- Email: [email protected]
Papillary apocrine metaplasia and columnar cell lesion with atypia: is there a shared common pathway?
Available online at www.sciencedirect.com
Annals of Diagnostic Pathology 14 (2010) 425 – 431
Papillary apocrine metaplasia and columnar cell lesion with atypia: is there a shared common pathway?☆,☆☆ Kemal Kosemehmetoglu, MD⁎, Gulnur Guler, MD Hacettepe University Faculty of Medicine, Department of Pathology, Ankara, Turkey
Abstract
Keywords:
Papillary apocrine metaplasia (PAM) and columnar cell lesion with atypia (CCL) are considered as candidates of early premalignant breast lesions. In this study, we investigated their relationship at the morphological level, as we noticed their histologic coexistence and proximity in daily routine. We selected 93 neoplastic and nonneoplastic cases with both PAM and CCL among 477 breast specimens and reevaluated sections by measuring the distance between these lesions. Ninety-three (19.4%) of 477 breast specimens contained both PAM and CCL; in 73.1% of the cases, the 2 lesions were in continuity with or adjacent to each other. Lesions less distant than 1 mm are grouped as “adjoining lesions”; and the rest, as “distant lesions.” A significant difference (P = .006) was found between adjoining (“zero” + “b1 mm”) and distant (“≥1 mm”) lesions; that is, PAM and CCL were much closer in the neoplastic group, especially tumors with low grade, high estrogen and progesterone receptor expression, and less lymph node metastasis. During the detailed examination of adjoining lesions, some “hybrid cells” showing properties of both lesions were encountered. Papillary apocrine metaplasia and CCL tend to appear in close contact, especially in neoplastic breasts with favorable features. This result implies that PAM and CCL may be included in the same pathogenetic pathway despite their distinct immunophenotypical properties. © 2010 Elsevier Inc. All rights reserved. Apocrine metaplasia; Flat epithelial atypia; Breast cancer
1. Introduction Although there are many proposed candidate precursors and premalignant lesions, such as ductal epithelial hyperplasia, columnar cell lesion with atypia (CCL), and atypical lobular hyperplasia [1-10], related to low-grade breast cancer, the only nonobligate precursor for high-grade invasive tumors is still high-grade ductal carcinoma in situ; and there is no well-established premalignant lesion for high-grade invasive tumors. Columnar cell lesion with atypia (“flat type” DIN, atypical cystic lobules, flat epithelial atypia, atypical columnar
☆ Presented as poster at the 21st European Congress of Pathology, Istanbul, September 2007. ☆☆ Conflict of interest statement: We declare that we have no conflict of interest. ⁎ Corresponding author. Hacettepe University, Department of Pathology, 06 100 Sihhiye/Ankara Turkey. Tel.: +90 312 305 1563; fax: +90 312 305 2621. E-mail address: [email protected] (K. Kosemehmetoglu).
1092-9134/$ – see front matter © 2010 Elsevier Inc. All rights reserved. doi:10.1016/j.anndiagpath.2010.06.009
alteration with prominent apical snouts and secretion, hyperplastic enlarged lobular unit) is characterized by enlarged, morphologically and immunophenotypically altered terminal duct lobular units with increased proliferation and estrogen/progesterone receptor (ER/PR) expression and decreased cell death [3,11,12]. The importance of CCL comes from its close relationship with low-grade breast cancer, especially tubular and lobular carcinomas [13,14]. Apocrine change not only occurs in normal breast and breast with benign lesions, but also accompanies in situ and invasive carcinomas [15-19]. The cysts lined by a single layer of apocrine epithelium are classified in nonproliferative breast lesions and not associated with any increased risk of subsequent carcinoma [10]. However; a subgroup called papillary apocrine metaplasia (PAM) is reported to have a slightly increased risk of subsequent carcinoma, even though most of the elevated risk was related with the presence of atypical hyperplasia in highly complex papillary apocrine change [20]. Loss of heterozygosity/allelic imbalance [9,21,22], aneuploidy [23,24], and oncogenic aberrations [25,26] in apocrine change suggest that at least some of them
426
K. Kosemehmetoglu, G. Guler / Annals of Diagnostic Pathology 14 (2010) 425–431
are clonal in nature and thus preneoplastic. Moreover, the genetic similarities between some benign and malignant apocrine lesions suggest that at least a subset of these benign lesions may behave in a nonobligate precursor fashion and/or have a role as an early premalignant lesion for high-grade breast cancers. Although PAM and CCL have distinct phenotypic and genotypic features, we occasionally noticed their histologic coexistence and proximity in our daily practice. Therefore, we decided to investigate their relation at the morphological level with a systematic approach. 2. Material and methods Cases were selected from archives between 2004 and 2006. All selected excision materials were totally exam-
ined, and mastectomy materials were sampled using a topographic map. The normal breast parenchyma in mastectomy specimens was represented with at least 10 samples (4 samples for quadrants, at least 2 samples for normal tissue adjacent to tumor, and at least 4 samples for normal tissue far from tumor). All mastectomy specimens were reported by the same breast pathologist (GG), and the morphological lesions in normal breast are always reported by using the same terminology. Pathology reports of 477 breast specimens, including small excisions and mastectomies, were looked over for diagnosis of both CCL and PAM in the same excision material or mastectomy specimen. Ninety-three (19.4%) of 477 breast specimens were found to fulfill this criterion. We (KK and GG) reevaluated all sections from these 93 cases, found the area of the closest distance between PAM and CCL in the
Table 1 Distribution of PAM and CCL togetherness among breast specimens
A. Nearly one fifth of breast specimens contain both columnar cell lesion with atypia (CCL) and papillary apocrine metaplasia (PAM). B. According to the morphometric measurements performed for assessment of the distance between 2 lesions, it is more likely to encounter lesions composed of closely allocated CCL and PAM in neoplastic breasts than nonneoplastic ones. C. When adjoining lesions (CCL and PAM distance b1 mm) and distant lesions (CCL and PAM distance ≥1 mm) are compared, togetherness and proximity of CCL and PAM are significantly more pronounced in neoplastic breasts than nonneoplastic counterparts.
