2020, Volume 36, Number 1, Page(s) 023-030
Metaplastic Carcinoma of the Breast: Analysis of 38 Cases from a Single Institute
Bermal HASBAY1, Filiz AKA BOLAT1, Hüseyin Özgür AYTAÇ2, Hülya ASLAN3, Ayşin PURBAGER3
1Department of Pathology, Başkent University, Dr. Turgut Noyan Application and Research Center, ADANA TURKEY
2Department of General Surgery, Başkent University, Dr. Turgut Noyan Application and Research Center, ADANA TURKEY
3Department of Radiology, Başkent University, Dr. Turgut Noyan Application and Research Center, ADANA TURKEY
Keywords: Metaplastic breast carcinoma, Survival, Immunohistochemistry
To evaluate the pathological and radiological features, hormone profiles, surgery and treatment methods of metaplastic breast
carcinoma cases diagnosed at our center in the light of current literature.
Material and Method: A total of 38 metaplastic breast cancer cases diagnosed between 2006-2018 at our center were included in the study.
The patients were evaluated in terms of age, tumor size, localization, histological grade, hormone profiles (ER, PR, Her2-neu), American Joint
Committee on Cancer (AJCC) Tumor, Lymph node status, Metastases (TNM) stage, progression, survival, radiological features, types of surgery
and therapy modalities (chemotherapy and / or radiotherapy).
Results: The age of the patients ranged between 32 and 95 years. Pathological evaluation of cases showed that 14 were pure epithelial (IC-NST
+ squamous cell carcinoma) and 24 were metaplastic carcinomas with mesenchymal differentiation. Ductal carcinoma in situ (DCIS) was
accompanying an invasive component in twenty cases. Seventeen patients had lymph node metastasis. Twelve patients developed distant
metastasis. Thirty patients were triple negative for hormone receptors. The mean follow-up period of the patients was 34 months. The estimated
life expectancy was 116 months. All of the patients received chemotherapy and 28 patients received adjuvant radiotherapy. There was no
correlation between tumor size and lymph node or distant metastasis in our series. Our findings are consistent with the literature.
Conclusion: Metaplastic breast carcinoma is a rare entity among breast carcinomas. Metaplastic carcinomas of the breast draw attention with the
differences in their clinical course and the radiological and pathological heterogeneity.
Metaplastic breast carcinoma (MBC) is a rare subtype and
accounts for 0.2% to 5% of all breast carcinomas 1,2
was first described as a mammary carcinoma with mixed
epithelial and sarcomatoid components by Huvos et al. in
. The current (2012) World Health Organization
(WHO) classification distinguishes five subtypes: low grade
adenosquamous carcinoma, fibromatosis-like metaplastic
carcinoma, spindle cell carcinoma, squamous cell
carcinoma, and metaplastic carcinoma with mesenchymal
differentiation (chondroid, osseous and other types of
mesenchymal differentiation) 2,4
MBC is a distinct group of breast cancer, in which
adenocarcinoma co-exists with a mixture of spindle cells
and squamous, chondroid or bone-forming neoplastic
cells, and differs from the classical invasive ductal or
lobular carcinoma regarding its incidence, pathogenesis
and prognosis 1,5. These non-adenocarcinoma elements
may be present as a microscopic foci or may dominate the histologic pattern 5. The molecular mechanism of
metaplastic carcinoma differs from other types of breast
carcinomas, including basal-like breast carcinomas 5,6.
It is suggested that upregulation of cancer stem cell (CSS)
and epithelial-mesenchymal transition (EMT) genes might
play a crucial role in the pathogenesis of MBC 1,5,7. EMT
activators and CSS present especially in the non-glandular
components of metaplastic carcinomas 8.
Due to its rarity, there is limited data correlating the imaging
features with clinical presentation and the histopathologic
features of MBC 9-11. Metaplastic cancers were
previously radiologically defined as benign lesions 9,10.
