Squamous cell carcinoma (SqCC) of the breast should be differentiated between the primary skin keratinizing squamous carcinoma and squamous metaplastic cancer. In the current study, the cases of two patients who were diagnosed with SqCC originated from skin and the breast were discussed. A fine-needle aspiration biopsy confirmed the presence of atypical squamous cells. In both cases, the microscopic examination of the surgical specimen revealed a malignant neoplasm differentiated into SqCC characterized by keratinizing cancer cells with abundant eosiphilic cytoplasm with large, hyperchromatic vesicular nuclei. Immunohistochemical studies showed negative for progesterone and estrogen receptors and human epidermal growth factor receptor 2. Moreover, negative expression of cytokeratin 7 and 20 was confirmed. The diagnosis of the both tumors was established based on the detailed analysis of clinical, macroscopical and microscopical information. SqCC localized in the breast is a great diagnostic challenge in pathomorphology and more attention should be paid for analysis of such lesions in daily practice.
Squamous cell carcinoma (SqCC) is a malignant neoplasm of epidermal keratinocytes that arises most commonly on the skin and organs lined with squamous cells. Squamous cell carcinoma is a rare form of metaplastic carcinoma in breast that accounts <0.1% (
The present study was performed in conformity with the Declaration of Helsinki for Human Experimentation and the protocol was approved by the Bioethics Committee of the Medical University of Bialystok. Written informed consent was obtained from both participants.
A 72-year-old female was admitted to the Department of Surgical Oncology in Bialystok (Poland) for planned surgery. There was no family history of malignant neoplasms. Patient had used some medication against hypertension. She complained of abdominal pain with normal peristalsis and had normal stools. She was postmenopausal and had given birth to 3 children. Previously, the histological examination of the biopsy material, obtained during a fine-needle aspiration (FNA), confirmed the presence of the cancer cell infiltrate in the left breast (
Macroscopically, the postoperative formalin-fixed material of the left breast 17.0×16.5 cm in size, showed a huge, ulcerative tumor with cauliflower-like appearance, 16.8×16.2 cm in size, of gray-brown surface with a narrow margin at the periphery of the skin without the presence of nipple. On cross-sections, tumor was solid, gray-brown color with gray-white foci of necrosis, coming near this deep incision line. Fourteen local lymph nodes were dissected with no evidence of metastases. The biggest lymph node was 3.1×1.8 cm in size. Optimal surgical margins were obtained (
The microscopic examination of the surgical specimen revealed a moderately differentiated (G2) squamous cell carcinoma according to WHO Classification of the Skin Tumours (
Patient was discharged home in good general condition and received five courses of chemotherapy with Taxotere + Cisplatin (110 mg i.v.). After 1.5 month following the surgery, patient visited the Surgical Outpatient Clinic and was directed to USG of abdomen and retroperitoneal space, and the FNA of right breast. Imaging studies confirmed the presence of a heterogeneous good well-isolated area with dimensions 27.0×22.0 mm, probably metastatic changes. The material obtained from the FNA cytology of right breast showed the presence of poorly differentiated cancer cells, probably originated from squamous cancer. The change was treated as a distant metastases. One month later, imaging studies of PET-CT confirmed an active metabolic process in the left side of nasopharynx. Patient was qualified for surgery under local anesthesia. Macroscopically, it was visualized a smooth mucosa of the nasopharynx without significant changes. The histopathological study of the nasopharynx did not show a presence of cancer cells but only morphological features of chronic inflammation markers. Another CT scan showed numerous secondary changes within both lungs, the largest diameter of 35.0 mm and a single focus in the segment V of the liver diameter of 24.0 mm. We did not detect secondary changes in the skeletal system. Disease progression of cancer was revealed.