K. Kosemehmetoglu, G. Guler / Annals of Diagnostic Pathology 14 (2010) 425–431
section, and measured the distance between these lesions on this area, using an Olympus BX51 microscope and Image Analysis System (Spot Software: 4.1; Diagnostic Instruments Inc, Sterling Heights, MI, USA). In neoplastic breasts, tumor type; grade; ER, PR, and c-erbB2 expression patterns; and regional lymph node status were also noted. Greater than 10% expression of either ER or PR among neoplastic population was accepted as positive. Status of cerbB2 was regarded as positive if greater than 10% of neoplastic cells showed intense membranous staining or if c-erbB2 gene amplification was shown with fluorescent in situ hybridization. For the diagnosis of CCL and PAM, criteria designated in the World Health Organization Classification of Tumours, Pathology and Genetics of Tumours of the Breast [27] and by Schnitt and Vincent-Salomon [3] and the criteria described by Page et al [20], respectively, were followed. Diagnostic feature for CCL was regarded as columnar cells with apical snouts, showing appreciable nuclear atypia and accompanying calcifications (not a strict requisite). Cases with significant cytological atypia that fulfilled the diagnosis of “clinging carcinoma” were excluded. Papillary apocrine metaplasia was characterized by cysts or lobules lined by apocrine cells without any significant cytological atypia, forming papillary structures. To decide whether the lesions are within the same terminal ductal lobular unit or not, 5 groups were described: “zero” for lesions with direct continuity, “b1 mm” for lesions in adjacent lobules, “1-2 mm,” “2-5 mm,” and “N5 mm.” In case of multiple lesions, the closest one was chosen for analysis. To examine the relationship between PAM and CCL in detail, ER (NeoMarkers, Clone SP1, monoclonal, Fremont, CA, USA) and PR (NeoMarkers, Clone SP2, monoclonal) immunostainings were performed on 12 cases of group “zero.” Staining was done on formalin-fixed, paraffinembedded, 4-μm–thick sections using standard staining procedures. After deparaffinization and antigen retrieval with boiling in citrate buffer pH 6, the sections were first incubated with primary antibody according to instructions in data sheet and then processed by biotinylated goat antimouse antibodies followed by streptavidin conjugated to horseradish peroxidase (UltraTek HRP Anti-Polyvalent Alb Pack, ScyTek, West Logan, UT, USA) with the use of diaminobenzidine as the chromogen (DakoCytomation, Carpinteria, CA, USA). For comparison of groups, χ2 test was used and P b .05 was accepted as significant. Analyses were performed with SPSS for Windows (Version 11.0.0; SPSS Inc, Chicago, IL) in a PC.
3. Results In 93 cases comprising both PAM and CCL, 38 were nonneoplastic and 55 were neoplastic among 197 nonneoplastic and 280 neoplastic (a total of 477 cases) breast
427
specimens. Distribution of cases within groups was shown in Table 1. In 68 (73.1%) of 93 cases, which comprised 14.3% of all breast specimens, PAM and CCL were either in continuity (group “zero”) or adjacent to each other (group “b1 mm”). Two main groups were formed from aforementioned 5 groups: the “zero” and “b1 mm” groups were considered together as “adjoining lesions,” and the rest were grouped as “distant lesions” (Fig. 1). “Adjoining lesions” are assumed to be included in the same terminal ductal lobular unit. When neoplastic and nonneoplastic specimens were compared, a significant difference (P = .006) was found between adjoining (“zero” + “b1 mm”) and distant (“≥1 mm”) lesions; that is, the PAM and CCL were much closer in the neoplastic group (Table 1C). Among the neoplastic group, 4 cases were diagnosed as ductal carcinoma in situ; and the rest were invasive carcinoma: ductal carcinoma, not otherwise specified (39 cases); mixed carcinoma (10 cases; 8 ductal + lobular, 1 ductal + mucinous, 1 tubular + lobular); apocrine carcinoma (1 case); lobular carcinoma (1 case); mucinous carcinoma (1 case); and papillary carcinoma (1 case). Fiftysix percent of tumors were metastasized to regional lymph nodes at presentation. The ER and PR were positive and c-erbB2 was negative in approximately 70% of tumors. Using the modified Bloom and Richardson grading system, tumors were graded as 1, 2, and 3 in 20%, 40%, and 40% of cases, respectively. In the neoplastic group in which CCL and PAM are in direct continuity (group “0”), tumors showed significantly lower grade, higher ER and PR expression, and less metastasis to regional lymph nodes than breasts with CCL and PAM with at least 1 mm of distance (Table 2). c-erbB2 expression did not differ significantly. Similar results were found when adjoining (“zero” + “b1 mm”) and distant lesions (“≥1 mm”) were compared (data not shown). During the detailed investigation of continuing lesions, at the conjunction of apocrine and atypical columnar cells, “hybrid cells” showing some characteristics of both PAM and CCL, such as granular eosinophilic cytoplasm with apical snouts and atypical low columnar nucleus, were also encountered (Fig. 2). On the other hand, cytoplasm of hybrid cells was not as large as apocrine cells of PAM. Furthermore, some of those cells expressed ER and PR, although somewhat weaker than CCL.
4. Discussion Our results revealed that nearly one fifth (93/477) of neoplastic and nonneoplastic breast specimens were diagnosed to have both PAM and CCL together. Although there was no difference between neoplastic (38/197, 19.2%) and nonneoplastic (55/280, 19.6%) breasts in terms of frequency of bearing PAM and CCL together, PAM and CCL tended to be in close contact (b1 mm distance) more frequently in
428
K. Kosemehmetoglu, G. Guler / Annals of Diagnostic Pathology 14 (2010) 425–431
Fig. 1. (A) Interdigitating areas of both atypical columnar cell lesion and apocrine metaplasia in the same ductolobular unit (200×, hematoxylin and eosin [H&E]). (B) Close-up view of panel A representing direct continuity of atypical columnar cell lesion and apocrine metaplasia (400×, H&E). (C) In 11 cases, CCL and PAM lesions were adjacent to each other; but we were unable to show direct continuity (200×, H&E). (D-F) The distance between CCL and PAM lesion was measured at the closest area and grouped accordingly (D: 100×, E: 40×, F: 400×; H&E).
K. Kosemehmetoglu, G. Guler / Annals of Diagnostic Pathology 14 (2010) 425–431
429
Table 2 Comparison of prognostic markers with distance of PAM and CCL in neoplastic breasts
Within the cases in the neoplastic group, when comparing the group “zero” with rest of the groups other than group “zero”, tumors are usually low grade, high ER and PR expressing, and less likely to metastasize in breasts with CCL and PAM in close contact. LN indicates lymph node. a All data are not available in all cases; total number of cases varies among variables. * P = .05. † P b .019. ‡ P = .037. § P = .006. ∥ P = .725.
