- Email: [email protected]
Argyrophilic cells in mammary carcinoma
Original Contributions Argyrophilic Cells in Mammary Carcinoma FRANCK FETISSOF, MD,* MAURICE P. DUBOIS,t BRIGlnE ARBEILLE-BRASSART, ScD,* JACQUES LANSAC, MD,' AND PIERRE JOBARD, MD* Breast tumor tissues were treated by the Grimelius procedure and examined for the presence of argyrophilic cells. Carcinomas found to contain argyrophilic cells did not include classic carcinoid tumors; the group was, in fact, heterogeneous, comprising poorly differentiated ductal carcinomas, lobular carcinomas, carcinomas of uncertain origin, and colloid carcinomas. Colloid tumors were the most frequently encountered. The prominence of argyrophilic cells in colloid carcinomas raises the possibility that development into mucin-producing cells is propicious for endocrine differentiation. Hum Pathol 14: 127-134, 1983.
The topic of mammary carcinoid tumors is at present relatively confusing. Some authors, such as Cubilla and Woodruff,' have recorded true primitive carcinoids, whereas others, including Taxy et a\.2 and Partanen and Syrjanen" have found argyrophilic cells in common ductal or lobular carcinomas. Furthermore, colloid carcinomas are considered by Fisher and Palekar" to be a mucinous variant of carcinoids, and by Capella et al. 5 to be tumors that could differentiate along endocrine cell lines. This is all the more paradoxical in that cells of endocrine lineage have never been isolated from the mammary gland, and the occurrence of carcinoids in other glands of ectodermal origin is extremely rare. 6- B Breast tumor tissues were stained by the Grimelius procedure, regardless of their morphologic features, for the purpose of identifying argyrophilic cells. As a result, we were able to identify a group of argyrophilic cell-containing tumors, whose relationship to carcinoid will be described. MATERIALS AND METHODS We studied 123 tumors (table 1), including 92 carcinomas, 12 fibroadenomas, and 19 dysplasias, and two lactating mammary glands. Tissues processed for light microscopic study were fixed in aqueous Bouin's fluid. Detection of argyrophilic cells was acReceived April 23, 1982, Revision accepted for publication June 7, 1982. * Laboratoire d'Anatomie Pathologique, CHU Bretonneau, Tours, France. t Station de Physiologie de la Reproduction, Nouzilly, France. Departernent de Microscopie Electronique, CHU Bretonneau, Tours. § Clinique Gynecologique et Obstetricale, CHU Bretonneau, Tours. Address correspondence and reprint requests to Dr. Fetissof: Laboratoire d'Anatomie Pathologique, CHU Bretonneau, 37044 Tours, France.
*
0046-8177 183/0200/0127
complished using the modified Grimelius method" combined at times with alcian blue
127
HUMAN PATHOLOGY
Volume 14. No.2 (February 1983)
filtrating component of isolated cells was present. The intralobular component contained focal areas of argyrophilic cells easily observed on routine preparations. The other tumor (case 18) was associated with a colloid carcinoma and will be described later. Cases 10, 11, and 12 were three of five tumors for which accurate classification as ductal or lobular was difficult. Case 10 could be consistent with a solid variant of lobular carcinoma, having features suggestive of carcinoid tumor. Case II (fig. 6) contained an in situ component of uncertain type; the invasive part had small tubules and large islands of neoplastic cells. Lymph node metastases were of a solid pattern with gland formation. Case 12 might be considered a basaloid ductal carcinoma. The only argyrophilic cells found were admixed with mucinous cells in the intraductal portion of tumor. Twenty carcinomas containing colloid elements were collected. Argyrophilic cells were found in seven of the 20 cases (cases 13-19). Colloid tumors that lacked argyrophilic cells had a disquieting appearance in most cases; they often harbored a solid infiltrating component as well as lymph node metastases. These colloid carcinomas were composed of atypical cells arranged in small nests, annular configurations, delicate trabeculae, or cribriform structures. In contrast, colloid carcinomas containing argyrophilic cells had an organoid growth pattern. They were composed of clumps of uniform cells, often quite large, with either regular (case 13) or irregular (case 14) contours. In case 15 (fig. 7) tall columnar cells outlined nests of neoplastic cells in a palisade arrangement highly reminiscent of type A carcinoid. Less often, plexiform
TABLE 1. ARGYROPHILIC CELLS IN 123 TUMORS AND TWO LACTATING MAMMARY GLANDS Type of Breast Lesion
Number of Grimeliuspositive Cases 7
Ductal carcinoma (n = 46) Tubular carcinoma (n = 1) Medullary carcinoma (n = 1) Lobular carcinoma (n = 19) Carcinoma of uncertain origin (n = 5) Colloid carcinoma (11 = 20) Fibroadenoma (n = 12) Dysplasia (n = 19) Lactating mammary gland (n = 2)
* One was
o o 3'"
3 7
o o o
associated with a culloid carcinoma.
sembling carcinoids lacked argyrophilic cells. Likewise, argyrophilic cells were not found in welldifferentiated ductal carcinomas or in single cases of tubular and medullary carcinomas. Of the 19 cases of lobular carcinoma studied, only one classic in situ tumor (case 8) contained scarce and weakly argyrophilic cells. It should be pointed out that the peripheries of intracytoplasmic lumens were often blurred on Crimelius preparations. One case of a mucinous variant was devoid of argyrophilic cells. Argyrophilic cells were demonstrated in two less typical lobular carcinomas (cases 9 and 18). Case 9 showed prominent intralobular foci of proliferation with occasional central necrosis and calcification. Several small cribriform cavities were noted in addition to massive interlobular duct involvement. An inTABLE 2.