Metaplastic carcinomas radiologically demonstrate benign
features compared to invasive ductal carcinomas such as an
oval or rounded shape, circumscribed margins and lack of
malignant calcification 12.
MBC cases are typically negative for hormone receptors
and do not exhibit Her2-neu overexpression 1,13,14.
Even though MBC is similar to triple negative breast cancers (TNBC) for receptor status, its molecular features
are different and the clinical outcomes are even worse than
for TNBC 1,14.
The aim of this study was to evaluate metaplastic carcinoma,
a rare subtype of breast tumors, in terms of histopathological
features, hormone receptor status, radiological features and
A total of 38 MBC patients diagnosed between 2006 and
2018 at Baskent University Faculty of Medicine, Adana
Research Hospital were included in the study. Ethics
committee approval was received for this study from local
ethics committee. A 12-year electronic data search was
performed in the laboratory information system using
the keywords metaplastic carcinoma plus breast in
the diagnostic line. Thirty-eight cases met the criteria
based on pathology reports and/or review of slides. Cases
showing a metaplastic tumor component were included
in the study. The patients were evaluated retrospectively
for age, tumor size, tumor localization, histological grade,
hormone receptor status (ER, PR, Her2-neu), American
Joint Committee on Cancer (AJCC) Tumor, Lymph node
status, Metastases (TNM) stage, progression, recurrence,
survival, radiological features, surgery, and treatment
modalities (adjuvant, neoadjuvant: chemotherapy and / or
All of the cases were re-reviewed according to the 2012
WHO classification. Clinicopathological and demographic
features were evaluated in detail. The pathologic diagnosis
of MBC was made by two pathologists who were specialized
in breast pathology and the sonographic and MRI features
were assessed by two breast radiologists.
Immunohistochemical (IHC) assays were performed
using monoclonal antibodies against ER (Clone EP1, Code
M3643, Dako, Denmark) and PR (Clone Y85, 60-0056-7,
Genemed, Germany) and Her2-neu (Code A0485, Dako,
Denmark). ER and PR were prepared by taking positive
and negative control tissues and using ready-to-use
solutions in the Leica Bond Max device. We followed the
ASCO and CAP recommendations for reporting the results
of the IHC assays for ER, PR and Her2/neu. For ER and PR,
all cases with at least 1% positive cells were considered as
receptor positive 5,15. The Allred score, which combines
the percentage of positive cells and the intensity of the
reaction, was used for ER-PR evaluation 16.
Her2-neu status can be determined by assessing protein
expression on the membrane of tumor cells using IHC or
by assessing the number of Her2-neu gene copies using in situ hybridization (ISH). The results for Her2-neu testing
by IHC were reported according to the intensity and the
percentage of positive staining in tumor cells (0, 1+, 2+,
3+). Scores of 0 and 1+ were considered as negative for
Her 2-neu amplification. A score of 3+ was considered as
positive. A score of 2 was considered as equivocal and ISH
was ordered for confirmation. Her 2 was considered to be
amplified if the average Her2-neu copy number was ≥6
signals/cells or the Her2/CEP 17 ratio was ≥ 2 (5, 17).
Statistical analysis was performed using the SPSS statistical
package software (Version 17.0, SPSS Inc., Chicago, IL,
USA). For each continuous variable, normality was checked
by Shapiro-Wilk tests and by histograms. All numerical data
were expressed as median values (Minimum-Maximum)
or as proportions. Comparisons between groups were
evaluated using the Mann-Whitney U test and the Kruskal-
Wallis test was used for the data not normally distributed.
The association with overall survival was analyzed using
the Wald test and the log-rank test was used to examine
their relationship when different variables were applied.
