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Ren# { 2 33 }G ille s , M D #{149}A lv ian L esn ik , M D #{149}Jean -M arc G uin eb re ti#{2 32}re, M D #{149}Anne T ard ivon , M DJacques M asselo t, M D #{149}G enev ieve C on tesso , M D . #{149}D an ie l V anel, M D

A pocrin e C arcin om a:Cl in ica l and M amm ograph ic F ea tu res

A bbrev ia tion : A C = ap ocr ine ca rcin om a.

PURPOSE : To descr ib e th e m amm o-g raph ic fea tu res o f apocrin e carc i-n om a and assess th e pa ttern s o f ca l-cif icat ions assoc ia ted w ith th eselesions.MATER IALS AND METHODS : Cimi -ca l and m amm ograph ic fea tu res from17 p atien ts w ith ap ocrine carc inom aw ere re trosp ec tiv ely rev iew ed . Sp e -cia ! a tten tion w a s pa id to th e p res-en ce of m ix ed fo rm , d iffu sely sca t-tered m icroca lc i.fica tion s onmammograms.RESULTS : Pa tien ts w ere re fe rred fo rcl in ica l (n = 1 0) , m a mm o gr ap hi c(n = 2 ), o r bo th c lin ica l an d m amm o -graphic (n = 5 ) ab norm a litie s . F in d -in gs a t c lin ica l exam ination inc lud eda pa lpab le b reast m a ss (n 12), m ul-t ip le b rea st m a sses (n = 1), andb lo ody n ipp le d ischarge (n = 2 ); tw opa tien ts had no rm a l f ind ings. F our-teen pa tien ts had opac itie s a t m am -m ography . T hese opa cit ies w ere a s-socia ted w ith m icroca lcif icatio ns in10 cases. T h ree pa tien ts had m icro-ca lc ifica tions w itho u t o pacitie s; oneof tho se three patien ts exh ib ited am ixed fo rm o f d iffu se ly sca ttered ca l-cff icat ions.CONCLUS ION : C lin ica l an d m am -m ograph ic fea tu res o f apocr in e carci-n om a do not d iffer from those o f in -va sive du c ta l carc in om a.

Index te rm s: B reas t, ca lc if ica tion , 00 .329 ,00 .815 #{149}B reas t neo pla sm s, 00 .32 9 , 0 0 .81 5B reas t neo pla sm s, d iagn osis, 0 0 .3 29 , 0 0 .8 15

R ad io lo gy 1994; 1 90:495 -49 7

I From the D epa rtm en ts of R adio lo gy (R .G .,AL ., A T ., J.M ., D V .) and H is topa tho log y C0MG ., G .C .), Ins titu t G ustave Rou ssy , 9 4805V illeju if C ed ex , F ran ce . R ece ived Jun e 8 , 1 993 ;rev isio n requ este d Ju ly 12 ; re v is ion rec eiv edA ugus t 8 ; a ccep ted A ugu st 18 . A ddre ss repr in treq ues ts to R .G .

C R SNA , 1 994

POCR INE carc inom a (A C ) is a rareb reas t t u m o r (1 -3 ). R ecen tly ,

Kopan s et a l (4 ) reported a se ries o f 10wom en w ith d iffu se ly sca tte red calc i-fica tions on m amm og ram s. T he ca lc ifi-c a t io n s w ere of m ixed fo rm becauseth ey d isp layed fea tu res cons id e redty p ica l o f b o th b e n ig n a n d m a lig n a n tpro cesses . In each case , apocrinem etap las tic transfo rm atio n of th e tu -m on ce lls w as dem on stra ted a t h isto -log ic ana lysis . T he au th o rs sugg esteda possib le ro le o f ap ocrine m etap las iain th e g e n e s is o f th e s e calc ifications . Ifth is w ere true , one m igh t hypo thesizea g re ate r tend en cy fo r u nusu a l ca lcifi-ca tion s in assoc iatio n w ith A C . Th epurposes o f th is study w e re to (a ) d e -s c r ib e th e mammog rap h i c fea tu res o fh isto lo g ically p ro ved A C and (b ) assessth e p atte rn s o f ca lcif icatio ns as soc iatedw ith th e s e le s io n s .

MATER IA LS AND M ETHOD SFrom 1979 to 1992 , 23 p atien ts w ere

t rea ted at o ur ins titu tio n fo r h isto lo g ic allyprov ed A C . C lin ica l and m amm ograph icda ta from 17 of these 2 3 pa tien ts w ere re -v iew ed by tw o rad io log is ts (R .G ., A L .).M ammogram s w e re n ot ava ilab le in thesix rem ain ing pa tien ts . A ge , h isto ry ofb rea st c an cer, an d re su l ts o f clin ic al e xam i-na tio n w ere record ed fo r all pat ien ts. A llscreen-f ilm m amm ogram s w ere rev iew ed ,and p ar ticu la r a tten tion w as pa id to thepresence of the m ixed fo rm of d iffuse lyscattere d ca lcif icat ion s described by K o-p ans e t a l (4 ).

