast metastasis was the first clinical presentation of disease, and 16 (41%) of these cases were initially misdiagnosed as breast primaries. In contrast, with known history of non-mammary primary tumors, only 4 of 197 (2%) cases were misdiagnosed (p<0.0001).

CONCLUSIONS

Metastatic tumors share many overlapping features with breast primary carcinomas. However, cases with a well-circumscribed tumor, lack of in situ component, ER/PR negativity, and unusual morphologic features should raise the consideration of metastatic disease. While clinical history is paramount for correct diagnosis, metastasis to the breast as the first clinical presentation is not uncommon.

The Effect of the Extent of Neuroendocrine Differentiation on Cytopathological Findings in Primary Neuroendocrine Neoplasms of the Breast

Objective:

This study aimed to describe the cytological features of neuroendocrine breast tumors and to show the effect of the extent of neuroendocrine differentiation on cytological features.

Methods:

Breast tumor excision materials showing immunostaining with neuroendocrine markers (Synaptophysin or Chromogranin A) were determined and divided into two groups: cases with focal (10%–50% of tumor cells) staining and cases with diffuse (>50% of tumor cells) staining. A group of cases without neuroendocrine features/staining was used as control group. Fine needle aspiration biopsy specimens of the tumor mass or metastatic lymph nodes were examined and compared.

Results:

Twenty cases with neuroendocrine differentiation were included. Eleven cases were in the diffuse group, nine cases were in the focal group. Clean background, high cellularity, loosely cohesive cell groups with monotonous appearance, and naked nuclei were more common in the diffuse group. On the contrary, tight cohesive cell groups, the proportion of large cells, nuclear pleomorphism, and nucleolar prominence were higher in the group with focal staining. Plasmocytoid appearance, isolated cell groups, and binucleation were in similar distribution in both groups. Although round-oval nuclei were dominant in both groups, round nuclei were observed to be slightly more in the diffuse group. Only two cases in diffuse group showed cytoplasmic granularity and one case in focal group showed necrosis and mitosis. In the control group, tight cohesive groups, large cell size, pleomorphism, prominent nucleoli, and coarse chromatin were more commonly encountered.

Conclusions:

Clean background, hypercellularity, loss of cohesion, naked nuclei, monotonous cells with round nucleus, and granular cytoplasm were more prominent in cases showing diffuse staining with neuroendocrine markers. Suspecting neuroendocrine differentiation in tumors that show focal staining with neuroendocrine markers can be challenging in cytological preparations.

Metastasis to Breast from Extramammary Solid Tumors and Lymphomas: A 20-Year Population-Based Study

To discuss the clinicopathological features and prognosis of metastases to the breast from extramammary solid tumors and lymphomas, we reviewed Cancer Hospital of Chinese Academy of Medical Sciences database from 01/01/2000 to 12/31/2020. Fifty-nine patients were identified. The most common primary sites for breast metastases were lymph node and pulmonary, followed by nasal cavity, ovary, skin, etc. All the patients were treated with chemotherapy, 18 were operated, 14 accepted radiotherapy. Metastasis to breast should be considered in any patient with tumor history presenting a breast lump. Pathological with immunohistochemical examination should be performed to identify the original site.

Bilateral breast metastases as the first manifestation of an occult pancreatic neuroendocrine tumor

Breast metastases are uncommon findings compared to primary breast cancer and in particular bilateral secondary breast lesions from neuroendocrine tumor (NET)s are extremely rare with just less over 13 cases described in literature. We reported herewith the case of a 54-year-old woman who presented to our Breast Unit after noticing multiple, mobile, bilateral breast lumps. Imaging studies confirmed the presence of multiple, circumscribed, bilateral breast masses with slightly spiculated margins, classified as suspicious for malignancy (BI-RADS 4). A tru-cut biopsy was carried out on the largest lesion of each side and histopathologic and immunohistochemistry examination was consistent with metastases from pancreatic neuroendocrine tumor (PNET). Total-body CT revealed the presence of a mass located in the pancreatic body - tail with associated abdominal lymphadenopathies and multiple secondary nodules in bilateral breast and in the liver. Stage IV disease was diagnosed, patient did not undergo surgery and started LAR – octreotide therapy. Although rare, breast metastases from NETs represent an important diagnostic challenge for practitioners because of the difficulty to differentiate from a primary breast carcinoma or even from benign breast lesions. Clinicians should be aware of the possibility of bilateral breast metastases in differential diagnosis of breast lesions in order to ensure the correct diagnosis and the most appropriate management of these patients.

