J Clin Pathol 1986;39:1355-1359

Endocrine variant of ductal carcinoma in situ ofbreast: ultrastructural and light microscopical studyM T ASHWORTH, M T HAQQANI

From the Department ofHistopathology, Walton Hospital, Liverpool

SUMMARY The ultrastructural and light microscopic presentation of the recently described entity ofthe in situ endocrine variant of ductal carcinoma of breast are presented.

Argyrophilic cells in breast ducts and ductules havebeen described by several workers in normal andabnormal breasts.'`4 Carcinoid tumours of thebreast were subsequently reported on the basis ofargyrophilia and dense core granules ultra-structurally.5 More recently, neurone specific enolasepositivity has contributed to the diagnosis. Someworkers have taken a sceptical view of the endocrinenature of such cells, stating that Grimelius stainingand dense core granules are not specific for endocrinecells.6 ' Azzopardi et al8 concluded that argyrophilcarcinomas of the breast should be regarded as a dis-tinctive group of tumours. In a recent study9 of endo-crine tumours they found that a high proportion of insitu ductal carcinomas show an organoid pattern,with distinctive structural and cytological features,

Accepted for publication 17 June 1986

neurone specific enolase positivity, and ultra-structural dense core granules. They applied the termendocrine variant of ductal carcinoma in situ to thesetumours.

Case histories

CASE 1A 73 year old woman presented in April 1985 with atender lump in the left breast, which she had noticedtwo weeks previously. Six years ago she had felt alump in the upper quadrant of the same breast thathad settled down before she was examined by thesurgeon. A xerogram performed at the same timenoted duct ectasia and collagenosis without any otherabnormality. Her medication comprised digoxin(250mg at night). She smoked 10 cigarettes daily anddid not drink alcohol.

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Fig 1 Solid lobules ofuniform cells with round or oval nuclei. Individual cells are polygonal tending to spindle shape,with palisaded arrangement towards periphery oflobules. (Haematoxylin and eosin.) x 250.

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Fig 2 Strong argyrophilia as seen with Grimelius stain. Virtually all cells show Grimelius positive granules.(Grimelius.) x 500.

Examination showed that the right breast was nor-mal. There was a rounded mobile swelling measuring5 cm in diameter in the left breast situated behind thenipple and without attachment to the skin or deepertissues. No nipple discharge was present and the nip-ple was normal. There were no palpable axillary orsupraclavicular lymph nodes. Physical examinationyielded otherwise normal results. Biochemical andhaematological indices were normal. Attempted aspi-ration was unsuccessful. The swelling was removed

via a transverse incision with insertion of a drain.Postoperative recovery was uneventful and woundhealing unremarkable. Six months postoperativelyshe remained well with no evidence of recurrence.The excised specimen consisted of a lobulated piece

of grey soft tissue measuring 5 x 5 x 3 cm andseemed to be circumscribed. The cut surface exhibitedsmall yellow streaks of necrosis. Histologically thetumour was composed of solid lobules of relativelyuniform cells with pale finely granular eosinophilic

Fig 3 Characteristic ultrastructural dense core granules. (Uranyl acetate and lead citrate.) x 7800.. -

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Endocrine variant of ductal carcinomas in situ

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Fig 4 Pseudoglandular structures and stromal inclusions in solid groups of cells (Haematoxylin and eosin.) x 250.

cytoplasm; vesicular, round, or oval nuclei; andinconspicuous nucleoli. The individual cells were

polygonal, sometimes tending to spindle shapeinstead, but those at the periphery of the lobules andaround stromal inclusions were columnar with a dis-tinct palisaded arrangement (fig 1). There were smallor large solid areas of trabecular arrangement withoccasional pseudorosettes. Stromal inclusions consis-ting of hyaline tissue and small blood vessels were

prominent, and in many areas could be seen to becontiguous with the surrounding stroma, which

showed evidence of old and recent haemorrhage.Fibrosis and inflammatory cell infiltration were

inconspicuous, and although pushing margins oftumour growth were seen, no convincing evidence ofinvasion could be identified. Scattered cells containedperiodic acid Schiff positive diastase resistant materialin their cytoplasm, particularly the peripheral pal-isaded cells. Most of the cells showed a strongargyrophilia with fine granular black staining of theircytoplasm by the Grimelius silver method (fig 2).