DISTRIBUTION OF ARGYROPHILIC CELLS IN NINETEEN GRIMELIUS-POSITIVE CASES
Age (years)
Type of Carcinoma
Colloid Component
Absent
Absent
+
+++ +++ ++ + + ++
Absent Absent Absent Absent Absent Absent Absent Absent Absent Absent Absent
++ ++
+++ +++
Absent Absent
No metastases
Case 1
42
Intraductal
Case Case Case Case Case Case Case Case Case Case Case Case Case
2 3 4 5 6 7 8 9 10 11 12 13 14
46 65 59 71 65
75 76
Invasive ductal Invasive ductal Invasive ductal Invasive ductal Invasive ductal Invasive ductal In situ lobular Atypical invasive lobular Invasive uncertain type Invasive uncertain type Invasive uncertain type Colloid Colloid
Absent Absent
Case 15 Case 16 Case 17
86 53 71
Colloid Colloid Colloid
Absent Absent Absent
Case 18
75
Complex tumor with a colloid component
33 50
52 50 74
60
Axillary Lymph Node Metastasis
Solid Invasive Component
Absent
+ ++
+++ ++
In situ Component
+ + ++ + ++ + Absent
+
Curettage not performed
No metastases
+++ ++ No metastases No metastases
Arnphicrine cells
Case 19
56
Complex tumor with a colloid component
KEV: - = No argyrophilic cells; + argyrophilic cells.
= Scarce
+++ Atypical
+++ + + +
lobular
+
Absent
++ Absent
+ + + Atypical
No metastases No metastases Curettage not performed No metastases
lobular - Colloid
+++
+++
Amphicrine cells
Am phicrine cells
No metastases
argyrophilic cells; ++ = Moderate number of argyrophilic cells; +++
128
= Numerous
ARGYROPHILIC CELLS IN MAMMARY CARCINOMA (Fetissof at al.)
Figure 1 (top lift ). Case 3. Conventiona l poorly differentiated infiltra ting ductal carci noma. Clusters o f varyi ng sizes are separated by broad bands of conn ective tissue. (Hematoxylin-eosin stain . X 170.) Figure 2 (middle lift) . Case 2. Poorly differentia ted ductal carcinoma. An in vasive co mponen t conta ins numero us argyroph ilic cells. (Grimelius stain . x 250. ) Figure 3 (bottom left) . Case 2. In traductal com ponent rich in ar gyrophilic cells. (Gri me lius stain. x300.) Figure 4 (lop right). Case 3. Abun da nce of de nd ritic argyrop h ilic cells surro un ding neoplastic nests. (Gr ime lius sta in. x 60 0.) Figure 5 (bottolll right ). Case 3. Detail of argyroph ilic cell whose fine cytoplasmic P I'OCCSS encircles one invas ive nest. (Grimelius sta in . x 1,3 00.)
HUMAN PATHOLOGY
Volume 14. No.2 (February 1983)
Figure 6. Case 11. Carcinoma of uncertain origin, with foci of intralobular proliferation containing argyrophilic cells. (Grimelius slain. x260.)
masses (case 17) or cribriform structures (case 18, fig. 10) were encountered. Colloid tumors had an occasional intraductal component that sometimes contained argyrophilic cells. No lymph node metastases were present in the six cases examined. In a single tumor, the distribution of argyrophilic cells varied from one element to another. Poorly argyrophilic elements were small clumps (case 16) or cribriform structures (case 18, fig. 10). Grimeliusalcian blue double-stain revealed no evidence of intracytoplasmic mucin in certain tumors (cases 13, 15, 16, and 18). Of interest, argyrophilic granules in case 13 were occasionally condensed into one principal mass. In case 15 (fig. 8) argyrophilic cells predominated in the peripheral rim. Case 17 (fig. 9) contained numerous mucinous cells and sparse argyrophilic cells; there was a reciprocal relationship in the frequency of mucinous and argyrophilic cells. Other tumors, such as those in cases 14 and 19, showed a mosaic of undifferentiated cells (nonmucinous, nonargyrophilic), argyrophilic cells, and mucinous and amphicrine cells of the m uco argyrophilic variant, which contained a seeding of argyrophilic granules dispersed throughout an alcianophilic material. The most com plica ted cases were cases 18 and
19. The tumor in case l Sjuxtaposed a colloid component (fig. 10) of cribriform structure with a solid component of lobular architecture, which had in situ and invasive argyrophilic elements. The solid portion was appreciably different from classic lobular carcinoma in that it had intralobular necrotic foci and the neoplastic cells were fusiform to plasmacytoid. Such an aspect is evocative of a spindle-cell carcinoid or thyroid medullary carcinoma. Electron microscopic study of deparaffinized material revealed numerous dense-core granules from 200 to 300 nm in diameter. The tumor in case 19 contained an association of intraductal, colloid, and solid invasive components. The intraductal and colloid constituents comprised cells of an undifferentiated type, argyrophilic cells (easily identified on routine preparations), and mucinous and amphicrine cells (fig. 11). The solid invasive element was composed of clusters with rare, weakly argyrophilic or alcianophilic cells. Electron microscopic study of the intraductal component (fig. 12) permitted the iden tification, albeit less clear-cut, of the four cell types observed on light microscopy. Argyrophilic cells contained many dense-core grari.ules, with diameters from 200 to 330 nm, and occasional mucinous vesicles. Some mucinous cells contained rare dense-core granules. An intricate mixture of dense-core granules and mucinous vesicles was seen in amphicrine cells. Last, the so-called undifferentiated cells were rich in reticulum and at times contained a few dense-core granules. All cell types had filaments, which were at times numerous and arranged in bundles, as well as interdigitations and junctions. Basement membrane invested the tumor masses. No argyrophilic cells were detected in the fibroadenomas (two of which contained foci of intralobular carcinoma) Or in dysplasias, which were either isolated or accompanied carcinomas. Dysplastic lesions comprised cysts, apocrine metaplasia, epitheliosis, adenosis, and papillomas. We were not successful in identifying argyrophilic cells in the two cases of lactating mammary glands or in morphologically normal areas of breasts that harbored carcinomas. The 19 carcinomas with argyrophilic cells gave negative Masson-Fontana reactions for argentaffin cells. Findings on indirect immunofluorescence examination of all tissue samples were consistently negative with antisera to adrenocorticotropic hormone, calcitonin, gastrin, serotonin, and somatostatin. DISCUSSION In our series, argyrophilic cell-containing carcinomas formed a heterogeneous group that comprised poorly differentiated ductal carcinomas, lobular (more often atypical) carcinomas, carcinomas of uncertain origin, and colloid carcinomas. Breast tumors with the morphologic feature of usual carcinoid were not encountered, although occasional
130
ARGYROPHILIC CELLS IN MAMMARY CARCINOMA (Fetlssof at 0 1.)
