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Thomas A, Reis-Filho JS, Geyer CE, Wen HY. Rare subtypes of triple negative breast cancer: Current understanding and future directions. NPJ Breast Cancer 2023; 9:55. [PMID: 37353557 DOI: 10.1038/s41523-023-00554-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Accepted: 05/19/2023] [Indexed: 06/25/2023] Open
Abstract
Rare subtypes of triple-negative breast cancers (TNBC) are a heterogenous group of tumors, comprising 5-10% of all TNBCs. Despite accounting for an absolute number of cases in aggregate approaching that of other less common, but well studied solid tumors, rare subtypes of triple-negative disease remain understudied. Low prevalence, diagnostic challenges and overlapping diagnoses have hindered consistent categorization of these breast cancers. Here we review epidemiology, histology and clinical and molecular characteristics of metaplastic, triple-negative lobular, apocrine, adenoid cystic, secretory and high-grade neuroendocrine TNBCs. Medullary pattern invasive ductal carcinoma no special type, which until recently was a considered a distinct subtype, is also discussed. With this background, we review how applying biological principals often applied to study TNBC no special type could improve our understanding of rare TNBCs. These could include the utilization of targeted molecular approaches or disease agnostic tools such as tumor mutational burden or germline mutation-directed treatments. Burgeoning data also suggest that pathologic response to neoadjuvant therapy and circulating tumor DNA have value in understanding rare subtypes of TNBC. Finally, we discuss a framework for advancing disease-specific knowledge in this space. While the conduct of randomized trials in rare TNBC subtypes has been challenging, re-envisioning trial design and technologic tools may offer new opportunities. These include embedding rare TNBC subtypes in umbrella studies of rare tumors, retrospective review of contemporary trials, prospective identification of patients with rare TNBC subtypes entering on clinical trials and querying big data for outcomes of patients with rare breast tumors.
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Affiliation(s)
- Alexandra Thomas
- Department of Internal Medicine, Atrium Health Wake Forest Baptist Cancer Center, Winston-Salem, NC, USA.
| | - Jorge S Reis-Filho
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Charles E Geyer
- Department of Medicine, University of Pittsburgh UPMC Hillman Cancer Center, Pittsburgh, PA, USA
| | - Hannah Y Wen
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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2
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Prognostic relevance of mixed histological subtypes in invasive breast carcinoma: a retrospective analysis. J Cancer Res Clin Oncol 2022:10.1007/s00432-022-04443-x. [DOI: 10.1007/s00432-022-04443-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Accepted: 10/19/2022] [Indexed: 11/06/2022]
Abstract
Abstract
Purpose
The prognostic and therapeutic power of special histological subtypes in breast cancer in pure form or in combination with other histological subtypes is still not established, and diagnostic guidelines are cautious regarding prognostic power based on the histological subtype alone. Therapy decisions are guided in most cases independently of the histological subtype and are directed by biomarkers and tumor stage. In this study, we analyzed a comprehensive large retrospective breast cancer cohort with a special focus on histological subtype (other than ductal non-special type or lobular carcinoma) and correlated pure or mixed histological forms with pathological tumor stage and overall disease-free survival.
Materials and methods
A total of 827 breast cancer cases with pure or mixed special histological types were retrospectively analyzed. Survival information was available in 645 of 827 cases.
Results
A total of 293 cases had pure forms, and 534 cases had mixed histological subtypes. The most common pure special types were mucinous (23.9%), micropapillary (21.2%), high-grade metaplastic (13%), male breast cancer (8.2%), cribriform (6.8%), metastases (6.1%), apocrine and papillary (each 5.46%), NST with medullary and clear cell pattern (up to 3.4%) and high-grade neuroendocrine carcinomas (2.7%). Mixed forms were most frequently encountered in NST carcinomas with micropapillary components (41.8%), followed by mucinous (9.93%) and cribriform (6.74%) mixed patterns. In univariate analysis, no pure form had prognostic relevance compared with any mixed form with the basic pure element. Pooling pure histological subtypes with tumor stage and age in a linear random-effects model, the cribriform subtype had the most favorable prognosis, while male breast cancer showed the poorest outcome (p < 0.001). All other frequent pure forms had intermediate prognostic power (p < 0.001).