Fig. 2. (A-B) High-power view of hybrid cells at the conjunction areas in a case classified in group “zero” with directly continuing CCL and PAM. They are named hybrid cells because their morphological properties simulate both CCL and PAM lesions (400×, H&E). (C-D) Some of the hybrid cells (shown by arrows) express esterogen receptor (ER) and progesteron receptor (PR) (400×).
430
K. Kosemehmetoglu, G. Guler / Annals of Diagnostic Pathology 14 (2010) 425–431
neoplastic breasts than nonneoplastic ones (84% vs 58%, P = .006). This result suggests that their association in the same breast is not always incidental. To the best of our knowledge, in the literature, there is no such other study showing PAM and CCL, although many studies have been performed to show the individual characteristics and the importance of each lesion. Columnar cell lesion with atypia and PAM represent 2 distinct morphological and immunophenotypical phenomena in the breast. Columnar cell lesion with atypia is reported in close relation with lobular carcinoma in situ, atypical ductal hyperplasia, and tubular and low-grade ductal carcinoma [13,14]. It shows high expression of ER, PR, bcl-2, and cyclin D1; high proliferation index; and low expression of p53 [28-30]. Apocrine lesions have also been reported with an increased incidence of breast cancer in some reports [31]; however, they are not investigated in as much detail as CCL, and their relationship with cancer is controversial. In contrast to CCL, apocrine cells express neither ER nor PR; instead, they show high expression of androgen receptors, low proliferation index, low expression of bcl-2, and high expression of p53 [26,27]. These distinct immunophenotypical features of CCL and PAM suggest distant places for them in recently proposed breast carcinogenesis pathways: CCL is thought to precede lowgrade breast carcinomas, whereas PAM is suggested to lead to higher-grade carcinomas [4]. To explain the proximity of CCL and PAM in neoplastic breasts, several suggestions can be made, which will be discussed subsequently: 1. Both may represent neoplastic precursors, into which normal cells transform, showing diverse response to the same stimulus. After the first hit leading to preneoplastic features, divergent phenotypical features of these lesions may appear as siblings of the same parent. 2. One of them may be preneoplastic; and the other, bystander or formed by response to stress. Because CCL is a well-known precursor of low-grade tumors and we encountered both CCL and PAM close together in our study, apocrine metaplasia can be regarded as a stress response of breast epithelium. Because of the high level of proliferation stress in the presence of CCL, breast epithelium can undergo a metaplastic process toward apocrine differentiation, a less proliferative and silent condition. But all the breast specimens included in this study had the diagnosis of CCL; and the patients with both CCL and PAM close to each other showed more favorable features, which suggest that togetherness of PAM and CCL has more impact than CCL alone in predicting the features of associated tumor. In addition, as mentioned earlier, there are wellestablished morphological and biological data in literature that show that at least some apocrine lesions are related to the formation of breast cancer.
3. Both are sessile when separate, but the fusion may lead to neoplastic change. Given the presence of a specific form of instability, which causes the epithelial unrest and in turn gives rise to formation of both CCL and PAM next to each other with some hybrid lesions, the same stimulus can also be responsible for the formation of associated low-grade tumors with favorable prognosis. Within the intersection areas of PAM and CCL, some cells surprisingly mimicking their neighboring lesions, PAM and CCL, were encountered; and we called these cells hybrid cells. Their nuclear details resembled CCL, whereas cytoplasmic properties were consistent with apocrine differentiation. Immunohistochemically, hybrid cells expressed ER and PR weaker than CCL. The presence of these hybrid cells may suggest that the cells forming PAM and CCL are of the same ancestor and represent the divergent phenotypic and genetic response to the same stimulus, which is unable to alter these hybrid cells to one way totally. This study has several limitations, as follows: (1) Although we chose excision materials sampled wholly and the mastectomies with at least 10 samples of parenchyma, there still might be cases without demonstrative lesion. We tried to overcome this problem with inclusion of a high number of cases. Actually, despite less amount of tissue sectioned in neoplastic mastectomies than nonneoplastic excision materials, togetherness of both CCL and PAM was encountered more frequently in neoplastic cases, showing that sampling error did not affect outcome significantly. (2) We did not measure the distance between lesions and tumors; nevertheless, this can be the subject of a different study. (3) The study of lesion “togetherness” based on histologic sections has an irreducible bias deriving from the normal anatomy of ductal system, which is tridimensionally interwoven; thus, pathologic foci, including CCL and PAM, may be hardly traced to just one of the 8 to 12 systems in a single tissue section, no matter how distant (or close) they appear to be on the glass slide. Even so, the presence of PAM and CCL in the same lobule can be stated accurately; and groups “0” and “b1” are believed to represent one lobule with these 2 lesions together. In summary, PAM and CCL, when found in the same breast tissue, tend to appear in close contact, especially in neoplastic breasts; and their togetherness was associated with tumors with better prognostic features. Regarding the study design limited to morphological backgrounds, it is difficult to draw conclusive statements; however, our results at least suggest that some of PAM and CCL may be included in the same pathogenetic pathway despite their distinct immunophenotypical properties. The proposed pathways for low- and high-grade breast tumors may not be so simple and may have more transitions than anticipated. Furthermore, our results show that apocrine lesions are not the null element of breast and are worth further study.