Figure 7 (topleft). Case 15. Colloid tu mor very rem iniscent of type A carcinoid . Note the we lt-developed periphe ral rim composed o f tall co lumnar cells. (He mato xylin-eo sin slain. x 140.) Figure 8 (middle lefl). Case 15. Arg yro philic cells concentrat ed in th e pe ripheral rim. (Gr im eliu s sta in. x3 00.) Figure 9 (bottom lefi) . Case 17. Co lloid carcino ma composed of plexi form masses containi ng nume ro us mucinous cells. Scarce a rgyrophilic cells dispersed among m ucino us cells. (Grimelius stain . x280.) Figure 10 (lap right). Case 18. Complex tumor. Collo id portio n with cribriform elem ents d isp osed within mucinous pool , (Hematoxylin-e osin stain . x (30.) Figure 11 (bottom right). Case 19. Complex tumor. Intraducta l component with argyrophilic cells. (Gri me lius sta in . x 280.)
HUMAN PATHOLOGY
Volume 14. No.2 (February 1983)
Figure 12. Case 19. Top, electron micrograph of the intraductal component. Endocrine cell (EC) contains intracytoplasmic dense-core granules, and undifferentiated cell (VC) has abundant reticulum. MC = mucinous cell. (x 10,000.) Bottom, high-power view ofamphicrine cell (AC) of mucoargyrophilic type, showing an intricate mixture of mucous vacuoles and dense-core granules. (x24,OOO.)
carcinomas contained foci of growth reminiscent of carcinoid tumor. The existence of mammary carcinoids was first reported in 1977 by Cubilla and Woodruff,1 followed by Kaneko et aL.,lO Devitt,"! and Fisher and Palekar. 4 These tumors were interpreted as carcinoids mainly on the basis of the presence of argyrophilic cells. It should be pointed out that their morphologic features and clinical behavior are often quite different from those expected of classic carcinoid. Our findings are more consonant with the findings of Gould and Chejfec.l" Partanen and Syrjanen," and Taxy et al.," who found argyrophilic cells in
conventional ductal or lobular carcinomas. We should like to emphasize the distinctive appearance of tumors that are composed, like that in case 18 of our study, of plasmacytoid and spindle cells. A similar tumor, which is very suggestive of medullary carcinoma of the thyroid, was reported by Cubilla and Woodruff.' Argyrophilic cells were encountered predominantly among colloid carcinomas. These cells were previously identified in colloid tumors by Feyrtcr and Hartmann.P Fisher and Palekar,! and Capella et aL.5 On the whole, the differences we observed between
132
ARGYROPHILIC CELLS IN MAMMARY CARCINOMA (Fellssot at al.)
colloid tumors containing or lacking argyrophilic cells concur with those reported by Capella et al. 5 Like Partanen and Syrjanen." we failed to detect argyrophilic cells in the fibroadenomas, even in those associated with lobular carcinoma. Eusebi and Azzopardi-:' and Govoni et al. 15 reponed the presence of argyrophilic cells in a variant of fibroadenoma that contained an endocrine lobular neoplasia morphologically distinct from lobular carcinoma. We did not observe any argyrophilic cells in mammary d ysplasias , confirming the results of Cubilla and Woodruff? and Partanen and Syrjanen." Such cells were found, however, by Vogler" and by Fisher and Palekar." At present, no argyrophilic cells have been identified in normal male or female mammary glands. I •3.4 The primary question by these findings concerns the nature of the argyrophilic granulations demonstrated by the Grimelius reaction. False-positive reactions are due to the presence of macrophages or foci of necrosis. Other techniques have been used to visualize argyrophilic cells in breast tissue, notably the reactions of Gros-Schultze.!" Gros-Bielschowsky;':' Boclian,I.10.14.15 Sevier-Munge r.P-" and modified Pascual." Only Devitt!' reported finding argentaffin cells. Gould et al., 19 Taxy et al.," and Waxman et al. 20 suggested that silver deposits could blur mucin droplets or lysosomes. The electron microscope1. 3.4.10.14.15 allowed characterization of the granulations as dense-core gl'anules with diameters from 80 to 355 nm . As in case 19 of this study, ultrastructural exam inat io ns-!" has revealed an intricate mixture of dense-core granules and mucinous vesicles in amphicrine cells of the mucoargyrophilic type. Our immunohistologic techniques failed to characterize any hormonal products. The two colloid carcinomas recorded by Feyrter and Hartmann 13 contained serotonin. The tumor examined by Kaneko et al.'? secreted norepinephrine. It is well known that conventional types of breast carcinomas can elaborate ad rcnoco rticotro pic hormone,2l,22 calcitonin,23,24 parathyroid hormone;" human chorionic gonadotropin," anel human placental lactogen.t? We did not find any argyrophilic cells in the two lactating mammary glands we examined, although Clayton et al. 17 suggested that argyrophylic granulations might represent milk protein. The relationship of argyrophilic cell-containing carcinomas to classic carcinoids must be considered. These tumors differ in their architectural pattern and often in their clinical behavior. Their only common feature is the presence of putative endocrine cells. Other organs provide examples of complex tumors that lack carcinoid architecture yet show common epithelial cells intermingled with argyrophilic endocrine cells. 2s - 3o Such tumors were named adenocarcinoid by Warkel et al.:lI Gould et al. 32 coined the term "neuroendocrine carcinoma" to designate "undifferentiated" tumors from various sites that contained argyrophilic cells. McDowell et al.33 reponed a series of common bronchial carcinomas that contained argyrophilic cells, which they called "atypical endocrine
tumors." According to these authors, endocrine cells arise, by divergent differentiation, from the same stem cells that. give rise to the epithelial elements. Such di fferent.iation along argyrophilic secretory lines is not surprising from a histogenetic standpoint, since it is likely that most cells of the diffuse endocrine system have a local origin in common with the epithelial elcrnents.P" The Grimelius method did not disclose argyrophilic cells in normal breast tissue . It follows that differentiation into argyrophilic secretory cells occurs during a neoplastic process that allows for multidirectional differentiation. This is in contradistinction to carcinoids, which are composed entirely of endocrine cells and are derived in most cases from a proliferation of well-individualized endocrine elements already present in nonturnoral tissue. Each conventional type of breast carcinoma may show variable degrees of focal endocrine differentiation. It should be stressed that the occurrence of argyrophilic cells among epithelial cells does not imply the edification of a carcinoid structure . At present, there is no direct evidence that solid argyrophilic ceil-containing carcinomas should be regarded as a class of tumors distinct from ordinary carcinomas. We find it worthwhile to reiterate the originality of the organoid growth pattern of colloid carcinomas containing argyrophilic cells, in which mucinous and endocrine differentiation, during a neoplastic process, arises from an undifferentiated stem cell.
