Abstract
Recurrent hemorrhagic cyst is an uncommon presentation of breast disease. The ordinary imaging could not demonstrate the malignant features of the cyst. However, the non-contrast dedicated breast computerized tomography could support the malignancy concern. Although tissue diagnosis cannot show the malignant cell, Surgical excision could be offered without uncompromising. Eventually, ductal carcinoma in-situ was diagnosed and further adjuvant treatment could be given. We reported the first case report of ductal carcinoma in-situ, hypersecretory type, presented by a hemorrhagic cyst.
Keywords
Case Report
A 66-year old female came to our institution with right breast mass with the history of minor trauma. No familial history of breast cancer was found. The physical examination showed well-defined deep mass at upper part of the right breast. She had the first mammogram and ultrasound showed two benign cysts in the right breast. The second digital tomosynthesis found a circumscribed hyperdense lesion at upper mid part of the right breast with unremarkable skin, nipples and axillary lymph node. (Hologic Selenia Dimensions, MA, USA) The ultrasonography demonstrated increased size of a circumscribed lobulated cyst with low internal echo at right upper mid part, measured 4.1 × 2.5 × 2.5 cm. No internal vascularity is seen. The presented cyst was aspirated. The cytological result suggested old blood clot without malignant cell. The next visit was instructed in next 2 weeks. The mentioned cyst was disappeared. The imaging study was appointed in 6 months. The third digital tomosynthesis showed increased size of a circumscribed hyperdense lesion at right upper mid part. Additional ultrasonography showed increased size of a circumscribed lobulated cyst with low internal echogenicity, measured 4.3 × 2.6 × 3.5 cm without internal vascularity [Fig. 1]. Supplement breast computerized tomography (Koning V1.5) showed lobulated hyperdense mass at right upper mid part with ill-defined margin at lower inner aspect of the mass. The Hounsfield was measured 40-50HU which compatable to blood [Fig. 2]. Repeated aspiration was done with bloody content. The repeated cytological result showed no malignant cell. Eventually, surgical excision was offered.
The surgical specimen showed single lobulated partially thick-wall cyst with bloody and mucinous content, measured 7 × 5 × 2 cm [Fig. 3]. Grossly, it was dark brown surface without solid part containing. Nevertheless, the gross specimen showed partially thicken wall at lower part of the cyst which was corresponding to the breast computerized tomography findings [Fig. 3]. The histological examination showed dilated duct lined by epithelial proliferation. There were cribiform, micropapillary and solid-cystic with colloid-like secretion in the proliferation. The cystic cavity contained fluid, fibrin and old blood clot [Fig. 4]. The immunohistochemistry showed focal negative myosin, positive oestrogen receptor (60%) and negative progesterone receptor [Fig. 4]. That was compatible to ductal carcinoma in-situ, cystic hypersecretory type. Accordingly, the adjuvant whole breast radiotherapy and antihormonal treatment were prescribed.
Discussion
Cystic breast lesions are a common breast disease. They range from benign cyst to invasive carcinoma. Breast cysts are frequently presented in premenopausal women. The postmenopausal women should be suspicious for non-benign causes. A gross breast cyst is including secretory cyst and transudative cyst. The secretory cyst is theoretically promoting atypical morphology [1]. The ultrasonography is the preferable device to distinguish cystic lesions. Simple cysts should be anechoic, resembling a black hole with an imperceptible circumscribed border, round or oval shape and posterior enhancement. While complicated cysts describe the alteration of echogenicity appearing of the intracystic content. The cyst with septation, complex cyst and intracystic mass described cyst with internal septation or mass that is demonstrated 22–30% risk of malignancy. The management of benign cyst and complicated cyst is according with BIRADS 2–3 [1,2].
Hemorrhagic cyst is not a pathognomonic sign of malignancy; nevertheless, mammary carcinoma should be highly concerned. Accordingly, malignant histological features presented as hemorrhagic cyst are including intracystic papillary carcinoma with or without invasion, ductal carcinoma with cystic degeneration, medullary carcinoma, squamous carcinoma and cystic hypersecretory intraductal carcinoma [3]. The prognosis is heterogenous. Intracystic papillary carcinoma is good. Meanwhile, high-grade ductal carcinoma with cystic degeneration is poor [4]. The previous report suggested cystic lesion with solid nodules and presence of residual mass after aspiration are strongly suspicious characteristics [5]. Other mistrustful situation is the short interval relapsed cyst [6]. Ultrasonography and cytology should be the initial diagnostic procedure. However, the cytology showed considerable false negative rate in some institution. Thus, core needle biopsy is substituted. Eventually, surgical excision is not inevitable [5].
Cystic hypersecretory lesions range from benign cystic hypersecretory hyperplasia to malignant cystic hypersecretory duct carcinoma. Ductal carcinoma in situ with cystic hypersecretory type is uncommon [7,8]. It is low-grade biology behavior. Conversely, the previous report showed highly aggressive case when invasive part is presented [8]. It grossly characterized as a combination of dilated ducts and cysts filled with a colloid-like secretion. Histological features are including cystically dilated ducts line by a mixture of benign, hyperplastic and malignant epithelium with micropapillary and cribiform-type arrangement. Moreover, the cells contain vacuolated cytoplasm reminiscent of lactating epithelium and stain positively for mucin that is consistent with secretory-type material. Underdiagnosis is not impossible. Ultrasonography is indistinguishable from fibrocystic disease. Cysts with papillary content or solid component are occasionally demonstrated. Because of various component of the lesion, tissue sampling is often questionable. Nonetheless, cytology showed atypical cells and colloid like secretion is helpful. Therefore, the level of suspicion and clinical judgment are very important. Treatment is including surgical removal and adjuvant radiation [8–10].
Conclusion
Recurrent hemorrhagic cyst increases the malignant concern. The attempt to showed malignant features by multimodality of breast imaging is important in unusual cases. Nonetheless, a discordant feature or recurrent enlarge hemorrhagic cyst could be indicated a surgical removal. Finally, ductal carcinoma in-situ should be a differential diagnosis in the presentation of hemorrhagic cysts.