K. Kosemehmetoglu, G. Guler / Annals of Diagnostic Pathology 14 (2010) 425–431
Acknowledgment We would like to thank to Dr Andrew Folpe for his review and suggestions on this manuscript, and Kenan Kosemehmetoglu for literal revision. References [1] Buerger H, Otterbach F, Simon R, et al. Different genetic pathways in the evolution of invasive breast cancer are associated with distinct morphological subtypes. J Pathol 1999;189:521-6. [2] Buerger H, Simon R, Schafer KL, et al. Genetic relation of lobular carcinoma in situ, ductal carcinoma in situ, and associated invasive carcinoma of the breast. Mol Pathol 2000;53:118-21. [3] Schnitt SJ, Vincent-Salomon A. Columnar cell lesions of the breast. Adv Anat Pathol 2003;10:113-24. [4] Simpson PT, Reis-Filho JS, Gale T, Lakhani SR. Molecular evolution of breast cancer. J Pathol 2005;205:248-54. [5] Lakhani SR, Collins N, Stratton MR, Sloane JP. Atypical ductal hyperplasia of the breast: clonal proliferation with loss of heterozygosity on chromosomes 16q and 17p. J Clin Pathol 1995;48:611-5. [6] Lakhani SR, Slack DN, Hamoudi RA, Collins N, Stratton MR, Sloane JP. Detection of allelic imbalance indicates that a proportion of mammary hyperplasia of usual type are clonal, neoplastic proliferations. Lab Invest 1996;74:129-35. [7] Moinfar F, Man YG, Bratthauer GL, Ratschek M, Tavassoli FA. Genetic abnormalities in mammary ductal intraepithelial neoplasia-flat type (“clinging ductal carcinoma in situ”): a simulator of normal mammary epithelium. Cancer 2000;88:2072-81. [8] Simpson PT, Gale T, Reis-Filho JS, et al. Columnar cell lesions of the breast: the missing link in breast cancer progression? A morphological and molecular analysis. Am J Surg Pathol 2005;29: 734-46. [9] Washington C, Dalbegue F, Abreo F, Taubenberger JK, Lichy JH. Loss of heterozygosity in fibrocystic change of the breast: genetic relationship between benign proliferative lesions and associated carcinomas. Am J Pathol 2000;157:323-9. [10] Larson PS, de las Morenas A, Cerda SR, Bennett SR, Cupples LA, Rosenberg CL. Quantitative analysis of allele imbalance supports atypical ductal hyperplasia lesions as direct breast cancer precursors. J Pathol 2006;209:307-16. [11] Fraser JL, Raza S, Chorny K, Connolly JL, Schnitt SJ. Columnar alteration with prominent apical snouts and secretions: a spectrum of changes frequently present in breast biopsies performed for microcalcifications. Am J Surg Pathol 1998;22:1521-7. [12] Lee S, Mohsin SK, Mao S, Hilsenbeck SG, Medina D, Allred DC. Hormones, receptors, and growth in hyperplastic enlarged lobular units: early potential precursors of breast cancer. Breast Cancer Res 2006;8:R6. [13] Abdel-Fatah TM, Powe DG, Hodi Z, Lee AH, Reis-Filho JS, Ellis IO. High frequency of coexistence of columnar cell lesions, lobular neoplasia, and low grade ductal carcinoma in situ with invasive tubular carcinoma and invasive lobular carcinoma. Am J Surg Pathol 2007;31: 417-26.
431
[14] Leibl S, Regitnig P, Moinfar F. Flat epithelial atypia (DIN 1a, atypical columnar change): an underdiagnosed entity very frequently coexisting with lobular neoplasia. Histopathology 2007;50:859-65. [15] Eusebi V, Damiani S, Losi L, Millisi RR. Apocrine differentiation of breast epithelium. Adv Anat Pathol 1997;4:139-55. [16] Nielsen M, Thomsen JL, Primdahl S, Dyreborg U, Andersen JA. Breast cancer and atypia among young and middle-aged women: a study of 110 medicolegal autopsies. Br J Cancer 1987;56:814-9. [17] Pagani A, Sapino A, Eusebi V, Bergnolo P, Bussolati G. PIP/GCDFP15 gene expression and apocrine differentiation in carcinomas of the breast. Virchows Arch 1994;425:459-65. [18] Viacava P, Naccarato AG, Bevilacqua G. Apocrine epithelium of the breast: does it result from metaplasia? Virchows Arch 1997;431: 205-9. [19] Dixon JM, McDonald C, Elton RA, Miller WR. Risk of breast cancer in women with palpable breast cysts: a prospective study. Edinburgh Breast Group. Lancet 1999;353:1742-5. [20] Page DL, Dupont WD, Jensen RA. Papillary apocrine change of the breast: associations with atypical hyperplasia and risk of breast cancer. Cancer Epidemiol Biomarkers Prev 1996;5:29-32. [21] Jones C, Damiani S, Wells D, Chaggar R, Lakhani SR, Eusebi V. Molecular cytogenetic comparison of apocrine hyperplasia and apocrine carcinoma of the breast. Am J Pathol 2001;158:207-14. [22] Selim AG, Ryan A, El-Ayat G, Wells CA. Loss of heterozygosity and allelic imbalance in apocrine metaplasia of the breast: microdissection microsatellite analysis. J Pathol 2002;196:287-91. [23] Izuo M, Okagaki T, Richart RM, Lattes R. DNA content in “apocrine metaplasia” of fibrocystic disease of the breast. Cancer 1971;27:643-50. [24] Vasiu R, Olinici CD. DNA nuclear content of apocrine cells in fibrocystic mastopathy and breast cancer. Morphol Embryol (Bucur) 1990;36:43-7. [25] Papamichalis G, Francia K, Karachaliou FE, Anastasiades OT, Spandidos DA. Expression of the c-myc oncoprotein in human metaplastic epithelial cells of fibrocystic disease. Anticancer Res 1988; 8:1217-22. [26] Selim AG, El-Ayat G, Wells CA. Expression of c-erbB2, p53, Bcl-2, Bax, c-myc and Ki-67 in apocrine metaplasia and apocrine change within sclerosing adenosis of the breast. Virchows Arch 2002;441: 449-55. [27] Tavassoli FA, Devilee P, International Agency for Research on Cancer. World Health Organization. Pathology and genetics of tumours of the breast and female genital organs. Lyon: IAPS Press; 2003. p. 432. [28] Dessauvagie BF, Zhao W, Heel-Miller KA, Harvey J, Bentel JM. Characterization of columnar cell lesions of the breast: immunophenotypic analysis of columnar alteration of lobules with prominent apical snouts and secretions. Hum Pathol 2007;38:284-92. [29] McLaren BK, Gobbi H, Schuyler PA, et al. Immunohistochemical expression of estrogen receptor in enlarged lobular units with columnar alteration in benign breast biopsies: a nested case-control study. Am J Surg Pathol 2005;29:105-8. [30] Tremblay G, Deschenes J, Alpert L, Quenneville LA. Overexpression of estrogen receptors in columnar cell change and in unfolding breast lobules. Breast J 2005;11:326-32. [31] Wellings SR, Alpers CE. Apocrine cystic metaplasia: subgross pathology and prevalence in cancer-associated versus random autopsy breasts. Hum Pathol 1987;18:381-6.