The authors thank Dr . M. P. Dubois, Station de Physiologic de la Reproduction de Nouzilly, for providing all immune sera used ill this study.
REFERENCES 1. Cubilla AL, Woodruff JM : Pr imary carcinoid tumoral' the breast: a report of eight patients. Am J Surg Pat hoi 1:283 , 1977 2. Taxy J B, Tischler AS. Insalaco 5J , et al : "Carcinoid" tumor of the breast: a variant of conventional breast cancer? Hum Paihol 12:170. 1981 3. Partaricn S, Syrjanen K: Argyrophilic cells in carcinoma of the female breast. Virchows Arch [Pa t ho l Anat] 391 :45, 1981 4. Fisher ER, Palekar AS : Solid and mucinous varieties of socalled mammary carcinoid tumors . AmJ Clin Pathol 72:909, 1979 5. Capella C, Eusebi V, Mann B, et al: Endocrine differentiation in mucoid carcinoma of the breast. Histopathology 4:613 , 1980 6. Murphy GF, Pilch BZ, Dickersin GR, et al: Carcinoid tumor of the middte ear. Am J Clin Pathol 73 :816, 1980 7. Nicod JI.: Carcinorde de la parotide. Bull Assoc Fr Cancer 45:214, 1958 8. Van Dijk C. Ten Seldarn RE.J: A possible primary cutaneous carcinoid. Cancer 36:1016, 1975 9. Lack E, Mercer L: A modified Grirnelius argyrophiltechniqllc for neurosecretory granules. Am J Surg Pat hoI 1:275. 1977 10. Kaneko H, I-Iojo H, Ishikawa S, CI. al: Norepinephrineproducing tumors of bilateral breasts: a case I·CpOJ"l. Cancer 41:2002, 1978 11. Devitt PC: Carcinoid tumour or the breast. Br Mecl J 2:327, 1978
133
HUMAN PATHOLOGY
Volume 14, No.2 (February 1983)
12. Gould VE, Chejfec G: Secretory features in lobular carcinoma of the breast. Ultrastrucr Pathol 1: 151, 1980 13. Feyrter F, Hartmann G: Ober die carcinoide Wuchsform des Carcinoma mammae, insbesondere das Carcinoma solidum (gelatinosum) mammae. Frankf Z Pat hal 73:24, 1963 14. Eusebi V, Azzopardi jG: Lobular endocrine neoplasia in fibroadenoma of the breast. Histopathology 4:413, 1980 15. Govoni E, Bazzocchi F, Pileri S, et al: Lobular endocrine neoplasia in a fibroadenoma of the breast: an ultrastructural study. Virchows Arch [Pathol Anat] 393:299, 1981 16. Vogler E: Uber das basilare Helle-Zellen-Organ del' menschlichen Brustdruse. Klin Med 2: 159, 1947 17. Clayton F, Ordonez NG, Sibley RK: Argyrophilic breast carcinomas: evidence of lactational differentiation. Am 1 Clin Pathol 77:236, 1982 18. Churukian C], Schenk EA: A modification of Pascual's argyrophil method. 1 Histotechnol 2: 102, 1979 19. Gould VE, lao W, Battifora H: Ultrastructural analysis in the differential diagnosis of breast tumors. Pathol Res Pract 167:45, 1980 20. Waxman M, Vuletin j C, Pertschuk LP: Lysosomes in Brenner's tumor simulating secretory argentaffin granules. Arch Pathol Lab Med 103:183, 1979 21. Cohlc SO, Tschen JA, Smith FE, et al: ACTH-secreting carcinoma of the breast. Cancer 43:2370, 1979 22. Woodard BH, Eisenbarth G, Wallace NR, et al: Adrenocorticotropin production by a mammary carcinoma. Cancer 47: 1823. 1981 23. Coombes RC, Easty GC, Detre SI, et al: Secretion of irnmunoreaction calcitonin by human breast carcinomas. Br Med14:197,1975
24. Sarnaan NA, Castillo S, Schultz PN et al: Serum calcitonin after pentagastrin stimulation in patients with bronchogenic and breast cancer compared to that in patients with medullary thyroid carcinoma. 1 Clin Endocrinol Metab 51:237, 1980 25. Mavligit GM, Cohen JL, Sherwood LM: Ectopic production of parathyroid hormone by carcinoma of the breast. N Engl.J Med285:154,1971 26. Tormey DC, Waalkes TP, Simon RM: Biological markers in breast carcinoma. I I. Clinical correlations with human chorionic gonadotrophin. Cancer 39:2391, 1977 27. Sheth NA, Suraiya.JN, Sheth AR, et al: Ectopic production of human placental lactogen by human breast tumors. Cancer 39: 1693, 1977 28. Kubo T, Watanabe H: Neoplastic argentaffin cells in gastric and intestinal carcinomas. Cancer 27:447, 1971 29. Matsuyama M, Inoue T, Ariyoshi Y, et al: Argyrophil cell carcinoma of the uterine cervix with ectopic production of ACTH, fl-MSH, serotonin, histamine and amylase. Cancer 44:1813,1979 30. Warner TFCS, Seo IS: Goblet cell carcinoid of appendix: ultrastructural features and histogenetic aspects. Cancer 44: 1700, 1979 31. Warkel RL, Cooper PH, Helwig EB: Adenocarcinoid, a mucin-producing carcinoid tumor of the appendix: a study of 39 cases. Cancer 42:27Bl, 197B 32. Gould VE, Memoli VA, Dardi LE: Multidirectional differentiation in human epithelial cancers. J Submicrosc Cytol 13:97, 1981 33. McDowell EM, Wilson TS, Trump BF: Atypical endocrine tumors of the lung. Arch Pathol Lab Med 105:20, 1981 34. Sidhu GS: The endodermal origin of digestive and respiratory tract APUD cells. Am.J Pathol 96:5, 1979
134
