In situ and infiltrating lobular carcinoma of the male breast

HU1>W4 PATHOLOGY

Volume 20, No. 12 (December1989)

the central veins; this would have been aided by the interrupted blood supply caused by the arteritis. The venoocclusive lesion of the portal vein radicles is more difficult to explain. One may hypothesize direct en dothelial injury to the portal vein radicles through retrograde flow, but this would more likely result in thrombi, which were not seen. In light of the suggestion that VOD of the central vein is caused by stasis of blood, a similar lesion in the portal vein radides may also be caused by slow flow. We do not have a good explanation as to why this could happen. Although theoretically, outflow obstruction by the central vein VOD may produce local stasis or backflow, other possibilities include proximal obstruction by tumor or scarring following surgery. The lesions seen in the portal vein radicles of our case are similar to those described in hepatoportal sclerosis, although the latter process has not been associated with typical VOD. Hypotheses regarding the cause of the lesion of hepatoportal sclerosis include organization of thrombi, resulting in sclerosis of the portal vein. Hepatoportal sclerosis has also been associated with toxic agents, particularly vinyl chloride and arsenic. II It is possible that our case represents the effect of FUDR on both cent ral and portal veins, leading to a comb ined process. In summary, we present a case report of a 65-year-old woman with metastatic colonic adenocarcinoma of the liver treated by intraarterial infusion of FUDR, leading to focal VOD of the liver with unusual venoocclusive lesions of the portal vein radicles.

IN

Acknowledgment. The authors acknowledge the clerical assistance of Sharon Leong and the photographic assistance of James McCabe in the preparation of this manuscipt. REFERENCES I. Bras G, Brant KH : Vascular disorders; in MacSween RNM, Anthony PP. Scheuer PJ (eds): Pathology of the Liver. edition 2. London, Churchill Livingstone , 1988. pp 478-502 2. Doria MI. Shepard KV. Levin B. et aI: Liver pathology following hepatic arterial infusion chemotherapy: Hepatic toxicity with FUDR. Cancer 58:855-861. HJ86 3. Bras G. Jeliffe DB. Stuart KL: Veno-occlusive disease of the liver with non -portal type of cirrhosis occurring in Jamaica. Arch Pathol 57:285300. 1954 4. Read AE, Wiesner RH, Labrecque DR, et al: Hepatic veno-occlusive disease associated with renal transplantation and azathioprine therapy. Ann Intern Med 104:651-654, 1986 5. Reed GB. Cox AJ: The human liver after rad iation i~ury : A fonn of veno-occlusive disease. AmJ PathoI48:597·611, 1966 6. Alpert Ll : Veno-occlusive d isease of the liver associated with oral contraceptives: Case report and review of the literature. HUM PATHOL 7:709· 718. 1976 7. Hohn D. Melnick J, Stagg R, et aI: Biliary sclerosis in patients receiving hepatic arte rial infusions of floxuridine, J Clin Oneol 3:38·102. 1985 8. Rappaport AM. Knoblau ch M. Zelin S. et aI: Experimental hepatic vena-occlusive disease. Adv Microcirc 2:69-79, 1969 9. Shulman HM. McDonald GB: Liver disease after marrow transplan. tations , Sale GE. Shulman HM (eds): The Pathology of Bone Marrow Transplantation. New York. Masson Publishing. 1984. pp 104-135 10. Ludwig]. Kim CH. Wiesner RH. et al: Floxuridine-induced sclerosing cholangitis: An ischemic cholangiopathy? Hepatology 9:215-218. 1989 11. Okuda K, Nakashima T . Okudaira M. et al: Liver pathology of idiopathic portal hypertension. Comparison with non-cirrhotic portal fibrosis of India. Liver 2:176-192.1982

snu AND INFILTRATING LOBULAR CARCINOMA OF THE MALE BREAST

KEITH

V. A.

NANCE,

MD, AND

ROBERT

L.

REDDICK ,

MS, MD

An 82-year-old man presented with a right breast mass. Histologic examination of an excisional biopsy showed lobular in situ and infiltrating carcinoma. The patient was phenotypicaUy male and hadfathered children. There was 7IQ history of predisposing factors to breast lesions, suchas drug use or gynecomastia. In our review, this is the first case of lobular in situ and infiltratingcarcinoma of the male breast in a phenotypic and apparently genotypic male. HUM PATHOL 20 :1220-1222. @ 1989 by WB. Saunders Company. Carcinoma of the male breast accounts for onl y 1% of cases of breast malignancy. In all large series, the predominant histologic type has been infiltrating ductal carcinoma. 1-6 A review of the literature disclosed few previous re~rts of small cell carcinoma occurring in the male breast' : -9 and a single example of lobular carcinoma in a patient with Klinefelter's syndrome.'? We report a case of infiltrating lobular carcinoma with an in situ component occurring in the breast of a phenotypic and apparently genotypic male .