Annals of Diagnostic Pathology 14 (2010) 425 – 431
Papillary apocrine metaplasia and columnar cell lesion with atypia: is there a shared common pathway?☆,☆☆ Kemal Kosemehmetoglu, MD⁎, Gulnur Guler, MD Hacettepe University Faculty of Medicine, Department of Pathology, Ankara, Turkey
Abstract
Keywords:
Papillary apocrine metaplasia (PAM) and columnar cell lesion with atypia (CCL) are considered as candidates of early premalignant breast lesions. In this study, we investigated their relationship at the morphological level, as we noticed their histologic coexistence and proximity in daily routine. We selected 93 neoplastic and nonneoplastic cases with both PAM and CCL among 477 breast specimens and reevaluated sections by measuring the distance between these lesions. Ninety-three (19.4%) of 477 breast specimens contained both PAM and CCL; in 73.1% of the cases, the 2 lesions were in continuity with or adjacent to each other. Lesions less distant than 1 mm are grouped as “adjoining lesions”; and the rest, as “distant lesions.” A significant difference (P = .006) was found between adjoining (“zero” + “b1 mm”) and distant (“≥1 mm”) lesions; that is, PAM and CCL were much closer in the neoplastic group, especially tumors with low grade, high estrogen and progesterone receptor expression, and less lymph node metastasis. During the detailed examination of adjoining lesions, some “hybrid cells” showing properties of both lesions were encountered. Papillary apocrine metaplasia and CCL tend to appear in close contact, especially in neoplastic breasts with favorable features. This result implies that PAM and CCL may be included in the same pathogenetic pathway despite their distinct immunophenotypical properties. © 2010 Elsevier Inc. All rights reserved. Apocrine metaplasia; Flat epithelial atypia; Breast cancer
1. Introduction Although there are many proposed candidate precursors and premalignant lesions, such as ductal epithelial hyperplasia, columnar cell lesion with atypia (CCL), and atypical lobular hyperplasia [1-10], related to low-grade breast cancer, the only nonobligate precursor for high-grade invasive tumors is still high-grade ductal carcinoma in situ; and there is no well-established premalignant lesion for high-grade invasive tumors. Columnar cell lesion with atypia (“flat type” DIN, atypical cystic lobules, flat epithelial atypia, atypical columnar
☆ Presented as poster at the 21st European Congress of Pathology, Istanbul, September 2007. ☆☆ Conflict of interest statement: We declare that we have no conflict of interest. ⁎ Corresponding author. Hacettepe University, Department of Pathology, 06 100 Sihhiye/Ankara Turkey. Tel.: +90 312 305 1563; fax: +90 312 305 2621. E-mail address: [email protected] (K. Kosemehmetoglu).
1092-9134/$ – see front matter © 2010 Elsevier Inc. All rights reserved. doi:10.1016/j.anndiagpath.2010.06.009
alteration with prominent apical snouts and secretion, hyperplastic enlarged lobular unit) is characterized by enlarged, morphologically and immunophenotypically altered terminal duct lobular units with increased proliferation and estrogen/progesterone receptor (ER/PR) expression and decreased cell death [3,11,12]. The importance of CCL comes from its close relationship with low-grade breast cancer, especially tubular and lobular carcinomas [13,14]. Apocrine change not only occurs in normal breast and breast with benign lesions, but also accompanies in situ and invasive carcinomas [15-19]. The cysts lined by a single layer of apocrine epithelium are classified in nonproliferative breast lesions and not associated with any increased risk of subsequent carcinoma [10]. However; a subgroup called papillary apocrine metaplasia (PAM) is reported to have a slightly increased risk of subsequent carcinoma, even though most of the elevated risk was related with the presence of atypical hyperplasia in highly complex papillary apocrine change [20]. Loss of heterozygosity/allelic imbalance [9,21,22], aneuploidy [23,24], and oncogenic aberrations [25,26] in apocrine change suggest that at least some of them
426
K. Kosemehmetoglu, G. Guler / Annals of Diagnostic Pathology 14 (2010) 425–431
are clonal in nature and thus preneoplastic. Moreover, the genetic similarities between some benign and malignant apocrine lesions suggest that at least a subset of these benign lesions may behave in a nonobligate precursor fashion and/or have a role as an early premalignant lesion for high-grade breast cancers. Although PAM and CCL have distinct phenotypic and genotypic features, we occasionally noticed their histologic coexistence and proximity in our daily practice. Therefore, we decided to investigate their relation at the morphological level with a systematic approach. 2. Material and methods Cases were selected from archives between 2004 and 2006. All selected excision materials were totally exam-
ined, and mastectomy materials were sampled using a topographic map. The normal breast parenchyma in mastectomy specimens was represented with at least 10 samples (4 samples for quadrants, at least 2 samples for normal tissue adjacent to tumor, and at least 4 samples for normal tissue far from tumor). All mastectomy specimens were reported by the same breast pathologist (GG), and the morphological lesions in normal breast are always reported by using the same terminology. Pathology reports of 477 breast specimens, including small excisions and mastectomies, were looked over for diagnosis of both CCL and PAM in the same excision material or mastectomy specimen. Ninety-three (19.4%) of 477 breast specimens were found to fulfill this criterion. We (KK and GG) reevaluated all sections from these 93 cases, found the area of the closest distance between PAM and CCL in the
Table 1 Distribution of PAM and CCL togetherness among breast specimens
A. Nearly one fifth of breast specimens contain both columnar cell lesion with atypia (CCL) and papillary apocrine metaplasia (PAM). B. According to the morphometric measurements performed for assessment of the distance between 2 lesions, it is more likely to encounter lesions composed of closely allocated CCL and PAM in neoplastic breasts than nonneoplastic ones. C. When adjoining lesions (CCL and PAM distance b1 mm) and distant lesions (CCL and PAM distance ≥1 mm) are compared, togetherness and proximity of CCL and PAM are significantly more pronounced in neoplastic breasts than nonneoplastic counterparts.