The topic of mammary carcinoid tumors is at present relatively confusing. Some authors, such as Cubilla and Woodruff,' have recorded true primitive carcinoids, whereas others, including Taxy et a\.2 and Partanen and Syrjanen" have found argyrophilic cells in common ductal or lobular carcinomas. Furthermore, colloid carcinomas are considered by Fisher and Palekar" to be a mucinous variant of carcinoids, and by Capella et al. 5 to be tumors that could differentiate along endocrine cell lines. This is all the more paradoxical in that cells of endocrine lineage have never been isolated from the mammary gland, and the occurrence of carcinoids in other glands of ectodermal origin is extremely rare. 6- B Breast tumor tissues were stained by the Grimelius procedure, regardless of their morphologic features, for the purpose of identifying argyrophilic cells. As a result, we were able to identify a group of argyrophilic cell-containing tumors, whose relationship to carcinoid will be described. MATERIALS AND METHODS We studied 123 tumors (table 1), including 92 carcinomas, 12 fibroadenomas, and 19 dysplasias, and two lactating mammary glands. Tissues processed for light microscopic study were fixed in aqueous Bouin's fluid. Detection of argyrophilic cells was acReceived April 23, 1982, Revision accepted for publication June 7, 1982. * Laboratoire d'Anatomie Pathologique, CHU Bretonneau, Tours, France. t Station de Physiologie de la Reproduction, Nouzilly, France. Departernent de Microscopie Electronique, CHU Bretonneau, Tours. § Clinique Gynecologique et Obstetricale, CHU Bretonneau, Tours. Address correspondence and reprint requests to Dr. Fetissof: Laboratoire d'Anatomie Pathologique, CHU Bretonneau, 37044 Tours, France.
*
0046-8177 183/0200/0127
complished using the modified Grimelius method" combined at times with alcian blue
127
HUMAN PATHOLOGY
Volume 14. No.2 (February 1983)
filtrating component of isolated cells was present. The intralobular component contained focal areas of argyrophilic cells easily observed on routine preparations. The other tumor (case 18) was associated with a colloid carcinoma and will be described later. Cases 10, 11, and 12 were three of five tumors for which accurate classification as ductal or lobular was difficult. Case 10 could be consistent with a solid variant of lobular carcinoma, having features suggestive of carcinoid tumor. Case II (fig. 6) contained an in situ component of uncertain type; the invasive part had small tubules and large islands of neoplastic cells. Lymph node metastases were of a solid pattern with gland formation. Case 12 might be considered a basaloid ductal carcinoma. The only argyrophilic cells found were admixed with mucinous cells in the intraductal portion of tumor. Twenty carcinomas containing colloid elements were collected. Argyrophilic cells were found in seven of the 20 cases (cases 13-19). Colloid tumors that lacked argyrophilic cells had a disquieting appearance in most cases; they often harbored a solid infiltrating component as well as lymph node metastases. These colloid carcinomas were composed of atypical cells arranged in small nests, annular configurations, delicate trabeculae, or cribriform structures. In contrast, colloid carcinomas containing argyrophilic cells had an organoid growth pattern. They were composed of clumps of uniform cells, often quite large, with either regular (case 13) or irregular (case 14) contours. In case 15 (fig. 7) tall columnar cells outlined nests of neoplastic cells in a palisade arrangement highly reminiscent of type A carcinoid. Less often, plexiform
TABLE 1. ARGYROPHILIC CELLS IN 123 TUMORS AND TWO LACTATING MAMMARY GLANDS Type of Breast Lesion
Number of Grimeliuspositive Cases 7
Ductal carcinoma (n = 46) Tubular carcinoma (n = 1) Medullary carcinoma (n = 1) Lobular carcinoma (n = 19) Carcinoma of uncertain origin (n = 5) Colloid carcinoma (11 = 20) Fibroadenoma (n = 12) Dysplasia (n = 19) Lactating mammary gland (n = 2)
* One was
o o 3'"
3 7
o o o
associated with a culloid carcinoma.
sembling carcinoids lacked argyrophilic cells. Likewise, argyrophilic cells were not found in welldifferentiated ductal carcinomas or in single cases of tubular and medullary carcinomas. Of the 19 cases of lobular carcinoma studied, only one classic in situ tumor (case 8) contained scarce and weakly argyrophilic cells. It should be pointed out that the peripheries of intracytoplasmic lumens were often blurred on Crimelius preparations. One case of a mucinous variant was devoid of argyrophilic cells. Argyrophilic cells were demonstrated in two less typical lobular carcinomas (cases 9 and 18). Case 9 showed prominent intralobular foci of proliferation with occasional central necrosis and calcification. Several small cribriform cavities were noted in addition to massive interlobular duct involvement. An inTABLE 2.
DISTRIBUTION OF ARGYROPHILIC CELLS IN NINETEEN GRIMELIUS-POSITIVE CASES
Age (years)
Type of Carcinoma
Colloid Component
Absent
Absent
+
+++ +++ ++ + + ++
Absent Absent Absent Absent Absent Absent Absent Absent Absent Absent Absent
++ ++
+++ +++
Absent Absent
No metastases
Case 1
42
Intraductal
Case Case Case Case Case Case Case Case Case Case Case Case Case
2 3 4 5 6 7 8 9 10 11 12 13 14
46 65 59 71 65
75 76
Invasive ductal Invasive ductal Invasive ductal Invasive ductal Invasive ductal Invasive ductal In situ lobular Atypical invasive lobular Invasive uncertain type Invasive uncertain type Invasive uncertain type Colloid Colloid
Absent Absent
Case 15 Case 16 Case 17
86 53 71
Colloid Colloid Colloid
Absent Absent Absent
Case 18
75
Complex tumor with a colloid component
33 50
52 50 74
60
Axillary Lymph Node Metastasis
Solid Invasive Component
Absent
+ ++
+++ ++
In situ Component
+ + ++ + ++ + Absent
+
Curettage not performed
No metastases
+++ ++ No metastases No metastases
Arnphicrine cells
Case 19
56
Complex tumor with a colloid component
KEV: - = No argyrophilic cells; + argyrophilic cells.