A ll h isto log ic sl ide s w ere rev iew ed , andth e d iagno sis o f AC was ba sed on cr iter iad efin ed b y A zzopard i (1 ). C arc in om as areco nside red to be apocn ine if they are com -posed of m o re th an 80% recogn izab le ap o-cn ine-typ e cel ls, w hich a re de fin ed by anabund an t ac ido ph ilic g ranu la r cy top lasmw ith ves icu la r nuc le i and p rom inen tnucleo li .

RESULTST he 17 w om en rang ed in age from

33 to 88 y e a rs (m ea n , 57 years ) . F o u rw om en h ad h ad co n tro la tera l (n = 3 )

o r i ps il at er al (n = 1 ) b reast can ce r1 -14 yea rs p re v io u s ly (m e a n , 8 y e a rs ).Two of th ose fo u r w om en h a d in v a -s ive carc in om a w ith a p o c r in e featu res .

In a ll ca se s, th e d iagn osis o f A C w asb ased o n c r ite r ia d e fin e d b y A z z o p a rd i(1 ) . A ll tu m o rs e x c e p t o n e d u c ta l c a rc i-n o m a in s itu w e re in v a s iv e A C th a tranged from 15 to 55 m m in d iam e te r( m e a n , 12 mm ). Tw o p atien ts h adm ultifocal AC .

Th e pa tien ts h a d b e e n re fe rre d fo rcl in ical (n = 1 0) , m a m m og ra ph ic(n = 2 ), or bo th cl in ical a n d m a m m o -g ra p h ic (n = 5) anom alies . F ind ing s atc lin ic al e xa min atio n in c lu d e d a p a l-p a b le b re a s t m a s s (n = 1 2), m ultip leb reast m asses (n = 1 ), o r b lo o d y n ip p led ischarge (n = 2); tw o pa tien ts ha dn o rm al fin d in g s . T he m am mogram ssh ow ed a reas o f o pa city (n = 14) o ri so la te d m i cr oc al ci fi ca ti on s (n = 3)(T ab le s 1 , 2 ) . O f the 1 4 p atien ts w ithan op ac ity (F ig 1 ), 1 0 a lso had m icro -ca lcif icatio ns. Tw o w om en had m u l -tip le o p a c itie s th a t w e re c o rre la te dwith m u ltifo c a l A C a t h is to lo g ic re -v iew . Am ong th e th re e p a tie n ts w ithiso lated m icroca lc ifica tio ns (F ig 2 ), oneex h ib ited th e m ix ed fo rm of d iffuse lys c a tte re d c a lc ific a tio n s d e s c rib e d b yK o p a n s e t a l (F ig 3) an d tw o h a d c lu s -te re d lin ea r c a lc ific atio ns (F ig 2 ) .

In the p atien t w ith the m ixed fo rmof d iffuse ly scatte red calc if ica tion s,in trad uc ta l A C w as d iagn osed a t h is-to p a th o lo g ic a n a ly s is . T h e c a lc ific a -tion s w ere loca ted inside the d uc talp ro lifera tion an d in b en ign cy stsa ro u n d th e tu m o r.

DISCUSSIONT here a re no tab le d isc repan cie s in

th e lite ra tu re re g a rd in g th e d iffe re n -tia l d iagn osis o f A C and breast ca rc i-n o m a w ith ap oc rin e m etap la sia . T hereported p rev alence o f A C ra n g e s

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44.

.r.. :

4qt; #{149}Radin inoy Feb ru ary 1 994

fro m 0 .4 % (1 ) to 6 0% (5). A ccord in g toA zzopard i (1 ) , o n ly c a r c i n o m a withm o re th a n 8 0 % re c o g n iz a b le a p o -c rim e-ty pe ce lls are A C . I n c on tr as t,H a a g e n s e n e t a l ( 5) c on si de r a ll b re as tc a rc in o m a s w ith a p o c rin e fe a tu re s tobe A C . A t o u r in s titu tio n , A C is d ia g -n o s e d o n th e bas is o f A z z o p a rd is c r i-te r ia .