K. Kosemehmetoglu, G. Guler / Annals of Diagnostic Pathology 14 (2010) 425–431
section, and measured the distance between these lesions on this area, using an Olympus BX51 microscope and Image Analysis System (Spot Software: 4.1; Diagnostic Instruments Inc, Sterling Heights, MI, USA). In neoplastic breasts, tumor type; grade; ER, PR, and c-erbB2 expression patterns; and regional lymph node status were also noted. Greater than 10% expression of either ER or PR among neoplastic population was accepted as positive. Status of cerbB2 was regarded as positive if greater than 10% of neoplastic cells showed intense membranous staining or if c-erbB2 gene amplification was shown with fluorescent in situ hybridization. For the diagnosis of CCL and PAM, criteria designated in the World Health Organization Classification of Tumours, Pathology and Genetics of Tumours of the Breast [27] and by Schnitt and Vincent-Salomon [3] and the criteria described by Page et al [20], respectively, were followed. Diagnostic feature for CCL was regarded as columnar cells with apical snouts, showing appreciable nuclear atypia and accompanying calcifications (not a strict requisite). Cases with significant cytological atypia that fulfilled the diagnosis of “clinging carcinoma” were excluded. Papillary apocrine metaplasia was characterized by cysts or lobules lined by apocrine cells without any significant cytological atypia, forming papillary structures. To decide whether the lesions are within the same terminal ductal lobular unit or not, 5 groups were described: “zero” for lesions with direct continuity, “b1 mm” for lesions in adjacent lobules, “1-2 mm,” “2-5 mm,” and “N5 mm.” In case of multiple lesions, the closest one was chosen for analysis. To examine the relationship between PAM and CCL in detail, ER (NeoMarkers, Clone SP1, monoclonal, Fremont, CA, USA) and PR (NeoMarkers, Clone SP2, monoclonal) immunostainings were performed on 12 cases of group “zero.” Staining was done on formalin-fixed, paraffinembedded, 4-μm–thick sections using standard staining procedures. After deparaffinization and antigen retrieval with boiling in citrate buffer pH 6, the sections were first incubated with primary antibody according to instructions in data sheet and then processed by biotinylated goat antimouse antibodies followed by streptavidin conjugated to horseradish peroxidase (UltraTek HRP Anti-Polyvalent Alb Pack, ScyTek, West Logan, UT, USA) with the use of diaminobenzidine as the chromogen (DakoCytomation, Carpinteria, CA, USA). For comparison of groups, χ2 test was used and P b .05 was accepted as significant. Analyses were performed with SPSS for Windows (Version 11.0.0; SPSS Inc, Chicago, IL) in a PC.
3. Results In 93 cases comprising both PAM and CCL, 38 were nonneoplastic and 55 were neoplastic among 197 nonneoplastic and 280 neoplastic (a total of 477 cases) breast
427
specimens. Distribution of cases within groups was shown in Table 1. In 68 (73.1%) of 93 cases, which comprised 14.3% of all breast specimens, PAM and CCL were either in continuity (group “zero”) or adjacent to each other (group “b1 mm”). Two main groups were formed from aforementioned 5 groups: the “zero” and “b1 mm” groups were considered together as “adjoining lesions,” and the rest were grouped as “distant lesions” (Fig. 1). “Adjoining lesions” are assumed to be included in the same terminal ductal lobular unit. When neoplastic and nonneoplastic specimens were compared, a significant difference (P = .006) was found between adjoining (“zero” + “b1 mm”) and distant (“≥1 mm”) lesions; that is, the PAM and CCL were much closer in the neoplastic group (Table 1C). Among the neoplastic group, 4 cases were diagnosed as ductal carcinoma in situ; and the rest were invasive carcinoma: ductal carcinoma, not otherwise specified (39 cases); mixed carcinoma (10 cases; 8 ductal + lobular, 1 ductal + mucinous, 1 tubular + lobular); apocrine carcinoma (1 case); lobular carcinoma (1 case); mucinous carcinoma (1 case); and papillary carcinoma (1 case). Fiftysix percent of tumors were metastasized to regional lymph nodes at presentation. The ER and PR were positive and c-erbB2 was negative in approximately 70% of tumors. Using the modified Bloom and Richardson grading system, tumors were graded as 1, 2, and 3 in 20%, 40%, and 40% of cases, respectively. In the neoplastic group in which CCL and PAM are in direct continuity (group “0”), tumors showed significantly lower grade, higher ER and PR expression, and less metastasis to regional lymph nodes than breasts with CCL and PAM with at least 1 mm of distance (Table 2). c-erbB2 expression did not differ significantly. Similar results were found when adjoining (“zero” + “b1 mm”) and distant lesions (“≥1 mm”) were compared (data not shown). During the detailed investigation of continuing lesions, at the conjunction of apocrine and atypical columnar cells, “hybrid cells” showing some characteristics of both PAM and CCL, such as granular eosinophilic cytoplasm with apical snouts and atypical low columnar nucleus, were also encountered (Fig. 2). On the other hand, cytoplasm of hybrid cells was not as large as apocrine cells of PAM. Furthermore, some of those cells expressed ER and PR, although somewhat weaker than CCL.
4. Discussion Our results revealed that nearly one fifth (93/477) of neoplastic and nonneoplastic breast specimens were diagnosed to have both PAM and CCL together. Although there was no difference between neoplastic (38/197, 19.2%) and nonneoplastic (55/280, 19.6%) breasts in terms of frequency of bearing PAM and CCL together, PAM and CCL tended to be in close contact (b1 mm distance) more frequently in
428
K. Kosemehmetoglu, G. Guler / Annals of Diagnostic Pathology 14 (2010) 425–431
Fig. 1. (A) Interdigitating areas of both atypical columnar cell lesion and apocrine metaplasia in the same ductolobular unit (200×, hematoxylin and eosin [H&E]). (B) Close-up view of panel A representing direct continuity of atypical columnar cell lesion and apocrine metaplasia (400×, H&E). (C) In 11 cases, CCL and PAM lesions were adjacent to each other; but we were unable to show direct continuity (200×, H&E). (D-F) The distance between CCL and PAM lesion was measured at the closest area and grouped accordingly (D: 100×, E: 40×, F: 400×; H&E).
K. Kosemehmetoglu, G. Guler / Annals of Diagnostic Pathology 14 (2010) 425–431
429
Table 2 Comparison of prognostic markers with distance of PAM and CCL in neoplastic breasts
Within the cases in the neoplastic group, when comparing the group “zero” with rest of the groups other than group “zero”, tumors are usually low grade, high ER and PR expressing, and less likely to metastasize in breasts with CCL and PAM in close contact. LN indicates lymph node. a All data are not available in all cases; total number of cases varies among variables. * P = .05. † P b .019. ‡ P = .037. § P = .006. ∥ P = .725.