A 59-years-old woman evaluated in our hospital for recent onset of pain and tenderness in the left breast. Physical examination revealed a palpable well circumscribed mass in the left upper lateral quadrant. The right breast appeared normal. There was no evidence of supraclavicular or axillary lympadenopathy. The overlying skin was unremarkable. An ultrasound examination of the left breast revealed a defined 3.0 cm mass with reduced central echogenicity, consistent with a cystic space. Mammography showed a round, high-density mass (without microcalcifications) with almost regular margins, measuring approximately 3.0 cm, which was classified as BIRADS 4. A fine-needle aspiration biopsy was performed and yielded 0.5 ml of white dense fluid material. Cytological preparations revealed markedly atypical squamous cells arranged in sheets, clusters and as a single cell as well as numerous neutrophils. Several cells were keratinized and some showed degenerative changes (
The patient had an ultrasound-guided core biopsy of the left breast mass at the local anesthesia. Patient underwent radical mastectomy with axillary lymph nodes dissection. Gross examination revealed a 6.0 cm tumor with central cystic space containing necrotic material (
Patient had adjuvant chemotherapy based on cisplatin and 5-fluorouracil. She had no evidence of recurrence 6 months after surgery.
Squamous cell carcinoma is one of the most common skin cancer that was developed in association with prolonged exposure to sunlight. However, not all squamous cell cancers are directly related to UV radiation. They can grow in the shores of chronic ulcers, within the scars burn of skin or as a result of damage to the epidermis the chemical or radiation therapy. Also patients with immune suppression have an increased risk of squamous cancer (
Squamous cell carcinoma of the skin develops in the form of initially small, hard lumps, often in the middle ulcers, modified necrotic or excessively keratinizing (
The large size of the tumor and advanced process of necrosis caused a difficulty of confirmation whether macroscopic tumor derived from the squamous epithelium of the skin or are created in the basis of abnormal glandular epithelium metaplasia. First tumor was built with bands of moderately differentiated squamous cancer cells with large vesicular nucleus. We observed prominent intracellular bridges, central keratinization and pearl formation. SqCC does not infiltrate along nerve sheaths and lymphovascular vessels. Cancer cells proliferated from the stratified squamous epithelium covering the breast into deeper layers of the body. Morphological image of metaplastic breast cancer is very similar. They also may have focal anaplastic component or focal clear cell changes (
Moreover, because of the similar changes in both histogenesis, we can not use immmunophenotype methods to differentiated cancer cells. Immunohistochemical analysis also does not allow to determine whether it is a primary lesion or metastatic one. In both of our cases, we recorded a positive expression of pancytokeratin which confirms the presence of cells differentiated towards squamous cell carcinoma. In case 1, the characteristics of immunophenotyping were: Cytokreatyna7 (−), cytokeratin 20 (−) and triple negative receptor status suggests that this lesion will probably not derive from the mammary gland. However, in the majority of metaplastic breast cancers also observed a lack of expression of estrogen, progesterone, and HER2 (
Treatment of squamous cell carcinoma of the skin and metaplastic breast cancer are depends mainly on the stage of the cancer. Typically, the patients are undergoing surgery in the first stage of therapy then adjuvant treatment such as radio- or chemotherapy was used (
In conclusion, cutanous squamous cell carcinoma and metaplastic cell carcinoma of breast are extremely rare lesions that should be differentiated from primary squmanous cell carcinoma in this localization and should be treated with special clinician's and pathomorpgologist's attention. In our opinion, such cases are great diagnostic challenge in pathomorphology and should be more carefully analyzed in daily practice.
Fine-needle aspiration biopsy (FNA). Case 1: Cluster of atypical squamous cells (A). Case 2: Atypical squamous cells showed abundant dense keratinized cytoplasm (B).
Macroscopy. Case 1: A huge, ulcerative tumor with cauliflower-like appearance, with enrolled nipple, covered the all left breast. On cross-section, there is gray-gray and gray-white tumor with necrotic foci (A). Case 2: Slightly delicate, solid, gray-white tumor, covering the middle part of the breast parenchyma (B).
Histopathological findings. Case 1: Squamonus cancer cells have abundant eosiphilic cytoplasm with large vesicular nucleus in the main tumour mass (A). The central keratinization and pearl formation were showed (B). Case 2: Similar to case 1, there were large polygonal cells with keratinizing eosinophilic cytoplasm (C). Higher magnification of tumor shows intercellular bridges, indicative of squamous cell differentiation (D). (H&E stain; magnification ×100, ×200).