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Case 11 Clinical history This patient presented at the age of 37 years with a four week history of a lump in the left breast. This felt malignant on clinical examination, imaging was suspicious and FNAC revealed malignant cells. A wide local excision and axillary sample were carried out, followed by breast irradiation and chemotherapy. Nine months later she was found to have a recurrent mass at the site of the previous surgery. FNAC was inadequate - C1 and an excision biopsy was performed. Histological appearances - A-E There is a background of focal fibrocystic change and involutional lobules, some of which show marked sclerosis and nuclear atypia (A,B). Extensive fibrosis is present, in which large atypical fibroblasts are present. Within the fibrous stroma are numerous highly atypical cells, singly and in groups (C,D). Differential diagnosis Radiation change Recurrent carcinoma The atypical cells noted above have appearances strongly suspicious of malignancy. Confirmation of their epithelial nature is obtained by positive immunostaining for cytokeratins (eg, Cam 5.2 (E)). Final diagnosis Recurrent carcinoma Further management Mastectomy was performed, and extensive recurrent disease found. Her original Nottingham Prognostic Index was 5.5 (tumour size 2.5 cm, histological grade 3, lymph node stage 3 - Poor Prognostic Group). Despite systemic chemotherapy she died two years after diagnosis. Learning points · The distinction between radiation fibroblasts and recurrent or residual carcinoma cells can be made with the help of immunostaining for epithelial markers. · Always obtain details of previous therapy in post-malignancy follow-up cases. |