Fig. 2. (A-B) High-power view of hybrid cells at the conjunction areas in a case classified in group “zero” with directly continuing CCL and PAM. They are named hybrid cells because their morphological properties simulate both CCL and PAM lesions (400×, H&E). (C-D) Some of the hybrid cells (shown by arrows) express esterogen receptor (ER) and progesteron receptor (PR) (400×).
430
K. Kosemehmetoglu, G. Guler / Annals of Diagnostic Pathology 14 (2010) 425–431
neoplastic breasts than nonneoplastic ones (84% vs 58%, P = .006). This result suggests that their association in the same breast is not always incidental. To the best of our knowledge, in the literature, there is no such other study showing PAM and CCL, although many studies have been performed to show the individual characteristics and the importance of each lesion. Columnar cell lesion with atypia and PAM represent 2 distinct morphological and immunophenotypical phenomena in the breast. Columnar cell lesion with atypia is reported in close relation with lobular carcinoma in situ, atypical ductal hyperplasia, and tubular and low-grade ductal carcinoma [13,14]. It shows high expression of ER, PR, bcl-2, and cyclin D1; high proliferation index; and low expression of p53 [28-30]. Apocrine lesions have also been reported with an increased incidence of breast cancer in some reports [31]; however, they are not investigated in as much detail as CCL, and their relationship with cancer is controversial. In contrast to CCL, apocrine cells express neither ER nor PR; instead, they show high expression of androgen receptors, low proliferation index, low expression of bcl-2, and high expression of p53 [26,27]. These distinct immunophenotypical features of CCL and PAM suggest distant places for them in recently proposed breast carcinogenesis pathways: CCL is thought to precede lowgrade breast carcinomas, whereas PAM is suggested to lead to higher-grade carcinomas [4]. To explain the proximity of CCL and PAM in neoplastic breasts, several suggestions can be made, which will be discussed subsequently: 1. Both may represent neoplastic precursors, into which normal cells transform, showing diverse response to the same stimulus. After the first hit leading to preneoplastic features, divergent phenotypical features of these lesions may appear as siblings of the same parent. 2. One of them may be preneoplastic; and the other, bystander or formed by response to stress. Because CCL is a well-known precursor of low-grade tumors and we encountered both CCL and PAM close together in our study, apocrine metaplasia can be regarded as a stress response of breast epithelium. Because of the high level of proliferation stress in the presence of CCL, breast epithelium can undergo a metaplastic process toward apocrine differentiation, a less proliferative and silent condition. But all the breast specimens included in this study had the diagnosis of CCL; and the patients with both CCL and PAM close to each other showed more favorable features, which suggest that togetherness of PAM and CCL has more impact than CCL alone in predicting the features of associated tumor. In addition, as mentioned earlier, there are wellestablished morphological and biological data in literature that show that at least some apocrine lesions are related to the formation of breast cancer.
3. Both are sessile when separate, but the fusion may lead to neoplastic change. Given the presence of a specific form of instability, which causes the epithelial unrest and in turn gives rise to formation of both CCL and PAM next to each other with some hybrid lesions, the same stimulus can also be responsible for the formation of associated low-grade tumors with favorable prognosis. Within the intersection areas of PAM and CCL, some cells surprisingly mimicking their neighboring lesions, PAM and CCL, were encountered; and we called these cells hybrid cells. Their nuclear details resembled CCL, whereas cytoplasmic properties were consistent with apocrine differentiation. Immunohistochemically, hybrid cells expressed ER and PR weaker than CCL. The presence of these hybrid cells may suggest that the cells forming PAM and CCL are of the same ancestor and represent the divergent phenotypic and genetic response to the same stimulus, which is unable to alter these hybrid cells to one way totally. This study has several limitations, as follows: (1) Although we chose excision materials sampled wholly and the mastectomies with at least 10 samples of parenchyma, there still might be cases without demonstrative lesion. We tried to overcome this problem with inclusion of a high number of cases. Actually, despite less amount of tissue sectioned in neoplastic mastectomies than nonneoplastic excision materials, togetherness of both CCL and PAM was encountered more frequently in neoplastic cases, showing that sampling error did not affect outcome significantly. (2) We did not measure the distance between lesions and tumors; nevertheless, this can be the subject of a different study. (3) The study of lesion “togetherness” based on histologic sections has an irreducible bias deriving from the normal anatomy of ductal system, which is tridimensionally interwoven; thus, pathologic foci, including CCL and PAM, may be hardly traced to just one of the 8 to 12 systems in a single tissue section, no matter how distant (or close) they appear to be on the glass slide. Even so, the presence of PAM and CCL in the same lobule can be stated accurately; and groups “0” and “b1” are believed to represent one lobule with these 2 lesions together. In summary, PAM and CCL, when found in the same breast tissue, tend to appear in close contact, especially in neoplastic breasts; and their togetherness was associated with tumors with better prognostic features. Regarding the study design limited to morphological backgrounds, it is difficult to draw conclusive statements; however, our results at least suggest that some of PAM and CCL may be included in the same pathogenetic pathway despite their distinct immunophenotypical properties. The proposed pathways for low- and high-grade breast tumors may not be so simple and may have more transitions than anticipated. Furthermore, our results show that apocrine lesions are not the null element of breast and are worth further study.