Neuroendocrine Carcinomas of the Canine Mammary Gland: Histopathological and Immunohistochemical Characteristics

Invasive mammary carcinomas with neuroendocrine differentiation are rare in women and were reported only once in female dogs. For the present study, ten cases of solid mammary carcinoma positive for chromogramin A in immunohistochemistry were selected. Histopathological characteristics of these tumors were described and immunohistochemical evaluation was performed with chromogranin A, synaptophysin, CD56, NSE, PGP 9.5, pancitokeratin, Ki67, estrogen receptor (ER), and progesterone receptor (PR). The average animal age was 13.2 years old and the average tumor size was 4.8 cm. In total, 70% of the neoplasms were classified as grade III and 30% as grade II by the Nottingham histological grade system. High mitotic index was observed with a mean of 27.5 mitoses in 10 high magnification fields. Only one case showed typical carcinoid tumor characteristics. In addition, vascular invasion was shown in 3 tumors. All carcinomas were positive for chromogran A, while only two cases were reactive to synaptophysin. For PGP 9.2, NSE and CD56, we observed positivity of 100, 90, and 70%, respectively, in the samples, being that no tumor was positive for all the neuroendocrine markers. All neoplasms showed ER and PR in at least 10% of neoplastic cells, while Ki67 varied from 29 to 95%, with mean mitotic index of 67%. Four of the ten animals died within 1 year of the tumor diagnosis. Neuroendocrine neoplasms occur in the canine mammary gland and are propably underdiagnosed. This is due to their non-specific morphological characteristics and the low use of neuroendocrine immunohistochemistric markers the diagnostic routine. More studies are necessary to determine the prognosis of this new histological type.

Primary neuroendocrine carcinoma of the breast: a rare presentation and review of the literature

Primary neuroendocrine carcinoma of the breast (NEBC) is a very rare occurrence accounting for less than 0.1% of all breast cancers. Typically, the tumor presents with ER- and PgR-positive and HER-2-negative status. Despite its luminal type, NEBC is associated with a more aggressive clinical course and poorer prognosis compared to the other types of invasive breast cancer. Clinical and radiological findings are nonspecific. The most common clinical manifestation is a palpable mass whereas in mammography the tumor most commonly appears as a round or oval mass without spiculated margins. Herein, a very rare case of NEBC is described in an asymptomatic patient who presented with an area of architectural distortion and the presence of microcalcifications that was incidentally detected on a screening mammography. A review of the literature has also been conducted. The diagnosis of NEBC requires a thorough investigation to exclude the possibility of a metastatic neuroendocrine tumor from another site because the two entities require different treatment approaches. Due to the rarity of the disease, the optimal therapeutic approach has not been clearly defined. Surgical resection is the mainstay of treatment. Further research is needed to better understand the molecular characteristics of NEBC and identify novel targeted therapies.

The rare entity of bilateral and unilateral neuroendocrine metastases to the breast: a case series and literature review

Introduction

Primary neuroendocrine neoplasms (NENs) in the breast are very rare. Until 2011, the prevalence was 0.1% of all breast lesions and 1% of all NENs, whereas metastatic breast NENs represent 1%–2% of all breast tumours. However, it seems that over the last 5 years the diagnostic frequency of breast NENs has increased, probably for more alert specialists and advanced diagnostic tools, leading to a prevalence of 2%–5% of diagnosed breast cancers, mostly in the elderly population. Breast metastases from extramammary malignancies are uncommon and bilateral ones are even more uncommon, with few reported in the literature. We describe four clinical settings of breast metastases from different NENs and the multidisciplinary approach for diagnosis and treatment.

Methods

Four patients were found to have NEN primaries metastasised to the breast. A literature review was conducted to identify similar cases and characterise breast metastases from neuroendocrinal tumors (NETs).

Results

Two patients presented with bilateral breast metastases (one with well-differentiated panNET and another with atypical lung carcinoid) and two had unilateral (one with moderately differentiated lung NET and one with atypical lung carcinoid). There are about 13 cases of NEN breast metastases reported in the English literature. The ileum is the most common primary site, followed by the appendix, duodenum, pancreas and lung.

Conclusion

Breast lesions from extramammary primary often pose a diagnostic challenge, since a breast nodule can be the first and often the only presentation of the disease. However, differentiating between primary and secondary NEN breast lesions is essential, owing to different clinical management and prognosis.

