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Presented by Hind Nassar, M.D. and prepared by Joseph J. Maleszewski, M.D.
Case 5: 46 year old woman with a breast mass.
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1. Question
Week 364: Case 5
46 year old woman with a breast mass.images/jjm090808/case5a.jpg
images/jjm090808/case5b.jpg
images/jjm090808/case5c.jpg
images/jjm090808/case5d.jpgCorrect
Answer: Medullary carcinoma
Histology: none provided
Discussion: Medullary carcinoma is one of the recognized special types of breast cancer, although it is very rarely diagnosed. It is defined by the presence of a syncitial growth pattern that represents more than 75% of the tumor, the absence of a glandular component, moderate to marked lymphocytic infiltrate, well circumscribed borders (originally, absence of DCIS used to be a criteria but not anymore). If there is >75% syncitial growth pattern and one or more of the other criteria (but not all) the tumor is called invasive ductal with medullary features or “atypical medullary carcinoma”. The importance to recognize medullary carcinoma as an entity comes from the fact that this subtype has a better prognosis compared to conventional high grade invasive carcinoma. The 5 y and 10 y survival rates are 95% and 84% respectively whereas they are 70% and 58% for the conventional non-medullary carcinoma. These tumors are usually negative for ER, PR and Her-2. Five to 19% of BRCA1 carcinomas are medullary type and a higher proportion display medullary features. On the other hand in a study of medullary carcinomas and atypical medullary carcinomas only 3 patients had BRCA mutation who actually had a personal or a strong family history of breast cancer. Therefore a medullary phenotype by itself does not justify genetic testing.
Incorrect
Answer: Medullary carcinoma
Histology: none provided
Discussion: Medullary carcinoma is one of the recognized special types of breast cancer, although it is very rarely diagnosed. It is defined by the presence of a syncitial growth pattern that represents more than 75% of the tumor, the absence of a glandular component, moderate to marked lymphocytic infiltrate, well circumscribed borders (originally, absence of DCIS used to be a criteria but not anymore). If there is >75% syncitial growth pattern and one or more of the other criteria (but not all) the tumor is called invasive ductal with medullary features or “atypical medullary carcinoma”. The importance to recognize medullary carcinoma as an entity comes from the fact that this subtype has a better prognosis compared to conventional high grade invasive carcinoma. The 5 y and 10 y survival rates are 95% and 84% respectively whereas they are 70% and 58% for the conventional non-medullary carcinoma. These tumors are usually negative for ER, PR and Her-2. Five to 19% of BRCA1 carcinomas are medullary type and a higher proportion display medullary features. On the other hand in a study of medullary carcinomas and atypical medullary carcinomas only 3 patients had BRCA mutation who actually had a personal or a strong family history of breast cancer. Therefore a medullary phenotype by itself does not justify genetic testing.