Conclusion
Our results show that the analyzed special histological breast cancer subtypes (other than ductal and lobular carcinomas) do not carry prognostic information alone, either in pure form or in any combination with other subtypes. Prognostic groups including special subtypes, however, can strongly stratify breast cancer if tumor stage, age and biomarkers are included in the prognostic measurements.
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Skenderi F, Alahmad MAM, Tahirovic E, Alahmad YM, Gatalica Z, Vranic S. HER2-positive apocrine carcinoma of the breast: a population-based analysis of treatment and outcome. Breast Cancer Res Treat 2022; 193:523-533. [PMID: 35355162 PMCID: PMC9090698 DOI: 10.1007/s10549-022-06578-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Accepted: 03/17/2022] [Indexed: 11/28/2022]
Abstract
PURPOSE Apocrine carcinoma of the breast (APO) expresses HER2 in 30-50% of cases. This study explored the clinicopathological features and outcome of HER2+/APO and matched HER2+/NST cohort. METHODS We used the SEER database to explore the cohorts. Univariate and multivariate analyses were used to assess the survival. Based on ER and PR [steroid receptors/SR/] and HER2 status, we divided the cohorts to match the intrinsic molecular subtypes for comparisons. RESULTS We retrieved 259 cases of HER2+/APO. Most HER2+/APO were SR negative (65%). HER2+/APO were more prevalent in the 80+ age group (24.7% vs. 15.7%, p < 0.001). HER2+/SR-/APO had a significantly lower histological grade than the HER2+/SR-/NST (p < 0.001). Breast cancer-related deaths were more prevalent in HER2+/NST (7.8% vs. 3.9%, p = 0.019). This was particularly evident between SR- subgroups (10.4% in HER2+/SR-/NST vs. 4.2% in HER2+/SR-/APO, p = 0.008) and was reaffirmed in breast cancer-specific survival in univariate analysis (p = 0.03). Other than race and SR status, HER2+/APO subgroups did not differ in clinicopathological parameters. CONCLUSIONS Our study confirms the rarity of the APO and reveals that SR status in APO does not affect these patients' prognosis. HER2+/APO tumors tend to have a less aggressive phenotype and a more favorable outcome despite a markedly lower ER/PR positivity.
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Affiliation(s)
- Faruk Skenderi
- Faculty of Health Sciences, University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | | | - Emin Tahirovic
- Faculty of Engineering and Natural Sciences, International University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Yaman M Alahmad
- College of Medicine, QU Health, Qatar University, PO Box 2713, Doha, Qatar
- Medical Education, Hamad Medical Corporation, Doha, Qatar
| | - Zoran Gatalica
- Department of Pathology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Semir Vranic
- College of Medicine, QU Health, Qatar University, PO Box 2713, Doha, Qatar.
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Tan BY, Lim EH, Tan PH. Special Histologic Type and Rare Breast Tumors - Diagnostic Review and Clinico-Pathological Implications. Surg Pathol Clin 2022; 15:29-55. [PMID: 35236633 DOI: 10.1016/j.path.2021.11.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Breast cancer is the most common malignant tumor in females. While most carcinomas are categorized as invasive carcinoma, no special type (NST), a diverse group of tumors with distinct pathologic and clinical features is also recognized, ranging in incidence from relatively more common to rare. So-called "special histologic type" tumors display more than 90% of a specific, distinctive histologic pattern, while a spectrum of tumors more often encountered in the salivary gland may also arise in the breast. Metaplastic carcinomas can present diagnostic challenges. Some uncommon tumors harbor pathognomonic genetic alterations. This article provides an overview of the key diagnostic points and differential diagnoses for this group of disparate lesions, as well as the salient clinical characteristics of each entity.
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Affiliation(s)
- Benjamin Yongcheng Tan
- Department of Anatomical Pathology, Singapore General Hospital, Level 10, Academia, 20 College Road, Singapore 169856, Singapore
| | - Elaine Hsuen Lim
- Division of Medical Oncology, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore 169610, Singapore
| | - Puay Hoon Tan
- Division of Pathology, Singapore General Hospital, Level 7, Diagnostics Tower, Academia, 20 College Road, Singapore 189856, Singapore.