= Scarce
+++ Atypical
+++ + + +
lobular
+
Absent
++ Absent
+ + + Atypical
No metastases No metastases Curettage not performed No metastases
lobular - Colloid
+++
+++
Amphicrine cells
Am phicrine cells
No metastases
argyrophilic cells; ++ = Moderate number of argyrophilic cells; +++
128
= Numerous
ARGYROPHILIC CELLS IN MAMMARY CARCINOMA (Fetissof at al.)
Figure 1 (top lift ). Case 3. Conventiona l poorly differentiated infiltra ting ductal carci noma. Clusters o f varyi ng sizes are separated by broad bands of conn ective tissue. (Hematoxylin-eosin stain . X 170.) Figure 2 (middle lift) . Case 2. Poorly differentia ted ductal carcinoma. An in vasive co mponen t conta ins numero us argyroph ilic cells. (Grimelius stain . x 250. ) Figure 3 (bottom left) . Case 2. In traductal com ponent rich in ar gyrophilic cells. (Gri me lius stain. x300.) Figure 4 (lop right). Case 3. Abun da nce of de nd ritic argyrop h ilic cells surro un ding neoplastic nests. (Gr ime lius sta in. x 60 0.) Figure 5 (bottolll right ). Case 3. Detail of argyroph ilic cell whose fine cytoplasmic P I'OCCSS encircles one invas ive nest. (Grimelius sta in . x 1,3 00.)
HUMAN PATHOLOGY
Volume 14. No.2 (February 1983)
Figure 6. Case 11. Carcinoma of uncertain origin, with foci of intralobular proliferation containing argyrophilic cells. (Grimelius slain. x260.)
masses (case 17) or cribriform structures (case 18, fig. 10) were encountered. Colloid tumors had an occasional intraductal component that sometimes contained argyrophilic cells. No lymph node metastases were present in the six cases examined. In a single tumor, the distribution of argyrophilic cells varied from one element to another. Poorly argyrophilic elements were small clumps (case 16) or cribriform structures (case 18, fig. 10). Grimeliusalcian blue double-stain revealed no evidence of intracytoplasmic mucin in certain tumors (cases 13, 15, 16, and 18). Of interest, argyrophilic granules in case 13 were occasionally condensed into one principal mass. In case 15 (fig. 8) argyrophilic cells predominated in the peripheral rim. Case 17 (fig. 9) contained numerous mucinous cells and sparse argyrophilic cells; there was a reciprocal relationship in the frequency of mucinous and argyrophilic cells. Other tumors, such as those in cases 14 and 19, showed a mosaic of undifferentiated cells (nonmucinous, nonargyrophilic), argyrophilic cells, and mucinous and amphicrine cells of the m uco argyrophilic variant, which contained a seeding of argyrophilic granules dispersed throughout an alcianophilic material. The most com plica ted cases were cases 18 and
19. The tumor in case l Sjuxtaposed a colloid component (fig. 10) of cribriform structure with a solid component of lobular architecture, which had in situ and invasive argyrophilic elements. The solid portion was appreciably different from classic lobular carcinoma in that it had intralobular necrotic foci and the neoplastic cells were fusiform to plasmacytoid. Such an aspect is evocative of a spindle-cell carcinoid or thyroid medullary carcinoma. Electron microscopic study of deparaffinized material revealed numerous dense-core granules from 200 to 300 nm in diameter. The tumor in case 19 contained an association of intraductal, colloid, and solid invasive components. The intraductal and colloid constituents comprised cells of an undifferentiated type, argyrophilic cells (easily identified on routine preparations), and mucinous and amphicrine cells (fig. 11). The solid invasive element was composed of clusters with rare, weakly argyrophilic or alcianophilic cells. Electron microscopic study of the intraductal component (fig. 12) permitted the iden tification, albeit less clear-cut, of the four cell types observed on light microscopy. Argyrophilic cells contained many dense-core grari.ules, with diameters from 200 to 330 nm, and occasional mucinous vesicles. Some mucinous cells contained rare dense-core granules. An intricate mixture of dense-core granules and mucinous vesicles was seen in amphicrine cells. Last, the so-called undifferentiated cells were rich in reticulum and at times contained a few dense-core granules. All cell types had filaments, which were at times numerous and arranged in bundles, as well as interdigitations and junctions. Basement membrane invested the tumor masses. No argyrophilic cells were detected in the fibroadenomas (two of which contained foci of intralobular carcinoma) Or in dysplasias, which were either isolated or accompanied carcinomas. Dysplastic lesions comprised cysts, apocrine metaplasia, epitheliosis, adenosis, and papillomas. We were not successful in identifying argyrophilic cells in the two cases of lactating mammary glands or in morphologically normal areas of breasts that harbored carcinomas. The 19 carcinomas with argyrophilic cells gave negative Masson-Fontana reactions for argentaffin cells. Findings on indirect immunofluorescence examination of all tissue samples were consistently negative with antisera to adrenocorticotropic hormone, calcitonin, gastrin, serotonin, and somatostatin. DISCUSSION In our series, argyrophilic cell-containing carcinomas formed a heterogeneous group that comprised poorly differentiated ductal carcinomas, lobular (more often atypical) carcinomas, carcinomas of uncertain origin, and colloid carcinomas. Breast tumors with the morphologic feature of usual carcinoid were not encountered, although occasional
130
ARGYROPHILIC CELLS IN MAMMARY CARCINOMA (Fetlssof at 0 1.)
