PMC7201766_01
(A) Diagnostic Mammogram: Right medio-lateral oblique view showing an irregular high density mass in the superior central aspect of the right breast. (B) Ultrasonography of right breast and axilla: Irregular hypoechoic macro-lobulated mass in the superior central aspect of the right breast.
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F1
Diagnostic mammogram and ultrasound (Figures 1A,B) indicated a 2.3 x 1.3 x 2.3 cm irregular mass in the upper outer quadrant of the right breast, highly suggestive of malignancy.
(A) Histopathological examination of the specimen stained on low (4x), (B) high power field (20x, 40x) showed neoplastic cells with high nuclear: cytoplasmic ratio, hyperchromatic nuclei, minimal cytoplasm, and indistinct nuclei, nuclear molding, high mitotic rate, consistent with the diagnosis of small cell carcinoma. Biopsy of breast cancer primary. Immuno-histochemical staining for TTF-1 synpatophysin, chromogranin, and p40 and smooth muscle myosin staining (SMMS) consistent with a diagnosis of primary SCCB, (C) small cell synaptophysin 20X. (D) small cell TTF-1 20X. (E)
In situ component with neuroendocrine differentiation p40. (F)
in situ component smooth muscle myosin stain. (G) Histopathological examination of the fine needle aspiration of the sub-carinal node revealed metastatic small cell carcinoma (Lymph node 40x).
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Ultrasound guided core needle biopsy revealed poorly differentiated neuroendocrine carcinoma/small cell carcinoma (Figures 2A,B), estrogen receptor (ER) negative, progesterone receptor (PR) positive (10% weak intensity), and human epidermal growth receptor 2 (HER2) negative. Immuno-histochemical staining was positive for thyroid transcription factor 1 (TTF-1), synaptophysin and chromogranin A, and rare cells positive for GATA3, consistent with primary SCCB (Figures 2C,D). In addition, a high grade neuroendocrine in situ component was identified (Figures 2E,F). Bronchoscopy and trans-bronchial fine needle aspiration of the sub-carinal node revealed metastatic small cell carcinoma with Ki-67 staining in >90% of cells (Figure 2G).
(A) PET CT scan showing the primary lesion in the right upper outer quadrant of the right breast. (B) A hyper metabolic right axillary lymph node, which is compatible with the patient's known right breast primary malignancy and a presumed metastatic right axillary lymph node. (C) PET scan after recurrence showing new lung nodules with FDG uptake. (D) PET scan after recurrence showing sub-carinal lymph node with new intense focus of FDG uptake.
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Additionally, a positron emission tomography (PET) computerized tomography (CT) scans showed no evidence of lung, pancreatic, adrenal, or pelvic masses (Figures 3A,B). Routine follow-up CT scans of the thorax showed a right lower lobe nodule and enlarged sub-carinal lymph node, which showed FDG avidity by PET scan (Figures 3C,D).