A C w a s firs t te rm ed ju ven ilec a rc in o m a b e c a u s e th e p a tie n ts w e rey o u n g w o m e n (6 ). In o u r s tu d y , a s ino thers , th e a g e d is tr ib u tio n o f w o m e nwith A C d o e s n o t a p p e a r to d iffe rfrom tha t o f w om en w ith in vasivec a rc in o m a (7 ,8 ). M o s t o f o u r p a tie n tsha d a p a lp a b le m a s s . T h e tim e a tw h i c h this re tro s p e c tiv e s tu d y w a sc o n d u c te d c o u ld p a rtia lly a c c o u n t fo rth e lo w ra tio o f is o la te d m a m m o -g ra p h ic a n o m a lie s . T h e p ro g n o s is o fAC has been repo rted to b e equa l totha t o f no napo crine du c tal ca rc in om a ;h o w e v e r, b e c a u s e o f th e ra r ity o fth e s e tu m ors , d e fin itiv e c o n c lu s io n scanno t b e m ade (2 ,3 ) .

Recen t ly , K o p a n s e t a l (4 ) d re w o u ra tten tion to th e m ix ed fo rm of d if-fu s e ly s c a tte re d c a lc ific a tio n s a s s o c i-a te d with b re a s t c a n c e r w ith a p o c r in efe a tu re s . It is n o t k n o w n h o w o fte ns u c h c a lc ific a tio n s o c c u r w ith o th e rf o rms o f b e n ig n a n d m a lig n a n t b re a s td isease. It is gene rally accep ted th atd iffu se ly s c a tte re d m ic ro ca lc ific a tio nsa re a ss oc ia te d w ith b en ign d isea se ,the no tab le e x c e p tio n b e in g e x te n s iv ec o m e d o c a rc in o m a w ith its c h a ra c te r-

is tic m ic roca lc ifica tions on m amm o -g ram s, w hereas c lu ste rs of microca lc i -fic a tio n s a re assoc iated w ith m alig nan td is e a s e (9 -1 3 ) . B ecause 50% of n on -pa lpab le b reast c a n c e r is d e te c te d a s are su lt o f m ic ro ca lc if ic atio ns o n m a m -m og ram s, th e desc rip tion re p o rte d b yKopans e t al (4 ) caused a d iag nos ticd i l emma f or r ad io lo gis ts (12 ,14 ,15) .T he se tro ub le so me mammog rap h i cpa tterns w ere th o u g h t to b e du e to

Figure 1. M amm ogram of a 5 9-year-o ldw om an sh ow s a sp icu la ted opac ity in th e lef tb reast. T he pa tien t w as c lin ica lly asym ptom -a tic . Invas ive A C w as d iag nosed a t h isto log icexamina t ion .

the sec re to ry activ ity o f ap oc rinem etap las tic transfo rm ation of the tu -m or cells (4 ).

Table 1Character ist ics of O pacities inP atie n ts w ith AC

Charac te r is t ic sNo . ofPat ien ts(a = 14 )

Dens i tyH om ogeneous 9H ete ro geneous 5

BordersI ll d e fi n ed 9Weildef ined 5

Numbe rS ing le 12Mult ip le

A ssoc iate d w ith m ic roc alcifica -2

t ions 10

Table 2Appearance of M icroca lc ifica tion s inPa tie n ts w ith AC

Charac te r is t ic sN o. ofPat ien ts

M icroca lcifica tio ns and op ac ity(n = 10 )

In side the opacity 7O uts ide the opacity IBo th ins ide and ou ts ide the

opac ity 2M icroca lcifica tio ns a lone (n = 3)

C lus te red and linear 2M ixed fo rm , d iffu sely sca t te red 1

2 3.F igu res 2 , 3 . (2 ) M ammogram of a 4 5-y ear -o ld w om an dem onstra te s iso late d c lustered lin ear and irreg u la r calcifications in the r igh t b rea st.T he pa tien t w as clin ica lly a sym ptom a tic. Inv asive A C w as d iagn osed a t su rg ical b io psy pe rfo rm ed a fte r preo pera tive loca lization . (3 ) M amm o-gram of a 46 -year-o ld w om an refer red fo r a b loody n ipp le d isch arge of the le ft b reas t. T he m amm ogram show s the m ix ed fo rm of d iffuse lyscat tered ca lc ifica tions rep orted by K opans e t a l (4 ) . In traduc ta l A C w as d iag nosed a t h isto log ic ana lysis o f the m as tec tom y spec im en .

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It m ust be s tated th at K opans e t a ls t udi ed breast cancer w ith apocrinefea tu re s , w h ile w e stud ied A C . T hed iffe rence b e tw een these tw o h isto -log ic en titie s is the ra tio o f tum o ra lce lls w ith apo crin e m etap las ia (m o rethan 8 0% in A C v s le s s th a n 8 0 % inbreast cancer w ith apocrine fea tu res).Because th e A C d iagnosed a t our in -s titu tion con ta ined a t least 80% tu-m oral ce lls w ith apocrine m etap las ia ,we an tic ip a ted f in d ing m amm o-grap h ic p atte rns com parab le to tho sedesc rib ed by K op an s e t a l. H ow eve r,such w as n o t the case ; on ly one pa-tie n t w ith AC h a d th e m ixed fo rm ,d iffusely sca ttered ca lc ifica tions a tm amm ograp hy . T here fo re , the sec re -to ry ac tiv ity o f ap ocrine ce lls cou ldno t acco un t fo r the se m am m og raph icpa tterns. It shou ld be no ted tha t them amm ogram s of on e pa tien t w ith A Cexh ib ited the m ixed fo rm of d iffuse lysca tte red ca lcif icatio ns (F ig 3 ) .