Histological clues to the diagnosis of metastasis to the breast from extramammary malignancies

AIMS

The aims of this study were to review the histological features useful for the identification of metastases to the breast and to investigate the impression that this diagnosis has become more common.

METHODS AND RESULTS

The histological features of metastases to the breast from 2008 to 2018 were reviewed. Seventy-four biopsies from 66 patients were identified: 1% compared with primary carcinoma of the breast. Non-haematological metastases comprised 0.75% compared with 0.3% in a series from 1996 to 2005. The most common tumour types were pulmonary carcinoma (22), lymphoma (15), melanoma (13), gastrointestinal carcinoma (eight) and serous papillary carcinoma (four). In 73% there were histological features that were not typical of primary mammary carcinoma. Some metastases were histologically similar to breast cancer and the history was essential to making the correct diagnosis. Useful histological clues included small-cell morphology for pulmonary carcinoma, glands containing necrosis for gastrointestinal carcinoma, intranuclear inclusions, marked pleomorphism and spindle cells for melanoma, clear cells for renal carcinoma, papillary architecture for serous papillary carcinoma and sheets of centroblasts or nodules of centroblasts and centrocytes for lymphoma. Useful immunohistochemical markers included TTF-1 for pulmonary carcinoma, S100, melan-A and HMB45 for melanoma, CK20 and CDX2 for colorectal carcinoma, PAX8 and WT1 for serous papillary carcinoma and lymphoid markers for lymphomas, in addition to the absence of expression of mammary markers ER, GATA3 and GCDFP-15.

CONCLUSION

The majority of metastases to the breast have histological clues to the diagnosis. Immunohistochemistry is helpful. This diagnosis is being made more frequently.

Medullary Thyroid Carcinoma Presenting as Metastatic Disease to the Breast

Medullary thyroid carcinoma (MTC) is a neuroendocrine tumor that is derived from C cells of the thyroid gland. It is a rare aggressive tumor, known to metastasize to lymph nodes, liver, bones, and lungs. A 41-year-old female, who presented with a breast mass, was initially diagnosed with invasive ductal carcinoma. She was also found to have a thyroid mass which was later diagnosed as MTC. On a rereview of the breast pathology, the morphologic features were strikingly similar to the MTC. Further investigation revealed that this was in fact a very rare case of MTC that had metastasized to the breast. We have identified 20 cases of MTC metastasizing to the breast in the literature that supports its occurrence as a real possibility. Albeit rare, medullary thyroid carcinoma should be considered in the differential diagnosis of a breast mass.

Primary Neuroendocrine Neoplasms of the Breast: Case Series and Literature Review

Primary neuroendocrine carcinoma of the breast (NECB) as defined by the World Health Organization (WHO) in 2012 is a rare, but possibly under-diagnosed entity. It is heterogeneous as it entails a wide spectrum of diseases comprising both well-differentiated neuroendocrine tumors of the breast as well as highly aggressive small cell carcinomas. Retrospective screening of hospital charts of 612 patients (2008–2019) from our specialized outpatient unit for neuroendocrine neoplasia revealed five patients diagnosed with NECB. Given the low prevalence of these malignancies, correct diagnosis remains a challenge that requires an interdisciplinary approach. Specifically, NECB may be misclassified as carcinoma of the breast with neuroendocrine differentiation, carcinomas of the breast of no special type/invasive ductal carcinoma, or a metastasis to the breast. Therefore, this study presents multifaceted characteristics as well as the clinical course of these patients and discusses the five cases from our institution in the context of available literature.

Histopathology and Cytopathology of Neuroendocrine Tumors and Carcinomas of the Breast: A Review

Neuroendocrine tumors (NET) and carcinomas (NEC) of the breast are rare diseases, but NEC has attracted attention in both cytopathology and surgical pathology because of its specific management and prognosis. Fine-needle aspiration biopsy (FNAB) cytology can make the diagnosis in many cases particularly with high-grade NEC, with definitive diagnosis based on histopathology and immunohistochemistry. This review describes the characteristics of the disease based on the WHO classification 2012 and recent literature and -includes discussion related to the International Academy of Cytology Yokohama System of Reporting Breast FNAB -cytology.

Metastases to the breast, an uncommon diagnosis: what do radiologists need to know?

OBJECTIVE

To analyze the imaging characteristics of histologically diagnosed metastases to the breast.

