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LETTER TO THE EDITOR
Year : 2015  |  Volume : 52  |  Issue : 4  |  Page : 535-536
 

Pathological examination after neoadjuvant chemotherapy (breast carcinoma): A diagnostic challenge in surgical pathology


Department of Pathology, Lady Hardinge Medical College and Associated Hospitals, New Delhi, India

Date of Web Publication10-Mar-2016

Correspondence Address:
Meenu Pujani
Department of Pathology, Lady Hardinge Medical College and Associated Hospitals, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-509X.178415

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How to cite this article:
Pujani M, Agarwal S, Madan NK. Pathological examination after neoadjuvant chemotherapy (breast carcinoma): A diagnostic challenge in surgical pathology. Indian J Cancer 2015;52:535-6

How to cite this URL:
Pujani M, Agarwal S, Madan NK. Pathological examination after neoadjuvant chemotherapy (breast carcinoma): A diagnostic challenge in surgical pathology. Indian J Cancer [serial online] 2015 [cited 2019 Dec 9];52:535-6. Available from: http://www.indianjcancer.com/text.asp?2015/52/4/535/178415


Sir,

Neoadjuvant chemotherapy (NAT), also called pre-operative chemotherapy, is becoming an increasingly popular integral component of the multimodality treatment of breast carcinoma. Commonly used chemotherapy regimens include fluorouracil, doxorubicin, and cyclophosphamide (FAC), doxorubicin and cyclophosphamide (AC), and regimens that incorporate a taxane (paclitaxel/docetaxel) either sequentially or in combination with an anthracycline. It provides several advantages such as providing the earliest possible treatment against preexisting micrometastasis, helping in subsequent breast conservation, and allowing assessment of disease response, which can be used to customize future chemotherapy.

We describe a case of a 55-year-old woman who presented with a right breast mass (6 × 5 cm) of 4 months duration. Fine needle aspiration cytology revealed features consistent with ductal carcinoma, breast. A tru-cut biopsy was performed that showed features of invasive duct carcinoma, Not otherwise specified (NOS) type, which was negative for Estrogen Receptor (ER), Progesterone Receptor (PR), and Her2-neu. Patient received 3 cycles of CAF-based chemotherapy following which there was a significant reduction in tumor size. A mastectomy with right axillary dissection was performed. Specimen received measured 19 × 10 × 3.5 cm. On giving serial sections, no grossly evident tumor mass was identified and only vague fibroelastotic streaks were seen. Multiple histologic sections were taken from the site of primary tumor to detect any residual tumor and to assess chemotherapy-induced changes. These sections revealed microscopic foci of residual tumor cells showing cytomorphologic changes induced by chemotherapy. Residual tumor cells were seen scattered singly as well as lying in small clusters in a dense fibrotic stroma [Figure 1]. Periductal elastosis and microcalcification was noted [Figure 1] and [Figure 2]. Individual cells showed cellular enlargement, cytoplasmic vacuolization, nuclear clumping, prominent nucleoli, and formation of giant cells [Figure 3]. Axillary lymph nodes dissected showed presence of foreign body giant cell reaction.
Figure 1: Periductal elastosis and singly scattered malignant cells in dense fibrotic stroma (H and E, x40)

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Figure 2: Tissue section showing a duct with microcalcification (H and E, x40)

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Figure 3: Malignant cell with cytoplasmic vacuolization, nuclear enlargement, chromatin clumping, and prominent nucleoli (H and E, x100)

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Clinical and radiologic evaluation of response to NAT is performed; however, pathologic evaluation of tumor size remains the gold standard for evaluation of residual tumor after chemotherapy. The current assessment of response to NAT includes four categories of clinical response: Complete response is defined as complete resolution of the entire tumor by physical examination and imaging; partial response is defined as incomplete tumor diameter reduction of >50%; stable disease as tumor diameter reduction of <50%; and progressive disease as an increase in tumor diameter.[1] Pathologic complete response (pCR) is defined as complete absence of invasive tumor seen in 3-30% of patients after NAT.[2]

In the post-treatment resection specimens, the size of the tumor may be reduced drastically to the limit that the tumor bed might be replaced by dense, fibrotic streaks. A reduction in tumor cellularity from a median of 40% in core needle as complete absence of invasive tumor seen in 3-30% of patients after NAT.[2]

In the post-treatment resection specimens, the size of the tumor may be reduced drastically to the limit that the tumor bed might be replaced by dense, fibrotic streaks. A reduction in tumor cellularity from a median of 40% in core needle biopsy to 10% in resection specimens is observed.[2] The most consistent and commonly encountered cytomorphologic change was seen to be cytoplasmic vacuolization.[3],[4] Other cytopathic changes include cellular enlargement, chromatin clumping, nuclear vacuolization, meganucleoli, apocrine and squamoid appearance, and formation of giant cells.[1] Histopathologic changes in benign breast parenchyma include fibrosis and increased vascularity of the tumor bed which is characterized microscopically by an area of hyalinized vascular stroma with edema, fibrosis, elastosis, and shows infiltration by foamy macrophages and lymphocytes.[5] Fibrosis and hyalinization are prominent in the subcapsular region of lymph nodes around which metastatic deposits are commonly found. Occasionally, residual tumor cells might be mistaken for reactive histiocytes, and immunostains for cytokeratin and epithelial membrane antigen might be useful in their distinction.[6] Cytological effect of treatment resulting in change in grade of carcinoma has not been clearly correlated with clinical outcome and it is not yet known whether it acts as a prognostic marker.[5] Chemotherapy is widely used in the treatment of early and locally advanced breast cancer. Familiarity with chemotherapy-induced changes in breast tissue and lymph node is of considerable importance in the accurate interpretation of these specimens.

 
  References Top

1.
Rajan R, Esteva FJ, Symmans WF. Pathologic changes in breast cancer following neoadjuvant chemotherapy: Implications for assessment of response. Clin Breast Cancer 2004;5:235-8.  Back to cited text no. 1
    
2.
Rajan R, Poniecka A, Smith TL, Yang Y, Frye D, Pusztai L, et al. Change in tumor cellularity of breast carcinoma after neoadjuvant chemotherapy as a variable in the pathologic assessment of response. Cancer 2004;100:1365-73.  Back to cited text no. 2
    
3.
Aktepe F, Kapucuoglu N, Pak I. The effect of chemotherapy on breast cancer tissue in locally advanced breast cancer. Histopathology 1996;29:63-7.  Back to cited text no. 3
    
4.
Moll UM, Chumas J. Morphologic effects of neoadjuvant chemotherapy in locally advanced breast cancer. Pathol Res Pract 1997;193:187-96.  Back to cited text no. 4
    
5.
Sahoo S, Lester SC. Pathology of breast carcinoma after neoadjuvant chemotherapy: An overview with recommendations on specimen processing and reporting. Arch Pathol Lab Med 2009;133:633-42.  Back to cited text no. 5
    
6.
Gupta R, Arora R, Sharma A, Dinda AK. Chemotherapy induced cytomorphologic changes in breast carcinoma: A potential diagnostic challenge for histopathologist. Indian J Pathol Microbiol 2009;52:583-5.  Back to cited text no. 6
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