Figure 7 (topleft). Case 15. Colloid tu mor very rem iniscent of type A carcinoid . Note the we lt-developed periphe ral rim composed o f tall co lumnar cells. (He mato xylin-eo sin slain. x 140.) Figure 8 (middle lefl). Case 15. Arg yro philic cells concentrat ed in th e pe ripheral rim. (Gr im eliu s sta in. x3 00.) Figure 9 (bottom lefi) . Case 17. Co lloid carcino ma composed of plexi form masses containi ng nume ro us mucinous cells. Scarce a rgyrophilic cells dispersed among m ucino us cells. (Grimelius stain . x280.) Figure 10 (lap right). Case 18. Complex tumor. Collo id portio n with cribriform elem ents d isp osed within mucinous pool , (Hematoxylin-e osin stain . x (30.) Figure 11 (bottom right). Case 19. Complex tumor. Intraducta l component with argyrophilic cells. (Gri me lius sta in . x 280.)
HUMAN PATHOLOGY
Volume 14. No.2 (February 1983)
Figure 12. Case 19. Top, electron micrograph of the intraductal component. Endocrine cell (EC) contains intracytoplasmic dense-core granules, and undifferentiated cell (VC) has abundant reticulum. MC = mucinous cell. (x 10,000.) Bottom, high-power view ofamphicrine cell (AC) of mucoargyrophilic type, showing an intricate mixture of mucous vacuoles and dense-core granules. (x24,OOO.)
carcinomas contained foci of growth reminiscent of carcinoid tumor. The existence of mammary carcinoids was first reported in 1977 by Cubilla and Woodruff,1 followed by Kaneko et aL.,lO Devitt,"! and Fisher and Palekar. 4 These tumors were interpreted as carcinoids mainly on the basis of the presence of argyrophilic cells. It should be pointed out that their morphologic features and clinical behavior are often quite different from those expected of classic carcinoid. Our findings are more consonant with the findings of Gould and Chejfec.l" Partanen and Syrjanen," and Taxy et al.," who found argyrophilic cells in
conventional ductal or lobular carcinomas. We should like to emphasize the distinctive appearance of tumors that are composed, like that in case 18 of our study, of plasmacytoid and spindle cells. A similar tumor, which is very suggestive of medullary carcinoma of the thyroid, was reported by Cubilla and Woodruff.' Argyrophilic cells were encountered predominantly among colloid carcinomas. These cells were previously identified in colloid tumors by Feyrtcr and Hartmann.P Fisher and Palekar,! and Capella et aL.5 On the whole, the differences we observed between
132
ARGYROPHILIC CELLS IN MAMMARY CARCINOMA (Fellssot at al.)
colloid tumors containing or lacking argyrophilic cells concur with those reported by Capella et al. 5 Like Partanen and Syrjanen." we failed to detect argyrophilic cells in the fibroadenomas, even in those associated with lobular carcinoma. Eusebi and Azzopardi-:' and Govoni et al. 15 reponed the presence of argyrophilic cells in a variant of fibroadenoma that contained an endocrine lobular neoplasia morphologically distinct from lobular carcinoma. We did not observe any argyrophilic cells in mammary d ysplasias , confirming the results of Cubilla and Woodruff? and Partanen and Syrjanen." Such cells were found, however, by Vogler" and by Fisher and Palekar." At present, no argyrophilic cells have been identified in normal male or female mammary glands. I •3.4 The primary question by these findings concerns the nature of the argyrophilic granulations demonstrated by the Grimelius reaction. False-positive reactions are due to the presence of macrophages or foci of necrosis. Other techniques have been used to visualize argyrophilic cells in breast tissue, notably the reactions of Gros-Schultze.!" Gros-Bielschowsky;':' Boclian,I.10.14.15 Sevier-Munge r.P-" and modified Pascual." Only Devitt!' reported finding argentaffin cells. Gould et al., 19 Taxy et al.," and Waxman et al. 20 suggested that silver deposits could blur mucin droplets or lysosomes. The electron microscope1. 3.4.10.14.15 allowed characterization of the granulations as dense-core gl'anules with diameters from 80 to 355 nm . As in case 19 of this study, ultrastructural exam inat io ns-!" has revealed an intricate mixture of dense-core granules and mucinous vesicles in amphicrine cells of the mucoargyrophilic type. Our immunohistologic techniques failed to characterize any hormonal products. The two colloid carcinomas recorded by Feyrter and Hartmann 13 contained serotonin. The tumor examined by Kaneko et al.'? secreted norepinephrine. It is well known that conventional types of breast carcinomas can elaborate ad rcnoco rticotro pic hormone,2l,22 calcitonin,23,24 parathyroid hormone;" human chorionic gonadotropin," anel human placental lactogen.t? We did not find any argyrophilic cells in the two lactating mammary glands we examined, although Clayton et al. 17 suggested that argyrophylic granulations might represent milk protein. The relationship of argyrophilic cell-containing carcinomas to classic carcinoids must be considered. These tumors differ in their architectural pattern and often in their clinical behavior. Their only common feature is the presence of putative endocrine cells. Other organs provide examples of complex tumors that lack carcinoid architecture yet show common epithelial cells intermingled with argyrophilic endocrine cells. 2s - 3o Such tumors were named adenocarcinoid by Warkel et al.:lI Gould et al. 32 coined the term "neuroendocrine carcinoma" to designate "undifferentiated" tumors from various sites that contained argyrophilic cells. McDowell et al.33 reponed a series of common bronchial carcinomas that contained argyrophilic cells, which they called "atypical endocrine
tumors." According to these authors, endocrine cells arise, by divergent differentiation, from the same stem cells that. give rise to the epithelial elements. Such di fferent.iation along argyrophilic secretory lines is not surprising from a histogenetic standpoint, since it is likely that most cells of the diffuse endocrine system have a local origin in common with the epithelial elcrnents.P" The Grimelius method did not disclose argyrophilic cells in normal breast tissue . It follows that differentiation into argyrophilic secretory cells occurs during a neoplastic process that allows for multidirectional differentiation. This is in contradistinction to carcinoids, which are composed entirely of endocrine cells and are derived in most cases from a proliferation of well-individualized endocrine elements already present in nonturnoral tissue. Each conventional type of breast carcinoma may show variable degrees of focal endocrine differentiation. It should be stressed that the occurrence of argyrophilic cells among epithelial cells does not imply the edification of a carcinoid structure . At present, there is no direct evidence that solid argyrophilic ceil-containing carcinomas should be regarded as a class of tumors distinct from ordinary carcinomas. We find it worthwhile to reiterate the originality of the organoid growth pattern of colloid carcinomas containing argyrophilic cells, in which mucinous and endocrine differentiation, during a neoplastic process, arises from an undifferentiated stem cell.