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An Update on the Molecular and Clinical Characteristics of Apocrine Carcinoma of the Breast. Clin Breast Cancer 2021; 22:e576-e585. [PMID: 35027319 DOI: 10.1016/j.clbc.2021.12.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 12/14/2021] [Accepted: 12/20/2021] [Indexed: 02/07/2023]
Abstract
Apocrine carcinoma of the breast is a rare malignancy. According to 2019 WHO classification, apocrine cellular features and a characteristic steroid receptor profile (Estrogen receptor (ER)-negative and androgen receptor (AR)-positive) define apocrine carcinoma. Her-2/neu protein expression is reported in ∼30-50% of apocrine carcinomas, while NGS analysis showed frequent PIK3CA/PTEN/AKT and TP53 mutations Followed by deregulation in the mitogen-activated protein kinase pathway components (mutations of KRAS, NRAS, BRAF). A recent miRNA study indicates various miRNAs (downregulated hsa-miR-145-5p and upregulated 14 miRNAs such as hsa-miR-182-5p, hsa-miR-3135b, and hsa-miR-4417) may target the commonly altered pathways in apocrine carcinomas such as ERBB2/HER2 and mitogen-activated protein kinase signaling pathway. Although AR expression is a hallmark of apocrine carcinoma, little is known regarding the efficacy/resistance to antiandrogens. Success of bicalutamide, a non-steroidal anti-androgen, was reported in a case of Her2-negative apocrine carcinoma. Two recent studies, however, described presence of anti-androgen resistance biomarkers (a splice variant ARv7 and AR/NCOA2 co-amplification) in a subset of AR+ apocrine carcinomas, cautioning the use of anti-androgens in AR+ triple-negative breast carcinomas. Apocrine carcinomas rarely show biomarkers predictive of response to immune checkpoint inhibitors (PD-L1 expression, MSI-H status, and TMB-high). Therefore, a comprehensive cancer profiling of apocrine carcinomas is necessary to identify potential therapeutic targets for a truly individualized treatment approach.
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Luján M, Varela G, Morán D. Breast carcinoma or sweat gland carcinoma? A report of two cases and a comparison with the literature. BIOMEDICA : REVISTA DEL INSTITUTO NACIONAL DE SALUD 2021; 41:409-419. [PMID: 34559489 PMCID: PMC8519603 DOI: 10.7705/biomedica.5758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 06/14/2021] [Indexed: 11/21/2022]
Abstract
Primary apocrine carcinoma of the sweat gland is a neoplasm with a very low incidence that may represent a clinical and histological diagnostic challenge, as well as for adequate local, adjuvant, and advanced disease management. The average age of patients is around 67 years with no gender preference. This cancer develops primarily at the axillary and scalp levels and is clinically characterized by slow growth, but can progress aggressively with local, nodal, and metastatic involvement (primarily lung, liver, and bone). The recommended management, once the histology is established, consists of a wide local resection with a clear margin of 1 to 2 cm and regional lymphadenectomy if clinically positive nodes are detected. The adjuvant treatment (radiotherapy or chemotherapy) and for the advanced disease is not established. We report here the cases of two female patients initially diagnosed with breast cancer who were finally diagnosed with apocrine carcinoma of the sweat gland.
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Affiliation(s)
- Mauricio Luján
- Oncología Clínica, Clínica de Oncología Astorga, Medellín, Colombia; Facultad de Medicina, Universidad Pontificia Bolivariana, Medellín, Colombia.
| | - Gabriel Varela
- Patología Oncológica, Hospital Pablo Tobón Uribe, Medellín, Colombia; Patología Oncológica, Clínica Aurora, Medellín, Colombia; Patología Oncológica, Hospital San Vicente Fundación, Medellín, Colombia.
| | - Diego Morán
- Oncología Clínica, Clínica de Oncología Astorga, Medellín, Colombia.