Ultrastructurally the tumour cells contained round

Fig 5 Grimelius positive cells in lobules (Grimelius.) x 500.

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Fig 6 Ultrastructural dense core granules. (Uranyl acetate and lead citrate.) x 7800.

dense core granules of a mean diameter of 360 nm.The number per cell varied from a few scattered gran-ules to numerous granules filling the cytoplasm (fig 3).Abundant rough endoplasmic reticulum was present,and there was a prominent Golgi body in many of thecells. Some of the cells, in addition to dense core gran-ules, also contained mucin vacuoles, although thesewere not a prominent feature.The organoid pattern, strong argyrophilia seen

with the Grimelius stain, and the ultrastructural densecore granules enabled us to diagnose endocrine vari-ant of ductal carcinoma in situ.

CASE 2A 72 year old woman presented with bloody painfuldischarge from the right nipple, which she had had forthree weeks. She had systemic hypertension, whichwas controlled with timolol (1Omg twice daily) andbendrofluazide (2 5 mg daily).

Physical examination showed a firm tender lumpmeasuring about 6 cm in diameter in the lower outerquadrant of the right breast, with skin tethering andnipple retraction. The left breast was grossly normaland general physical examination was unremarkable.Biochemical and haematological indices were normal.Right simple mastectomy with axillary clearance wasperformed. Postoperatively there was prolongedserous discharge from the surgical wound thateventually healed fully. The patient remained aliveand well without evidence of recurrent or metastaticdisease three months later.The resected specimen consisted of a breast mea-

suring 22 x 17 x 7-5cm with attached axillary fat.Deep within the tissue was a nodular circumscribed

grey tumour measuring 4 x 3 3 x 3 cm, which hadnot spread to skin, nipple, or deeper tissue. The sur-rounding breast tissue contained dilated ducts.

Histologically the tumour was similar to thatdescribed in case 1 (fig4), with the exception thatmany of the tumour units showed polypoidprojections into cystic spaces, some covered withductal epithelium. There were also areas of con-ventional ductal carcinoma in situ with a cribriformpattern. The histological changes not only werepresent in the main tumour mass but also in ducts ofsurrounding breast, including the large ducts beneaththe nipple. Staining by the Grimelius method showedstrong argyrophilia in most of the tumour cells (fig 5).No staining was seen in the areas of conventionalductal carcinoma in situ. Ultrastructurally the cellscontained moderate numbers of dense core granuls(fig 6).Discussion

Volger' in 1947 found argyrophilic cells in breastducts of one of 18 specimens studied. Other workershave failed to find argyrophil cells in normal breast orbenign breast lesions.2 3 A recent report,4 however,has described argyrophilic and chromogranin reactiveendocrine cells in breast ducts and ductules in three of27 cases of normal breast tissue.

In 1977 Cubilla and Woodruff' reported 10 pri-mary tumours of the breast, which they termed carci-noids. The tumours had an organoid appearance,exhibited argyrophilia, and, in three cases examinedultrastructurally, contained dense core granules.Several case reports followed,'0" including an

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Endocrine variant of ductal carcinomas in situ 1359

argentaffin carcinoid reported by Devitt,'2 althoughits validity is doubtful Taxy et al6 reported a furthercase, but in addition examined 21 "ordinary" carcino-mas of the breast and found focal argyrophilia in 11(an incidence of 52%). They took a sceptical view ofthe endocrine nature of such cells, stating that Grime-lius staining was not specific for endocrine cells andthat dense core granules described in these cells mayhave been lysosomes or mucin vacuoles. They con-cluded that, "some breast cancers may focally exhibita carcinoid-like differentiation." Anderson et al7doubted that all three features-that is, dense coregranules, neurone specific enolase, and Grimeliuspositivity were specific for endocrine cells in thebreast.The high percentage of argyrophilia in con-