MATERIAL AND METHODS

We selected patients histologically diagnosed with metastases to the breast in our diagnostic and interventional breast imaging unit between March 2010 and September 2018.

RESULTS

A total of 9 patients (all women; mean age, 60 y; age range, 28-89 y) were diagnosed with metastases to the breast. In 1 (11.11%) case, the primary disease was diagnosed from the breast lesion. The primary tumors were melanoma (n=5), neuroendocrine tumor (n=2, one from the small bowel and one from the cervix), lung adenocarcinoma (n=1), and ovarian cancer (n=1). The clinical and imaging manifestations depend on the type of dissemination of disease and can simulate benign and malignant primary breast lesions.

CONCLUSION

There is no specific imaging pattern for metastases to the breast that would help to orient the diagnosis. It is important to consider this etiological possibility if the patient has a history of a primary tumor in another organ.

A case report on metastatic ileal neuroendocrine neoplasm to the breast masquerading as primary breast cancer: A diagnostic challenge and management dilemma

RATIONALE

Metastatic neuroendocrine neoplasms (NENs) to the breast are very rare entities comprising only 1% to 2% of all metastatic breast tumors. In this article, we describe a case of a neuroendocrine ileal neoplasm metastatic to breast and liver, with breast metastatic tumor to be the initial manifestation of the disease.

PATIENT CONCERNS

We herein report a rare case of a female patient admitted to our department with a palpable painful mass on her left breast.

DIAGNOSIS

The surgical and histological investigation revealed a metastatic neuroendocrine neoplasm to the breast originated from terminal ileum.

INTERVENTIONS

A left lumpectomy, right hemicolectomy, cholecystectomy, left hepatectomy along with liver metastasectomies (V, VI, VIII) plus radiofrequency ablation of lesions to the right liver lobe plus standard lymphadenectomy was performed.

OUTCOMES

Considering the advanced stage of the disease, the patient received an adjuvant therapy of somatostatin analog plus everolimus. Under the guidance of oncological consultation, patients follow-up with CT and MRI scan and clinical re-evaluations in the first 3 and 6 months, substantiates no evidence of recurrence and she presents herself asymptomatic.

LESSONS

An appropriate level of suspicion and selective immunohistochemistry in these cases, particularly where no prior history of a known primary neuroendocrine neoplasm occurs, may help to diagnose a previously undetected neuroendocrine tumor elsewhere in the body and provide guidance for the appropriate treatment selection.

[A misleading breast metastasis of medullary thyroid carcinoma]

Recognition of mammary metastases by pathologists is fundamental because their prognosis and treatment are different from those of primary mammary carcinomas. We report the case of a 54-year-old woman presenting on her mammography a left breast nodule known for 5 years, having discreetly increased in size. Breast ultrasound showed a regular 1.2cm hypoechogenic nodular formation. A microbiopsy was performed. On microscopic examination, we observed a tumor proliferation realizing nests within a small, richly vascularized stroma. The tumor cells had a moderately abundant, eosinophilic, granular cytoplasm and a rounded, slightly atypical nucleus. One mitosis was found for 10 fields at×400 magnification. Tumor cells did not express hormone receptors but chromogranin A, synaptophysin, TTF1 and thyrocalcitonin. The proliferation index established by the anti-Ki67 antibody was 5 %. The diagnosis was a secondary localization of a well-differentiated neuroendocrine tumor which immunohistochemical profile firstly suggests a thyroid origin. We later learned that the patient had a history of total thyroidectomy 13 years ago. It was a sporadic medullary carcinoma of the thyroid. Bone scintigraphy revealed a lacunar lesion of the posterior part of the right iliac wing suspicious of secondary location. This right iliac lesion was biopsied. It was also a localization of the medullary thyroid carcinoma. The final diagnosis is a metastatic medullary thyroid carcinoma, slowly progressive, the mammary metastasis having probably existed for 5 years.