The survival curve was plotted using standard Kaplan-
Written consent was not obtained from the patients since
the study was designed retrospectively and needed no
The age of the patients ranged from 32 to 95 years and
the mean age was 55.34 ± 14.08 years. The left breast was
involved in 22 of the 38 (57.9%) patients and the right
breast in 16 (42.1%). The mean tumor diameter was 4.48
± 2.53 cm (max. 11.5, min. 1.8 cm). Of the 38 cases, 7 were
dead, 31 were alive. The mean age of the surviving patients
was 53.74 ± 12.98 years (32-95) and the mean tumor size
was 4.46 (1.8-11.5) cm.
The estimated life expectancy of all patients was 116.3 ±
10.2 months (95% CI 96.3-136.3); 1-year survival 94.7%;
3-year survival 75%; 5-year survival 75%. While the
estimated mean life expectancy of those with a tumor size
≤ 3 cm was 107.7 ± 9.6 months (95% CI 88.9-126.5), for
those with a tumor size > 3 this was found to be 108.5 ±
11.1 months (95% CI 76.7-140.3) (p= 0.217 log-rang test)
(Figure 1). Therefore, tumor size below 3 cm or above 3 cm
had no effect on survival.
The mean age of the dead patients was 62.43 ± 17.57 years
(46-95) and their mean tumor size was 4 (3-5) cm. Tumor
histological grade was three for all patients. Eighteen of our
patients underwent a mastectomy, of which 15 had axillary dissection and three had sentinel lymph node biopsy
(SLNB). While one of the other 17 patients underwent
only segmental mastectomy, 16 patients had segmental
mastectomy and SLNB. A patient who was diagnosed
with metastatic axillary lymph node at the age of 95 had
only axillary lymph node sampling. Two patients were
diagnosed from paraffin blocks as consultation cases and
then were out of follow-up.
In the radiological examination of the patients, twentytwo
patients underwent ultrasound where seventeen had
malignant appearing solid masses, one had a mass of
suspected malignancy, three had well-defined solid masses
and one had an appearance compatible with mastitis.
Eighteen patients had mammograms and MRI, where
12 showed solid masses of malignant appearance with irregular margins, asymmetric opacity and intermittent
microcalcifications. In three cases with well-limited nodules
on ultrasound, MRI showed solid lesions suspicious for
Pathological results of the cases were as follows: pure epithelial
carcinoma (IC-NST + squamous cell carcinoma) in
14 cases, mesenchymal component metaplastic carcinoma
in 24 cases: (carcinoma including chondroosseous areas
(Figure 2), mixed carcinoma (two pleomorphic sarcoma,
one chondrosarcoma, one leiomyosarcoma), matrix-producing
type carcinoma (Figure 3) and carcinomas with
squamous and spindle cell areas cases). Ductal carcinoma
in situ was accompanying an invasive component in twenty
cases. Of these, the most common was the solid type, followed
by the comedo and cribriform types. Axillary lymph
nodes were observed to be benign in 18 of 35 patients (51%),
and metastatic in 17 of 35 (49%). Among those with metastatic
axillary nodes, 14 cases had pN1 and 3 cases had pN2.
In terms of pN, 1-year survival was 100% for pN0, 87.5%
for pN1, 66% for pN2 with a significant p value (0.009)
(Figure 4). Twelve patients developed distant metastasis.
Four patients had lung metastasis, two had supraclavicular
lymph node metastasis, one had mediastinal lymph node
metastasis, one had bone, liver and lung metastasis, two
had bone metastasis and one had brain metastasis. Mean
life expectancy of M0 (without metastasis) patients was
128.6 ± 9.9 months (95% CI 109.1-148.0) while the figure
for M1 (with metastasis) patients was 55.7 ± 10.8 month
(95% CI 34.6-76.9) (p = 0.077 log-rang test). In our series
of 38 cases, two patients had ER positive, one had ER and
PR positive, one had ER and Her2-neu positive, four had
only Her2-neu positive tumors and the remaining 30 had tumors negative for all receptors. A summary of the hormone
receptor profiles of the cases can be seen in Table I.