From the Departmentof Pathology. The University of North CarolinaSchool of Medicine, ChapelHill. Accepted for publication June 20, 1989. Address correspondence and reprint requests to Robert L. Reddick, MS, MD, The University of North Carolina School of Medicine. Department of Pathology. Division of Surgical Pathology, Chapel Hill, NC 27599. © 1989 by W.B. Saunders Company. 0046-8177/8912012-0016$5.00/0

REPORT OF A CASE An 80-year-old man presented to his local physician with various medical complaints, including a mass in the breast. Physical examination revealed a firm, ill-defined mass in the right breast that measured approximately 2 cm in .g rea ~es t dimension. There was dimpling of the overlying skin. BIOpsy of the breast mass was refused by the patient and his family. The patient had fathered four children. There was no history of gynecomastia, liver disease , estrogen administration, or of the use of digoxin, spironolactone, or phenothiazines. He had clinically evident severe atherosclerotic vascular disease, used aspirin on a chronic basis, and was taking Persantin and intermittent furosemide. Eighteen months later. the patient was readmitted to the hospital for a urinary tract infection. The breast mass had increased in size to approximately 3 em and a biopsy was performed. Histologic examination of the mass showed an infiltrating lobular carcinoma. A liver-spleen scan was unremarkable and further evaluation to detect metastatic disease was not performed. No chromosomal studies were performed. The family of the patient refused further therapeutic intervention or diagnostic work-up. The patient is alive 5 months after biopsy. with the extent of disease unknown . PATHOLOGIC FINDINGS The biopsy specimen consisted of a hard, gritty, graytan mass that measured 2.5 x 2.0 x 1.5 em . Microscopic

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CASE STUDIES

._..

,

~

,

,

FIGURE 1. This survey photograph shows both In situ and infiltrating lob ula r carcinoma. The Infiltrating cells are in single file pattems .

::

.... ---... .•:

. . ..= ...

, .1"" • •

FIGURE 2. At higher magnification. the in situ component consists of densely pocked, uniform small cells similar to those infiltrating through the dense stroma.

I

TABLE 1. Lobular Carcinoma of the Male Breast· Size of

No. of Cases

Age/Race

2 I

67/Black 74/Blaek

Yogore 8

I

Sanchez et allOt

I

Source Giffler

7

Nance & Reddick (present study)

Skin Changes

In Situ Component

Side

1.5 x I x I em 4.0 x 2 x 1 em

Yes Not stated

No No

Left Left

561Blaek

2.5 x 2.5 em

No

No

Left

61fWhite

3 x 2.5 x 2 em

Yes

Yes

Right

80fWhite

2.5 x 2 x 1.5 em

Yes

Yes

Right

Mass

• The ease described by Haagensen " is excluded due to insufficient data. t Klinefelter's synd rome.

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HUMAN PATHOLOGY

Volume 20. No, 12 (December1989)

sections showed a dense fibrous stroma infiltrated by a uniform population of small cells with enlarged, hyperchromatic nuclei and small nucleoli, and small amounts of pale, eosinophilic cytoplasm (Fig 1). Mitoses were not prominent. The neoplastic cells infiltrated the stroma primarily as single file arrays that surrounded scattered lobular acini filled with cohesive neoplastic cells cytologically identical to the infiltrating cells. In some areas, the tumor cells were in perineural locations (Fig 2). The resected specimen consisted largely of infiltrating tumor cells with a minor lobular in situ component. No residual ducts or evidence of gynecomastia were present. The tumor was found to be negative for both estrogen and progesterone receptors using the dextran-coated charcoal assay. DISCUSSION Male breast carcinoma represents an uncommon event, with only approximately 1% of breast carcinomas occurring in men. Most of these tumors are described in elderly men and usually present as a central firm mass with retraction of the overlying skin. 1, ~-6 In all large series, the predominant histologic type has been infiltrating ductal carcinoma. with the diagnosis of lobular carcinoma being conspicuously absent. 1·6 This finding has been generally ascribed to a lack of lobules in the male breast.' Nonetheless, a review of the li.terature disclosed a few r~orts of small cell variant carcmoma of the male breast 1, -9 (Table I). In these reports, the neoplasm was histologically identical to infiltrating lobular carcinoma in females. II In none of these cases was an in situ component described. Each of these cases would fulfill the criteria proposed by Fechner for infiltrating lobular carcinoma present in the female breast. 1 1 Recently, a case of characteristic infiltrating lobular carcinoma with an in situ component was re~orted in a phenotypic male with Klinefelter's syndrome. 0 We describe a case of infiltrating and in situ lobular carcinoma that occurred in a phenotypic normal male. Definite etiologic factors for male breast cancer have been difficult to establish, but gynecomastia and hormonal factors contributing to its development have been associated with an increased incidence of breast cancer in that

CORRESPONDENCE Guidelines for Letters Letters to the Editor will be published at the discretion of the editor as space permits and are subject to editing and abridgement. They should be typewritten, double-spaced, and submitted in triplicate. They should be limited to 500 words or less and to no more than five pertinent references.