The authors thank Dr . M. P. Dubois, Station de Physiologic de la Reproduction de Nouzilly, for providing all immune sera used ill this study.
REFERENCES 1. Cubilla AL, Woodruff JM : Pr imary carcinoid tumoral' the breast: a report of eight patients. Am J Surg Pat hoi 1:283 , 1977 2. Taxy J B, Tischler AS. Insalaco 5J , et al : "Carcinoid" tumor of the breast: a variant of conventional breast cancer? Hum Paihol 12:170. 1981 3. Partaricn S, Syrjanen K: Argyrophilic cells in carcinoma of the female breast. Virchows Arch [Pa t ho l Anat] 391 :45, 1981 4. Fisher ER, Palekar AS : Solid and mucinous varieties of socalled mammary carcinoid tumors . AmJ Clin Pathol 72:909, 1979 5. Capella C, Eusebi V, Mann B, et al: Endocrine differentiation in mucoid carcinoma of the breast. Histopathology 4:613 , 1980 6. Murphy GF, Pilch BZ, Dickersin GR, et al: Carcinoid tumor of the middte ear. Am J Clin Pathol 73 :816, 1980 7. Nicod JI.: Carcinorde de la parotide. Bull Assoc Fr Cancer 45:214, 1958 8. Van Dijk C. Ten Seldarn RE.J: A possible primary cutaneous carcinoid. Cancer 36:1016, 1975 9. Lack E, Mercer L: A modified Grirnelius argyrophiltechniqllc for neurosecretory granules. Am J Surg Pat hoI 1:275. 1977 10. Kaneko H, I-Iojo H, Ishikawa S, CI. al: Norepinephrineproducing tumors of bilateral breasts: a case I·CpOJ"l. Cancer 41:2002, 1978 11. Devitt PC: Carcinoid tumour or the breast. Br Mecl J 2:327, 1978
133
HUMAN PATHOLOGY
Volume 14, No.2 (February 1983)
12. Gould VE, Chejfec G: Secretory features in lobular carcinoma of the breast. Ultrastrucr Pathol 1: 151, 1980 13. Feyrter F, Hartmann G: Ober die carcinoide Wuchsform des Carcinoma mammae, insbesondere das Carcinoma solidum (gelatinosum) mammae. Frankf Z Pat hal 73:24, 1963 14. Eusebi V, Azzopardi jG: Lobular endocrine neoplasia in fibroadenoma of the breast. Histopathology 4:413, 1980 15. Govoni E, Bazzocchi F, Pileri S, et al: Lobular endocrine neoplasia in a fibroadenoma of the breast: an ultrastructural study. Virchows Arch [Pathol Anat] 393:299, 1981 16. Vogler E: Uber das basilare Helle-Zellen-Organ del' menschlichen Brustdruse. Klin Med 2: 159, 1947 17. Clayton F, Ordonez NG, Sibley RK: Argyrophilic breast carcinomas: evidence of lactational differentiation. Am 1 Clin Pathol 77:236, 1982 18. Churukian C], Schenk EA: A modification of Pascual's argyrophil method. 1 Histotechnol 2: 102, 1979 19. Gould VE, lao W, Battifora H: Ultrastructural analysis in the differential diagnosis of breast tumors. Pathol Res Pract 167:45, 1980 20. Waxman M, Vuletin j C, Pertschuk LP: Lysosomes in Brenner's tumor simulating secretory argentaffin granules. Arch Pathol Lab Med 103:183, 1979 21. Cohlc SO, Tschen JA, Smith FE, et al: ACTH-secreting carcinoma of the breast. Cancer 43:2370, 1979 22. Woodard BH, Eisenbarth G, Wallace NR, et al: Adrenocorticotropin production by a mammary carcinoma. Cancer 47: 1823. 1981 23. Coombes RC, Easty GC, Detre SI, et al: Secretion of irnmunoreaction calcitonin by human breast carcinomas. Br Med14:197,1975
24. Sarnaan NA, Castillo S, Schultz PN et al: Serum calcitonin after pentagastrin stimulation in patients with bronchogenic and breast cancer compared to that in patients with medullary thyroid carcinoma. 1 Clin Endocrinol Metab 51:237, 1980 25. Mavligit GM, Cohen JL, Sherwood LM: Ectopic production of parathyroid hormone by carcinoma of the breast. N Engl.J Med285:154,1971 26. Tormey DC, Waalkes TP, Simon RM: Biological markers in breast carcinoma. I I. Clinical correlations with human chorionic gonadotrophin. Cancer 39:2391, 1977 27. Sheth NA, Suraiya.JN, Sheth AR, et al: Ectopic production of human placental lactogen by human breast tumors. Cancer 39: 1693, 1977 28. Kubo T, Watanabe H: Neoplastic argentaffin cells in gastric and intestinal carcinomas. Cancer 27:447, 1971 29. Matsuyama M, Inoue T, Ariyoshi Y, et al: Argyrophil cell carcinoma of the uterine cervix with ectopic production of ACTH, fl-MSH, serotonin, histamine and amylase. Cancer 44:1813,1979 30. Warner TFCS, Seo IS: Goblet cell carcinoid of appendix: ultrastructural features and histogenetic aspects. Cancer 44: 1700, 1979 31. Warkel RL, Cooper PH, Helwig EB: Adenocarcinoid, a mucin-producing carcinoid tumor of the appendix: a study of 39 cases. Cancer 42:27Bl, 197B 32. Gould VE, Memoli VA, Dardi LE: Multidirectional differentiation in human epithelial cancers. J Submicrosc Cytol 13:97, 1981 33. McDowell EM, Wilson TS, Trump BF: Atypical endocrine tumors of the lung. Arch Pathol Lab Med 105:20, 1981 34. Sidhu GS: The endodermal origin of digestive and respiratory tract APUD cells. Am.J Pathol 96:5, 1979
134