Metastatic breast cancer simulating well-differentiated neuroendocrine neoplasms of visceral organs

A series of metastatic breast carcinoma (MBC) mimicking visceral well-differentiated neuroendocrine neoplasms has not previously been reported. We identified 5 consultation cases originally submitted as neuroendocrine neoplasms in women but that were found to be MBC on subsequent review. All 5 neoplasms demonstrated nested architecture and relatively uniform nuclei. Four patients had a known history of breast cancer (remote in 3 and concurrent in 1), but the metastases (3 liver, 1 lung) labeled for chromogranin and/or synaptophysin, prompting misdiagnosis as neuroendocrine neoplasm. In a fifth case, a liver metastasis in a patient with a known pancreatic endocrine neoplasm was originally thought to be of pancreatic origin; an occult concurrent primary breast cancer (PBC) was subsequently identified as the source. On further immunohistochemistry (IHC), all metastases evaluated were diffusely, strongly positive for estrogen receptor (5/5 cases) and GATA3 (4/4 cases). Three patients had previously received ineffective treatment for neuroendocrine carcinoma. Based on the consultation diagnosis, all 4 patients with follow-up received hormone therapy, which was effective in 3. In a separate tissue microarray cohort of paired PBCs and hematogenous MBCs, chromogranin and/or synaptophysin IHC labeling was typically negative and increased from the PBC to the MBC in only 5% of cases. In conclusion, although neuroendocrine differentiation is uncommon in breast cancer and does not commonly increase in metastases, MBC with neuroendocrine differentiation should be considered in patients with visceral neuroendocrine neoplasms of unknown primary site. Diffuse IHC labeling for estrogen receptor and GATA3 helps establish the correct diagnosis.

Neuroendocrine Tumors of the Breast

Primary neuroendocrine tumors of the breast are a rare and underrecognized subtype of mammary carcinoma. Neuroendocrine tumors of the breast occur predominately in postmenopausal women. The tumors are subclassified into well-differentiated and poorly differentiated neuroendocrine tumors, and invasive breast carcinoma with neuroendocrine features. Well-differentiated tumors show architectural similarity to carcinoids of other sites but lack characteristic neuroendocrine nuclei. Poorly differentiated neuroendocrine tumors are morphologically identical to small cell carcinoma of the lung. Neuroendocrine differentiation, seen in up to 30% of invasive breast carcinomas, is most commonly associated with mucinous and solid papillary carcinomas. The diagnosis of neuroendocrine differentiation requires expression of the neuroendocrine markers synaptophysin or chromogranin. The main differential diagnosis is a metastatic neuroendocrine tumor from an extramammary site. Neuroendocrine tumors of the breast are treated similarly to other invasive breast carcinomas. Although no consensus has been reached on the prognosis, most studies suggest a poor outcome.

Merkel cell carcinoma, melanoma, metastatic mimics of breast cancer

Merkel cell carcinoma and melanoma can each occur primarily in breast skin, or metastasize to the breast. The breast is a rare site of metastasis of essentially any and every type of tumor, including carcinomas, sarcomas, and hematolymphoid neoplasms, and 10-30% of breast metastases may represent the initial presentation of disease. Although metastases generally recapitulate histologic features of the primary tumor, they are diagnostically challenging given their rarity and morphologic overlap with breast carcinoma, including special types of breast cancer. Histologic clues may include lack of carcinoma in situ, lack of central elastosis, pattern of infiltration around normal breast structures, yet none of these are specific. Careful correlation with clinical history and judicious use of immunostain panels is essential in approaching these cases.

Low-Grade Neuroendocrine Carcinoma of the Skin (Primary Cutaneous Carcinoid Tumor) as a Distinctive Entity of Cutaneous Neuroendocrine Tumors: A Clinicopathologic Study of 3 Cases With Literature Review

There is scarcity of information on primary cutaneous low-grade neoplasms commonly known as carcinoid tumors, owing to their rarity. The authors present 3 cases that were named "low-grade neuroendocrine carcinoma of the skin" (LGNECS). These occurred in the dermis and subcutis of the anterior chest or the inguinal region in the elderly. Histologically, the tumors showed infiltrating proliferation of nests of various sizes, with low-grade neuroendocrine cytologic features but without mucin production. All cases exhibited varying degrees of intraductal tumor components. On immunohistochemical examination, these tumors expressed estrogen receptor alpha, progesterone receptor, androgen receptor, gross cystic disease fluid protein 15, mammaglobin, and GATA3 as well as neuroendocrine markers. Although a literature review revealed 8 additional possible cases with no evidence of other diseases, it was difficult to determine if these were true cases of LGNECS, because of the limited information available. Based on its characteristic histologic features and immunoprofile, it can be proposed designating LGNECS as a distinct entity among cutaneous neuroendocrine tumors. Otherwise, such tumors could be misdiagnosed as mammary carcinomas (particularly when involving the skin of the breast) or as metastatic visceral neuroendocrine tumors of the skin.