K. Kosemehmetoglu, G. Guler / Annals of Diagnostic Pathology 14 (2010) 425–431
Acknowledgment We would like to thank to Dr Andrew Folpe for his review and suggestions on this manuscript, and Kenan Kosemehmetoglu for literal revision. References [1] Buerger H, Otterbach F, Simon R, et al. Different genetic pathways in the evolution of invasive breast cancer are associated with distinct morphological subtypes. J Pathol 1999;189:521-6. [2] Buerger H, Simon R, Schafer KL, et al. Genetic relation of lobular carcinoma in situ, ductal carcinoma in situ, and associated invasive carcinoma of the breast. Mol Pathol 2000;53:118-21. [3] Schnitt SJ, Vincent-Salomon A. Columnar cell lesions of the breast. Adv Anat Pathol 2003;10:113-24. [4] Simpson PT, Reis-Filho JS, Gale T, Lakhani SR. Molecular evolution of breast cancer. J Pathol 2005;205:248-54. [5] Lakhani SR, Collins N, Stratton MR, Sloane JP. Atypical ductal hyperplasia of the breast: clonal proliferation with loss of heterozygosity on chromosomes 16q and 17p. J Clin Pathol 1995;48:611-5. [6] Lakhani SR, Slack DN, Hamoudi RA, Collins N, Stratton MR, Sloane JP. Detection of allelic imbalance indicates that a proportion of mammary hyperplasia of usual type are clonal, neoplastic proliferations. Lab Invest 1996;74:129-35. [7] Moinfar F, Man YG, Bratthauer GL, Ratschek M, Tavassoli FA. Genetic abnormalities in mammary ductal intraepithelial neoplasia-flat type (“clinging ductal carcinoma in situ”): a simulator of normal mammary epithelium. Cancer 2000;88:2072-81. [8] Simpson PT, Gale T, Reis-Filho JS, et al. Columnar cell lesions of the breast: the missing link in breast cancer progression? A morphological and molecular analysis. Am J Surg Pathol 2005;29: 734-46. [9] Washington C, Dalbegue F, Abreo F, Taubenberger JK, Lichy JH. Loss of heterozygosity in fibrocystic change of the breast: genetic relationship between benign proliferative lesions and associated carcinomas. Am J Pathol 2000;157:323-9. [10] Larson PS, de las Morenas A, Cerda SR, Bennett SR, Cupples LA, Rosenberg CL. Quantitative analysis of allele imbalance supports atypical ductal hyperplasia lesions as direct breast cancer precursors. J Pathol 2006;209:307-16. [11] Fraser JL, Raza S, Chorny K, Connolly JL, Schnitt SJ. Columnar alteration with prominent apical snouts and secretions: a spectrum of changes frequently present in breast biopsies performed for microcalcifications. Am J Surg Pathol 1998;22:1521-7. [12] Lee S, Mohsin SK, Mao S, Hilsenbeck SG, Medina D, Allred DC. Hormones, receptors, and growth in hyperplastic enlarged lobular units: early potential precursors of breast cancer. Breast Cancer Res 2006;8:R6. [13] Abdel-Fatah TM, Powe DG, Hodi Z, Lee AH, Reis-Filho JS, Ellis IO. High frequency of coexistence of columnar cell lesions, lobular neoplasia, and low grade ductal carcinoma in situ with invasive tubular carcinoma and invasive lobular carcinoma. Am J Surg Pathol 2007;31: 417-26.
431
[14] Leibl S, Regitnig P, Moinfar F. Flat epithelial atypia (DIN 1a, atypical columnar change): an underdiagnosed entity very frequently coexisting with lobular neoplasia. Histopathology 2007;50:859-65. [15] Eusebi V, Damiani S, Losi L, Millisi RR. Apocrine differentiation of breast epithelium. Adv Anat Pathol 1997;4:139-55. [16] Nielsen M, Thomsen JL, Primdahl S, Dyreborg U, Andersen JA. Breast cancer and atypia among young and middle-aged women: a study of 110 medicolegal autopsies. Br J Cancer 1987;56:814-9. [17] Pagani A, Sapino A, Eusebi V, Bergnolo P, Bussolati G. PIP/GCDFP15 gene expression and apocrine differentiation in carcinomas of the breast. Virchows Arch 1994;425:459-65. [18] Viacava P, Naccarato AG, Bevilacqua G. Apocrine epithelium of the breast: does it result from metaplasia? Virchows Arch 1997;431: 205-9. [19] Dixon JM, McDonald C, Elton RA, Miller WR. Risk of breast cancer in women with palpable breast cysts: a prospective study. Edinburgh Breast Group. Lancet 1999;353:1742-5. [20] Page DL, Dupont WD, Jensen RA. Papillary apocrine change of the breast: associations with atypical hyperplasia and risk of breast cancer. Cancer Epidemiol Biomarkers Prev 1996;5:29-32. [21] Jones C, Damiani S, Wells D, Chaggar R, Lakhani SR, Eusebi V. Molecular cytogenetic comparison of apocrine hyperplasia and apocrine carcinoma of the breast. Am J Pathol 2001;158:207-14. [22] Selim AG, Ryan A, El-Ayat G, Wells CA. Loss of heterozygosity and allelic imbalance in apocrine metaplasia of the breast: microdissection microsatellite analysis. J Pathol 2002;196:287-91. [23] Izuo M, Okagaki T, Richart RM, Lattes R. DNA content in “apocrine metaplasia” of fibrocystic disease of the breast. Cancer 1971;27:643-50. [24] Vasiu R, Olinici CD. DNA nuclear content of apocrine cells in fibrocystic mastopathy and breast cancer. Morphol Embryol (Bucur) 1990;36:43-7. [25] Papamichalis G, Francia K, Karachaliou FE, Anastasiades OT, Spandidos DA. Expression of the c-myc oncoprotein in human metaplastic epithelial cells of fibrocystic disease. Anticancer Res 1988; 8:1217-22. [26] Selim AG, El-Ayat G, Wells CA. Expression of c-erbB2, p53, Bcl-2, Bax, c-myc and Ki-67 in apocrine metaplasia and apocrine change within sclerosing adenosis of the breast. Virchows Arch 2002;441: 449-55. [27] Tavassoli FA, Devilee P, International Agency for Research on Cancer. World Health Organization. Pathology and genetics of tumours of the breast and female genital organs. Lyon: IAPS Press; 2003. p. 432. [28] Dessauvagie BF, Zhao W, Heel-Miller KA, Harvey J, Bentel JM. Characterization of columnar cell lesions of the breast: immunophenotypic analysis of columnar alteration of lobules with prominent apical snouts and secretions. Hum Pathol 2007;38:284-92. [29] McLaren BK, Gobbi H, Schuyler PA, et al. Immunohistochemical expression of estrogen receptor in enlarged lobular units with columnar alteration in benign breast biopsies: a nested case-control study. Am J Surg Pathol 2005;29:105-8. [30] Tremblay G, Deschenes J, Alpert L, Quenneville LA. Overexpression of estrogen receptors in columnar cell change and in unfolding breast lobules. Breast J 2005;11:326-32. [31] Wellings SR, Alpers CE. Apocrine cystic metaplasia: subgross pathology and prevalence in cancer-associated versus random autopsy breasts. Hum Pathol 1987;18:381-6.