I n c on clu sio n, the m ix ed fo rm ofd iffu se ly sca ttered ca lc ifica tio nsshou ld b e se rious ly conside red b yrad io log ists becau se , in ad d itio n to

the 10 cases reported by K opans e t al,on e w a s fo u n d in o u r s e rie s a s s o c i-a ted w ith breas t cancer. H ow ev er, th ep a th o lo g ic e x p la n a tio n p roposed byK opans e t a l d oes n o t ap pear to ac-c o u n t fo r th is m amm ograph ic pa tte rn .M oreov e r, the m am m og raph ic pa t-tern s o f AC do no t d iffer from those o fcomm on inv as ive carcinom as. #{149}

A cknow led gm ents: W e th an k Lo rna Sain t-A ng e for ed it ing th e m anu scrip t, Isa be lle L afo n tfo r ed ito ria l as sis tan ce, an d A rnaud C h#{233 }ronfo rph oto graph y assista nce .

Refe r en ces1 . A zzopa rd i J. Prob lem s in bre ast p ath o l-

o gy . V ol 2 , M ajo r p rob lem s in p ath o lo gy .L ondon , E ng lan d : Sau nd ers, 19 79 .

2 . M oss ler J , B arto n T , B r ink hon s A , M cCar-thy K , M oylan J, M cC ar thy K Jr . A po crined if fere n tia tio n in hum an m amm ary carci-nom a. C ancer 1 980 ; 46 :24 63-2471 .

3 . G ad a leanu V . G ala tar N . A pocrine carci-nom a of the bre ast . M orpho l Em bry ol 198 6;32 :33-38 .

4 . K opans D , N guyen P , K oern er F , et a l.M ixed form , d iffusely scat tere d ca lcif ica-tion s in bre ast c an cer w ith apoc rin e fea -tu res. R ad io logy 1990; 177 :80 7-8 11 .

5 . H aag ensen C , Bodian C , H aagensen D .B reas t carcin om a: risk and d ete ctio n . Ph ila-de lph ia , P a: Sau nd ers , 19 81 .

6 . D iv i tt R , S tew a rt F . B reas t ca rcinom a inch ild ren . JAM A 1966; 19 5:3 88-390 .

7. A ba ti A , K imm el M , Ro sen PP . A poc rinem amm ary ca rcin om a. Am J C lin P atho l1 9 90 ; 9 4: 37 1 -3 7 7.

8 . E useb i V , M illis R , C attan i M , Bo sso lat i C ,Azzo p a r d i J. A pocrine ca rcinom a o f thebre ast . A m J P ath ol 1 98 6; 1 23 :5 32 -5 41 .

9 . Eg an R L , Sw een ey M B , S ew ell CW . In tra-m amm ary calc ific atio ns w itho ut an as soc i-a ted m ass in b en ign and m alignan t d is -eases. R ad io logy 1980; 137 :1-6 .

1 0 . Lanyi M . M icroca lcifica tio ns in the bre asta b less ing or a curse? D iagn Im ag ing C linM ed 1 9 85 ; 5 4 :1 2 6- 1 45 .

11 . S ick le s E . B rea st calc ificat ion s: m ammo -graph ic ev alua tio n . R ad io lo gy 1986; 1 60:289-293 .

12 . S ick les E . M amm og rap hic featu re s of 30 0consecu tiv e nonpa lpab le bre ast can ce rs.A JR 1 98 6; 1 46 :6 61 -6 63 .

13 . S tom per PC , C onnolly JL , M ey erJE , H arrisJR . C lin ical ly o ccu lt d uc tal carc inom a ins itu de tected w ith m ammograp hy : ana lys iso f 10 0 cases w ith rad io log ic-path o lo g ic co r-re la t ion . R adio log y 1989 ; 17 2:2 35 -24 1 .

1 4 . S ick les EA . M ammographic fea tu res o f ear ly b rea st c anc er. A JR 1984; 143 :46 1-464 .

1 5 . S igfusson B , A nde rsson I, A speg ren K ,Jan-zon L , L in ell F , L jun gbe rg 0 . C lusteredbrea st calc if icat ion s. A c ta R ad io l 1 98 3; 24 :273-281 .