Primary neuroendocrine breast carcinomas: a retrospective analysis and review of literature

Background

Primary neuroendocrine breast carcinomas (NEBCs) are a rare type of breast carcinomas that lack comprehensive recognition, including the clinicopathological features, therapeutic strategies, and prognostic significance. The aim of this retrospective analysis is to present and analyze our own data of primary NEBCs.

Materials and methods

We retrospectively reviewed the medical records from 2005 to 2015 in The First Affiliated Hospital of Chongqing Medical University, Chongqing, People’s Republic of China to obtain a cohort of breast carcinoma patients who were confirmed to have primary NEBC by histopathology. The detailed clinical data along with histopathology, treatment, and follow-up aspects were gathered for analysis.

Results

This retrospective analysis included 19 patients with a histopathological diagnosis of primary NEBC from 2005 to 2015. Their mean age was 59.2 years (ranging from 17 to 82 years). The majority of patients (15/19) focused on stages I and II. Of the 15 patients, 14 were positive for estrogen receptor, and 11 were positive for progesterone receptor. For neuroendocrine markers, the expression rates were 8/19, 14/18, 12/14, and 2/6 for chromogranin A, synaptophysin, neuron-specific enolase, and CD56, respectively. All operable patients except the one stage M1 underwent a surgery and 4/18 had axillary lymph node metastasis. Chemotherapy was performed in 12/19, and endocrine therapy in 8/10. With a median follow-up of 59.2 months, only 2 cases progressed after postoperative systemic therapy.

Conclusion

The understanding of NEBC is limited due to its rarity. More evidence should be provided to enhance the understanding of NEBC, especially for diagnosis, treatment, and prognosis.

Comparison of metastatic neuroendocrine neoplasms to the breast and primary invasive mammary carcinomas with neuroendocrine differentiation

Metastatic neuroendocrine neoplasms to the breast may show considerable morphologic overlap with primary mammary carcinomas, particularly those showing evidence of neuroendocrine differentiation, and may be misdiagnosed as such. Accurate distinction between these two entities is crucial for determination of appropriate clinical management. The histologic and immunohistochemical features of metastatic neuroendocrine neoplasms to the breast were studied and compared with the features of primary invasive mammary carcinomas with neuroendocrine differentiation, which served as controls. Of the metastatic neuroendocrine neoplasms, 15 were well-differentiated neuroendocrine tumors with carcinoid tumor-type morphology and 7 were poorly differentiated/high-grade neuroendocrine carcinomas with small-cell or large-cell neuroendocrine carcinoma morphology. The majority of the metastatic neoplasms originated in the lung and gastrointestinal tract. There were histologic similarities between metastatic neuroendocrine neoplasms and invasive mammary carcinomas with neuroendocrine differentiation, both of which exhibited neuroendocrine histologic features (nested and trabecular architecture, minimal tubular differentiation, and characteristic nuclear features). Only one case of the invasive mammary carcinomas with neuroendocrine differentiation was modified Bloom-Richardson grade 1 (largely due to minimal tubular differentiation on most such tumors), and the invasive mammary carcinomas with neuroendocrine differentiation were often associated with in situ carcinoma. Immunohistochemistry was helpful in distinguishing metastatic neuroendocrine neoplasms from invasive mammary carcinomas with neuroendocrine differentiation. Whereas the majority of invasive mammary carcinomas with neuroendocrine differentiation were positive for estrogen receptor and GATA3, metastatic neuroendocrine neoplasms were typically negative for estrogen receptor and GATA3, and metastatic well-differentiated neuroendocrine tumors often showed immunoreactivity for site-specific markers. Although the histologic and immunohistochemical features of a breast tumor may raise the suspicion of a metastatic neuroendocrine neoplasm, the pathologic findings should be interpreted in the context of the clinical history and imaging findings in order to establish an accurate diagnosis.