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Quinn CM, D’Arcy C, Wells C. Apocrine lesions of the breast. Virchows Arch 2021; 480:177-189. [PMID: 34537861 PMCID: PMC8983539 DOI: 10.1007/s00428-021-03185-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 07/28/2021] [Accepted: 08/11/2021] [Indexed: 02/06/2023]
Abstract
Apocrine change is recognised in benign, atypical and malignant lesions of the breast. Apocrine metaplasia, a frequent finding in the breast of women over the age of 25 years, is most commonly seen in benign cysts with a simple or papillary configuration. Apocrine change is also recognised in other benign lesions including sclerosing adenosis, now known as apocrine adenosis. Apocrine atypia usually refers to cytological atypia in which there is at least threefold variation in nuclear size but architectural atypia may also occur. The distinction between atypical apocrine hyperplasia and non-high-grade apocrine ductal carcinoma in situ may be difficult due to the relative rarity of these entities and the lack of validated diagnostic criteria. Lobular carcinoma in situ (LCIS) with apocrine change is considered to be a variant of pleomorphic LCIS. An apocrine variant of encapsulated papillary carcinoma is also recognised. Apocrine change is described in invasive carcinoma, including no special type, lobular, micropapillary and mucinous variants. The recent WHO 2019 update recognises 'carcinoma with apocrine differentiation' as a special type breast carcinoma based on the presence of apocrine morphology in at least 90% of the tumour. Tumours with apocrine morphology are usually but not always hormone receptor negative. Human epidermal growth factor receptor 2 (HER-2) status is variable. Molecular studies have identified breast tumours with apocrine features and high expression of androgen receptor mRNA including 'luminal androgen receptor tumours' and 'molecular apocrine tumours'. The term 'pure apocrine carcinoma' has been proposed to describe an invasive carcinoma with apocrine morphology that is oestrogen and progesterone receptor negative and androgen receptor positive. HER-2 status may be positive or negative. This article reviews the pathology of benign, atypical and malignant apocrine lesions of the breast, with emphasis on diagnostic criteria including an approach to evaluation of apocrine lesions on needle core biopsy, and recent advances in our understanding of invasive apocrine carcinoma.
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Affiliation(s)
- Cecily M. Quinn
- Irish National Breast Screening Programme and Department of Histopathology, St. Vincent’s University Hospital, Elm Park, Dublin 4, Ireland
- School of Medicine, University College Dublin, Dublin, Ireland
| | - Clare D’Arcy
- Irish National Breast Screening Programme and Department of Histopathology, St. Vincent’s University Hospital, Elm Park, Dublin 4, Ireland
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Vranic S. Letter to Editor: Apocrine carcinoma is the fact. Comment on the recent paper entitled “Invasive apocrine carcinoma of the breast: Myth or fact?” by Gurrado et al (Breast J. 2019;26(3):545‐546.). Breast J 2020; 26:838. [DOI: 10.1111/tbj.13681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Accepted: 10/15/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Semir Vranic
- College of Medicine QU Health Qatar University Doha Qatar
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9
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Altundag K. Neo‐adjuvant treatment in invasive apocrine carcinoma of the breast. Breast J 2019; 25:568. [DOI: 10.1111/tbj.13285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 01/03/2019] [Indexed: 11/28/2022]
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10
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Imamovic D, Bilalovic N, Skenderi F, Beslagic V, Ceric T, Hasanbegovic B, Beslija S, Vranic S. Letter to the Editor/Response. Breast J 2019; 25:569. [PMID: 30980590 DOI: 10.1111/tbj.13284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 01/03/2019] [Indexed: 11/26/2022]
Affiliation(s)
- Denira Imamovic
- School of Medicine, University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Nurija Bilalovic
- Department of Pathology, Clinical Center, University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Faruk Skenderi
- Department of Pathology, Clinical Center, University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Vanesa Beslagic
- Department of Radiology, Clinical Center, University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Timur Ceric
- School of Medicine, University of Sarajevo, Sarajevo, Bosnia and Herzegovina.,Department of Oncology, Clinical Center, University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Berisa Hasanbegovic
- Department of Oncology, Clinical Center, University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Semir Beslija
- School of Medicine, University of Sarajevo, Sarajevo, Bosnia and Herzegovina.,Department of Oncology, Clinical Center, University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Semir Vranic
- School of Medicine, University of Sarajevo, Sarajevo, Bosnia and Herzegovina.,Department of Pathology, Clinical Center, University of Sarajevo, Sarajevo, Bosnia and Herzegovina.,College of Medicine, Qatar University, Doha, Qatar
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