Click Here to Zoom
|Figure 2: Epithelial component and chondroosseous areas (arrows) (H&E; x200).
Click Here to Zoom
|Figure 4: Relationship between pathological node (pN) values
and survival (p= 0.009).
Mean follow-up period of patients was 34 months and
ranged between 4 and 147 months. Five of the patients who
died had pT2 and two had pTx tumors. All the patients
who had pT1c, pT3 and pT4 survived. A detailed summary
of dead patients is provided in Table II.
Among the patients that we followed-up, seven had
chemotherapy (CT); three had chemotherapy, radiotherapy
(RT) and Transtuzumab; two had CT, RT and Tamoxifen;
and 24 had CT and RT. As a result, all patients were treated
with CT, and 28 of them also received RT. When viewed
in terms of treatment, there was no difference in survival
between CT or CT+RT and the p value was 0.391. The
clinico-pathological characteristics of the 38 patients with
MBC are detailed in Table III.
Click Here to Zoom
|Table III: Clinico-pathological characteristics of 38 patients with MBC. [n (%)]
Metaplastic breast carcinoma has a poor prognosis and
is usually triple negative. MBC pathologically comprises
different histologic components of both epithelial and
mesenchymal origins 1,2
. It constitutes between 0.2% and
5% of all breast cancers and is generally observed in the
sixth decade of life 2
. The mean age of our patients was
54 years, which was consistent with the literature. Patients
with MBC usually present with large size, higher grade
and hormone receptor negative tumors 13,14
mean tumor size of our cases was 4.48 (1.8-11.5) cm, all of
them were histologically grade 3, and 79% had a negative
hormone profile. Three of the cases were pT1c, 20 were
pT2, four were pT3, and three were pT4. Another 7 patients
were evaluated as pTx because three of them were sampled
after chemotherapy, and four were diagnosed using
preformed archival paraffin blocks of different centers.
Even though MBC is usually reported to be an aggressive
tumor with fewer nodal metastases 1,14,
there are some
studies demonstrating a frequency of nodal metastases of
up to 21% to 64% 1,18,19
. In our series, 17 patients (49%)
had axillary lymph node metastasis which was consistent
with the literature. Thirteen of seventeen patients with
lymph node metastasis had pure epithelial component,
one patient had carcinosarcoma and three patients had
metaplastic carcinoma with mesenchymal differentiation.
Ductal carcinoma in situ may be visible adjacent to
metaplastic carcinoma at a rate of 11% to 65%. The presence
of DCIS strongly supports the diagnosis of metaplastic
carcinoma 20. In our series, 20 of 38 (52.14%) cases had
DCIS which was also consistent with the literature.
MBC is a heterogeneous disease with different subgroups.
According to the 2012 WHO classification, it is divided
into 5 groups: low grade adenosquamous carcinoma,
fibromatosislike metaplastic carcinoma, squamous cell
carcinoma, metaplastic carcinoma with mesenchymal
differentiation (chondroid, osseous, other types of
mesenchymal differentiation) and spindle cell carcinoma
2,4. We did not observe any low grade adenosquamous
carcinoma or fibromatosis-like metaplastic carcinoma in
Several hypotheses have been suggested for the
etiopathogenesis of MBC. The first one is the cancer
stem cell hypothesis, which describes the cells that have
the capacity to self-renew and differentiate into different
cell types 21,22. The carcinomatous and sarcomatous
components may develop from separate progenitor cells
or both components may develop from multipotential progenitor cells. One other theory is related to the changes
in the expression of membrane proteins involved in cell
polarity and in the tight linkage functions between cells
which is called ¨Claudin¨ 22.
Optimal treatment of MBC is in the same way as IC-NST.