[Neuroendocrine neoplasms of the breast]

Neuroendocrine neoplasms (NEN) of the breast are specific tumor entities. According to the literature up to 5% of breast neoplasms are malignant epithelial neoplasms of the breast. They are defined by a neuroendocrine (NE) architecture and cytology combined with an expression of the neuroendocrine vesicle markers chromogranin A and/or synaptophysin. The diagnosis is supplemented by the receptor status and the proliferative activity. According to the World Health Organization (WHO) classification of 2012 the following groups of NEN are distinguished: (1) invasive breast carcinoma with NE differentiation, (2) well-differentiated neuroendocrine tumor (NET) and (3) poorly differentiated small cell carcinoma (NEC). This review article focuses on (1) the definition and basic principles of diagnostics, (2) the history, nomenclature and WHO classification from 2003 and 2012, (3) the frequency of breast NEN, (4) the hereditary background and functional activity, (5) the expression of receptors and (6) the possible clinical implications. In addition, the first results of a retrospective single center study (n = 465 patients with breast cancer over a time period of 4 years) on the frequency of NEN of the breast at the Breast Center of the University Hospital Düsseldorf are presented. In this study a frequency of 4.5% of NEN was found based on a diagnostic cut-off of > 50% Chromogranin A and/or synaptophysin positive tumor cells.

Breast metastasis as the first clinical manifestation of ileal neuroendocrine tumor. A challenging diagnosis with relevant clinical implications

Ileal neuroendocrine tumors are slow-growing grade 1 or, more rarely, grade 2 neuroendocrine tumors which, however, are frequently metastatic to regional lymph nodes and the liver. A few cases of ileal neuroendocrine tumors that are metastatic to the breast have also been reported in the medical literature. The knowledge of this uncommon clinical presentation is of great importance because it needs to be differentiated from primary breast carcinomas with neuroendocrine features, which represent completely different entities with a different therapeutic approach. The diagnosis of a breast metastasis from an ileal neuroendocrine tumor and its distinction from a well-differentiated primary neuroendocrine tumor of the breast is a challenging task for clinicians and pathologists. This workup is particularly difficult when the breast lesion is the first sign of malignancy. In the present paper, we describe the clinicopathological features of an ileal neuroendocrine tumor first presenting with a breast metastasis in a 50-year-old woman and we discuss the key diagnostic features for the differential diagnosis with primary well-differentiated neuroendocrine tumor of the breast. Moreover, we have reviewed the medical literature to give the reader a comprehensive overview on this topic.

Fine-needle aspiration detects primary neuroendocrine carcinoma of the breast in a patient with breast implants

Breast augmentation with implantation represents a challenge for subsequent radiographic imaging and pathological sampling. Fine-needle aspiration biopsy (FNAB) is an excellent technique to sample suspicious lesions that are adjacent to fragile implants. We report a case of a 51-year-old woman with breast implants presenting with an initial diagnosis of fibroadenoma by imaging studies. A definite diagnosis of mammary carcinoma with plasmacytoid cells was made on ultrasound (US)-guided FNAB of the breast mass with rapid on-site evaluation which initiated core needle biopsy of the mass and subsequent mastectomy with sentinel lymph node biopsy. Our case exemplifies the role of US-guided FNAB for the initial investigation of breast masses in patients with implants. In addition, the case illustrates the cytomorphological features of the tumor cells in primary neuroendocrine carcinoma of the breast.

Papillary and neuroendocrine breast lesions: the WHO stance

In this review, we highlight adaptations in the WHO 2012 classification of papillary and neuroendocrine breast lesions as compared with the previous 2003 version. Consensus criteria for distinguishing atypical ductal hyperplasia from ductal carcinoma in situ within an intraductal papilloma are proposed. The absence of myoepithelial cells around the wall of an encapsulated papillary carcinoma, although raising consideration of an indolent tumour with minimal invasion, is currently regarded as in-situ disease for staging purposes. The majority of solid papillary carcinomas are classified as in-situ tumours, but lesions with irregular tumour islands within desmoplastic stroma may be considered to be invasive. The diagnosis of solid papillary carcinoma without further qualification as either in-situ or invasive disease is discouraged. When invasive papillary carcinoma is seen in the breast, metastatic papillary carcinoma from other organ sites needs to be excluded. WHO 2012 classifies neuroendocrine breast tumours as well-differentiated neuroendocrine tumour, small-cell carcinoma, and invasive breast carcinoma with neuroendocrine differentiation. There is currently no clinical impact of identifying neuroendocrine differentiation in conventional invasive breast carcinomas, apart from acknowledging its frequent occurrence in subtypes such as the hypercellular variant of mucinous carcinoma and solid papillary carcinoma.

Primary neuroendocrine carcinoma of the breast: clinical, imaging, and histologic features

OBJECTIVE

The purpose of this study was to evaluate the clinical, imaging, and histopathologic findings of primary neuroendocrine carcinoma of the breast.