Lymphomatoid Granulomatosis Versus Lymphoma of the Brain and Central Nervous System In the Acquired Immunodeficiency Syndrome

To the Editor:-The high incidence of central nervous system (eNS) involvement by lymphoma associated with immune deficiency in general and with the acquired immunodeficiency syndrome (AIDS) in particular has not yet been explained. Equally not understood is the predilection

population.~·6-12 In our patient, there was no antecedent clinical history of gynecomastia and no histologic evidence of this condition was identified in the breast specimen. Although chromosomal studies were not performed in this patient, the patient's paternal history and physical features militate against a diagnosis of Klinefelter's syndrome. In summary, we present what appears to represent the seventh reported case of infiltrating lobular carcinoma developing in the male breast, and the first such case with well-documented in situ lobular carcinoma occurring in a phenotypic male. Acknowledgment. The authors greatly acknowledge the support ofJuan Rosai, MD,who reviewedthe slidesfrom this case and confirmed the diagnosis, and thank Vicki Wingate for secretarial assistance.

REFERENCES I. Norris HJ, Taylor HB: Carcinoma of the male breast. Cancer 23: 1428-1435, 1969 2. Visfedlt J, Scheike 0: Male breast cancer. Histologic typing and grading of 187 Danish cases. Cancer 32:985-990, 1973 3. Scheike 0: Male breast cancer 5. Clinical manifestations in 257 cases in Denmark. BJ Cancer 28:552-561,1973 4. Erlichman C. Murphy KC, Elhakim T: Male breast cancer: A 13year review of 89 patients. J Clin Oneal 2:903-909, 1984 5. Hultborn R, Friberg S, Hultborn KA: Male breast carcinoma. I. A study of the total material reported to the Swedish cancer registry 1958.1967 with respect to clinical and histopathologic parameters. Acta Oncol 26:241256. 1987 6. Bezwada WR, Hesdorffer C, Dansey R, et al: Breast cancer in men: Clinical fetures, hormone receptor status, and response to therapy. Cancer 60: 1337-1340, 1987 7. Giffler RF, Kay S: Small-cell carcinoma of the male mammary gland: A tumor resembling infiltrating lobular carcinoma. Am J Clin Pathol 66:715-722, 1976 8. Yogore MG. Sahgal S: Small-cell carcinoma of the male breast: Report of a case. Cancer 39:1748-1752,1977 9. Haagensen CD: Carcinoma of the male breast, in Haagensen CD (ed): Diseases of the Breast, ed 2. Philadelphia, Saunders, 1971, pp 779-792 10. Sanchez AG, Villanueva AG, Redondo C: Lobular carcinoma of the breast in a patient with Klinefelter's syndrome: A case with bilateral, synchronous, histologically different breast tumors. Cancer 57:1181-1183, 1986 11. Fechner RE: Histologic variants of infiltrating lobular carcinoma of the breast. HUM PATHOL 6:373-378, 1975 12. Evans DB, Crichlow RW: Carcinoma of the male breast and K1inefelter's syndrome: Is there an association? CA 37:246-251,1987

of lymphoma under conditions of immune deficiency to arise primarily in the brain; there were 13 cases, that is, over 13%, in our series of 94 AIDS lymphoma patients as compared with less than 1% in the general population. In view of these and other unsolved questions, the publication in the same issue of Human Pathology of two opposing views on the subject of cerebral lymphoma in AIDS is of great interest. In their study, Anders et al present three AIDS patients with the diagnosis of cerebral lymphomatoid granulomatosis (LG).\ In the difficult differential diagnosis with malignant lymphoma (ML), according to these investigators, preference was given to LG on the basis of multicentricity of lesions, angiocentric patterns of growth with occasional vascular involvement, extensive necrosis, nuclear pleomorphism, and peripheral accumulations of inflammatory cells. However, as pointed out by Colby in his editorial comments, none of these features is exclusively specific for cerebral LG.2 Indeed, in our own cases of AIDS cerebral lymphomas, the involvement was often multicentric and the aggregates of lymphoma cells were predominantly perivascular, accompanied by large areas of necrosis (Figs I and 2).

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