Surgery is the main curative approach. Mastectomy or
breast conserving surgery have been the most commonly
performed procedures 23,24. All of the patients received
surgical treatment in our series. The most common surgical
procedure was the modified radical mastectomy, which
was performed in 18 patients. Seventeen patients had
breast conserving surgery. All of our patients were treated
with chemotherapy after surgery and 28 of them received
Hormonal therapy generally has no role in the management
of patients with MBC. There is a high incidence of
hormone receptor negativity as well as lower Her2-neu
overexpression in MBC. In our series of 38 patients, only
four were hormone positive and five were Her2-neu
positive, and the rest of them were negative hormone
receptors. Her2-neu overexpression rate has been variable
in the literature, between 2% and 26% 13,14,20,25. ER
positivity varies between 6% and 12% in various studies
20. In our series, only 5 of 38 (13%) cases had positive
Her2-neu and 4 of 38 (10.52%) cases had positive ER
which is also consistent with the literature. In the study of
Rakha et al., these three markers were more often positive
in squamous carcinomas 13. In our cases, all ER and
Her2-neu positive cases were metaplastic carcinomas with
squamous cell carcinoma (Table I). Tamoxifen was added
to the treatment of ER positive patients, and Transtuzumab
for Her2-neu positive patients.
The median follow-up for MBC patients was 34 (range
4-147) months. Among patients who developed distant
metastasis during follow-up, the lung was the most common
site as seen in four patients. Bone metastasis was seen in
two patients, supraclavicular lymph node involvement in
two patients, mediastinal lymph node metastasis in one
patient, both bone, liver and lung metastasis in one patient
and brain metastasis in one patient.
Diagnosis of MBC cannot rely on imaging features alone.
Core needle biopsy and aspiration cytology may aid in the
pre-operative diagnosis, but the probability of misdiagnosis
would increase in the presence of hemorrhage or necrosis
due to inadequate sampling or a poor choice of puncture
region 12,26. Excisional biopsy is the gold standard
without doubt and should be used in all patients prior to
If core biopsy shows the appearance of a pure malignant
mesenchymal tumor, this may be a primary malignant
mesenchymal tumor of the breast, a malignant phyllodes
tumor or a metaplastic carcinoma with mesenchymal
differentiation. Once the hematoxylin and eosin stained
slides are examined, a decisioni can be made as follows: If the
tumor was pure sarcomatoid, then it had to express at least
2 epithelial markers in the immunohistochemistry analysis
(cytokeratin 5/6, high molecular weight cytokeratin, P63,
pancytokeratin, CK7) for the diagnosis of MBC. According
to the histopathological appearance of the sarcomatoid
component, it is possible to add S-100, Smooth Muscle
Actin (SMA), CD68, Calponin, and Desmin. It is more
appropriate to provide a definite diagnosis on excisional
biopsy specimens. In the majority of cases, the transition
foci between MBC and IC-NST were only observed
following surgical biopsies 12,26. Metaplastic carcinoma
should also be considered when a spindle cell lesion is seen
on a breast tru-cut biopsy. Extensive sampling from the
surgical biopsy and an immunohistochemical examination
should therefore be performed to avoid misdiagnosis.
The differential diagnosis between MBC, sarcoma and
phylloides tumor is important as SLNB sampling is
mandatory for MBC, but not for others.
In conclusion, MBC is a rare entity among breast
carcinomas. It is an aggressive tumor that is more likely to
present with worse prognostic indicators such as tumor size
and stage. However, low-grade adenosquamous carcinoma
in this group has a good prognosis.
The diagnosis of MBC is difficult in some cases and requires
rigorous use of immunohistochemistry. Most of the cases
present with poor prognostic indicators and show lack of
expression of hormone receptors as well as Her2-neu. It
is evident that more studies are needed to understand the
true biologic potential of this tumor compared with other
forms of breast carcinoma. In conclusion, our findings are
consistent with the literature. Prospective multi-center
wide scale studies should be carried out in the future to cast
light on the clinical and pathologic aspects of MBC.
CONFLICT of INTEREST
No conflict of interest was declared by the authors.
The authors declared that this study has received no
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