MATERIALS AND METHODS

A pathology database was searched for the records of patients with a histopathologic diagnosis of primary neuroendocrine carcinoma of the breast who had undergone mammography, sonography, or MRI between 1984 and 2011. The imaging studies of eligible patients were retrospectively reviewed according to the BI-RADS lexicon, and clinical presentation and histopathologic characteristics were documented. Imaging characteristics were compared with historical controls of invasive mammary carcinoma.

RESULTS

Eighty-seven patients (84 women, three men; mean age, 62.9 years; range, 28-89 years) were included in the study. The mean tumor size was 3.1 cm (range, 0.6-11 cm). Sixty-five of 84 (77.4%) cancers were estrogen and progesterone receptor positive and ERBB2 negative. A palpable mass (55.8%) was a common clinical manifestation. A high-density, round or oval, or lobular mass with nonspiculated margins on mammograms and an irregular (65.4%), hypoechoic (78.4%) mass, with indistinct margins (43.5%), no or enhanced posterior acoustic features (77.9%) on sonograms were common findings. MRI revealed an irregular mass (83.3%), irregular margins (63.6%), and washout kinetics (85.7%). Neuroendocrine carcinoma presented more frequently as masses on mammograms. Calcifications were infrequent compared with their occurrence in invasive mammary cancer.

CONCLUSION

Primary neuroendocrine carcinoma of the breast has mammographic features that differ from those of invasive mammary carcinoma. A round, oval, or lobular mass with nonspiculated margins, positive estrogen and progesterone receptor results, and negative ERBB2 results should raise suspicion of primary neuroendocrine carcinoma.

Metastases from neuroendocrine tumors to the breast are more common than previously thought. A diagnostic pitfall?

BACKGROUND

Metastases from neuroendocrine tumors (NETs) to the breast have been described as a rare phenomenon. Presentation, imaging results, and cytopathologic findings of these tumours may closely mimic those of a mammary carcinoma.

METHODS

This study was a retrospective review of 661 patients with metastatic NETs, of whom 280 were females, treated at Uppsala University Hospital, Uppsala, Sweden. Patients with pathological breast lesions were identified. Histopathological slides from available NET breast lesions were analyzed for mammary carcinoma and neuroendocrine markers.

RESULTS

We have identified 20 female patients with NET metastases to the breast, 11/235 with small intestinal NETs, 8/55 with lung NETs, and 1/6 with thymic NETs. There were no male patients with NET metastatic to the breast. Four patients had their breast lesion initially diagnosed as mammary carcinoma. Retrospectively, these lesions showed negative staining for mammary carcinoma markers.

CONCLUSIONS

Metastases to the breast from neuroendocrine tumors may be more common than previously thought. Patients with a lesion to the breast and symptoms typical for NET may benefit from additional histopathological investigation, because NET metastases and mammary carcinoma have different immunohistochemical profiles.

Use of immunohistochemistry in the diagnosis of problematic breast lesions

Most diagnoses in breast pathology can be made with H&E sections. Nevertheless immunohistochemistry plays a useful supplementary role. This article reviews the common uses of immunohistochemistry in diagnostic breast pathology. It is important to be aware of the limitations of individual antibodies. Such problems can often be overcome by using panels of antibodies. Quality control is also essential: internal and external controls should show appropriate staining. Immunohistochemistry must be interpreted in combination with the morphology seen on H&E sections. Myoepithelial markers, such as smooth muscle actin, smooth muscle myosin heavy chain and p63, are useful for distinguishing invasive carcinoma from sclerosing lesions and ductal carcinoma in situ (DCIS), and in the classification of papillary lesions. Basal cytokeratins can help distinguish epithelial hyperplasia of usual type (UEH) and clonal proliferations such as DCIS and lobular carcinoma in situ (LCIS). UEH usually shows patchy expression whereas DCIS and other clonal proliferations are typically negative. E-cadherin can usually separate DCIS and LCIS: DCIS typically shows membrane staining and most LCIS is negative. Cytokeratins can be used to detect small nodal metastases or subtle invasive carcinomas such as invasive lobular carcinomas. Immunohistochemistry plays a useful role in diagnosing spindle cell lesions such as a panel of cytokeratins to identify spindle cell carcinomas. Immunohistochemistry is helpful in recognising metastases to the breast. Different antibodies are useful for different tumours: WT1 for ovarian carcinoma; TTF1 for pulmonary adenocarcinoma; S100, melan-A and HMB45 for melanoma; and lymphoid markers for lymphoma.