ventional breast carcinomas found by Taxy et al hasnot been found by other workers. Azzopardi et al8found argyrophilia in 4-5% of 67 invasive breast car-cinomas. Partanen and Syrjanen2 reported a figure of3-3% for 90 adenocarcinomas and Fetisof etal3reported an incidence of 4-8% in 92 carcinomas.Azzopardi et at8 described 14 so called "carcinoid"

tumours of the breast, which had been tentativelyselected on their histological and cytological appear-ance and subsequently confirmed by Grimelius stain-ing. Four of these 14 tumours (28-5%) were theargyrophil type of ductal carcinoma in situ, five(35 7%) invasive ductal carcinoma, one (7-1%)invasive lobular carcinoma and the others were com-plex types. They concluded that "argyrophil carcino-mas" of the breast should be regarded as forming areasonably distinctive and relatively small group oftumours. As the so called "carcinoid tumour" hadbeen difficult to define in the breast in a more recentstudy9 the authors studied 30 consecutive cases of insitu carcinoma of the breast in an attempt to clarifythe complex problems entailed. Seven of the 30 cases(23 3%) were considered to be the entity of endocrinevariant of ductal carcinoma in situ identified byorganoid pattern, structural and cytological charac-teristics, argyrophilia, and ultrastructurally, by densecore granules. They regarded it as a variant of thesolid type of ductal carcinoma in situ, arising by div-ergent differentiation from ductal epithelium. Our

two cases represent further examples of this dis-tinctive newly recognised entity.

We are grateful to Professor J G Azzopardi for hishelp with the diagnosis of the first case and his generalhelpful advice. We thank consultant surgeons Mr BHaggart and Mr D Sykes for allowing us to publishdetails of their patients. We also thank Mr W Fellowsfor his help with electron microscopy and Mrs CeliaWallace for typing.

References

I Volger E. Ober das basilare Helle Zellen Organ der menschilichenBrustdruse. Klin Med (Musk) 1947;2:159-68.

2 Partanen S, Syrjanen K. Argyrophilic cells in carcinoma of thefemale breast. Virchow Arch (Pathol Anal) 1981;391:45-51.

3 Fetissof F, Dubois MP, et al. Argyrophilic cells in mammarycarcinoma. Hum Pathol 1983;14(2):127-34.

4 Bussolati G, Gugliotta P, Sapina A, Eusebi V, Lloyd RV.Chromogranin-reactive endocrine cells in argyrophilic carcino-mas ("carcinoids") and normal tissue of the breast. Am JPathol 1985;120(2):186-92.

5 Cubilla Al, Woodruff JM. Primary carcinoid tumour of thebreast: a report of eight patients. Am J Surg Pathol1977;4:283-92.

6 Taxy JB, Tischler AS, Insalaco SJ, Battifora H. "Carcinoid"tumours of the breast-a variant of conventional breastcancer? Hum Pathol 1981;12(2):170-79.

7 Anderson TJ, Battersby S, Ferguson DJP. Argyrophilic andendocrine cells in breast cancer. Histopathology 1985;9:1247-9.

8 Azzopardi JG, Muretto P, Goddeeris P, Eusebi V, LauwerynsJM. "Carcinoid" tumours of the breast: the morphologicalspectrum of argyrophil carcinomas.. Histopathology 1982;6:54969.

9 Cross AS, Azzopardi JG, Krausz T, Van Noorden S, Polak JM.A morphological and immunocytochemical study of adistinctive variant of ductal carcinoma in-situ of the breast.Histopathology 1985;9:21-37.

10 Kaneko H, Hojo H, Ishikawa S, Yamanouchi H, Sumida T, SaitoR. Norepinephrine-producing tumours of bilateral breasts:a case report. Cancer 1978;41:2002-7.

11 Fisher ER, Palekar AS, NSABP collaborators. Solid and mucin-ous varieties of so-called mammary carcinoid tumours. Am JClin Pathol 1979;72:909-16.

12 Devitt PG. Carcinoid tumour of the breast. Br MedJ 1978;II:327.

Requests for reprints to: Dr M T Haqqani, Department ofPathology, Walton Hospital, Rice Lane, Liverpool L9 IAE,England.

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