A Case of Estrogen Receptor Positive Secretory Carcinoma in a 9 ...

Case Report
A Case of Estrogen Receptor Positive Secretory Carcinoma
in a 9-Year-old Girl With ETV6–NTRK3 Fusion Gene
Kyoko Yorozuya 1,* , Emiko Takahashi 2 , Junko Kousaka 1 , Yukako Mouri 1 , Miwa Yoshida 1 , Kimihito Fujii 1 ,
Miwa Akizuki 1 , Shogo Nakano 1 , Takashi Fukutomi 1 , Yasutaka Umemoto 3 , Toyoharu Yokoi 2 and Hiroshi Imai 4
1 Division of Breast and Endocrine Surgery, Department of Surgery, Aichi Medical University, 2 Pathology Division,
Division of Breast and Endocrine Surgery, Aichi Medical University, 3 Division of Breast and Endocrine Surgery,
Department of Plastic Surgery, Aichi Medical University, Aichi and 4 Pathology Division, Mie University Hospital,
Tsu, Mie, Japan
*For reprints and all correspondence: Kyoko Yorozuya, Division of Breast and Endocrine Surgery, Department
of Surgery, Aichi Medical University, 21 Yazako-Karimata, Nagakute-cho, Aichi-gun, Aichi 480-1195, Japan.
E-mail: kyorozuya@green.ocn.ne.jp
Received May 30, 2011; accepted November 26, 2011
INTRODUCTION
Japanese Journal of Clinical Oncology Advance Access published December 29, 2011
The patient was a 9-year-old premenarcheal pediatric female, whose chief complaint was a
well-circumscribed palpable right breast mass without nipple discharge. Although the patient
had noticed the lump 2 years prior to hospital admission, its size (1.5 1.3 cm) had been
stable. There was no family history or previous history of malignancies. Physical examination
showed a well-delimited, elastic-firm and movable tumor just beneath the nipple and areolar
complex. Regional lymph nodes were not palpable. Ultrasonography and breast computed
tomography revealed a subareolar oval-shaped tumor exhibiting homogeneous echogenicity
with clear margins. Distant metastases could not be detected using whole-body computed
tomographic scans. A fine-needle aspiration cytology specimen showed atypical cells with
prominent nucleoli and abundant intracellular secretory material, suggesting the possibility of
secretory carcinoma. Histopathological analysis of the core needle biopsy specimen revealed
that the tumor was a secretory carcinoma. The patient underwent total mastectomy with sentinel
lymph node biopsy. Metastases were not observed in the removed lymph nodes.
Estrogen receptor was weakly positive and progesterone receptor was negative. Human epidermal
growth factor receptor 2 expression was also negative. In addition, the ETV6 (exon 5)
and NTRK3 (exon 13) fusion gene was detected using the reverse transcription–polymerase
chain reaction method. This gene is considered specific for secretory carcinoma.
Immunohistochemistry revealed weak basal differentiation [cytokeratin 5/6(CK5/6)(þ),
vimentin(þ) and epidermal growth factor receptor(þ)]. The patient has received no adjuvant
therapy and is currently disease free at 12 months after surgery.
Key words: juvenile breast cancer – secretory carcinoma – estrogen receptor – ETV6–NTRK3
fusion gene – basal marker
Breast cancer is extremely rare in children and adolescents. It
has been reported to comprise ,0.1% of breast cancers and
,1% of pediatric cancers (1–3). Secretory carcinoma (SC)
occurs with an incidence of 0.1–0.3% of all breast cancers.
Although SC is known to occur more frequently in adults, the
Jpn J Clin Oncol 2011
doi:10.1093/jjco/hyr187
majority of breast cancers in the pediatric population are SC
(4). The typical genomic profile of SC involves the harboring
of the ETV6–NTRK3 fusion gene (5,6). Immunohistological
examination has revealed that SCs frequently show triplenegative
features and basal-like differentiation (7). We herein
report on a case involving a 9-year-old girl with SC which
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Page 2 of 4 Secretory carcinoma in a 9-year-old girl
Figure 1. (a) Tumor section showing neoplastic cells with abundant clear intracytoplasmic material those present in glands and nests. (b)
Immunohistochemically stained tumor section. More than 10% of the tumor cells show expression of estrogen receptor in nuclei (SP1, Predilute: Roche).
had an ETV6–NRK3 fusion gene with weak basal-like differentiation,
who underwent mastectomy with sentinel node
biopsy. In children with clinically node-negative breast
cancer, we believe that fine-needle aspiration cytology
(FNAC) is needed, even if the lesion appears to be benign,
and that to avoid life-long complications, sentinel node
biopsy is an appropriate alternative to axillary dissection.
CASE REPORT
The patient was a 9-year-old premenarcheal pediatric female,
whose principal complaint was a well-circumscribed palpable
right breast mass. The lump had been noticed by the patient 2
years previously and its size had been stable. There was no
prior or family history of malignancies. The patient’s development
was normal for her age. Physical examination showed
a well-delimited, elastic-firm and movable tumor just beneath
the nipple and areolar complex. Nipple discharge or retraction
was not observed. The patient did not feel spontaneous pain
but felt tenderness at the lesion. The size of the tumor was
1.5 1.3 cm and it was not fixed to the muscle. The axillary
or supraclavicular lymph node was not palpable. The left
breast was unremarkable. Ultrasonography revealed a subareolar
oval-shaped tumor showing homogeneous echogenicity
with clear margins (15.9 13.9 mm in size). The ultrasonographic
findings related to the tumor were defined as
Category 3b (8). The lactiferous duct or mammary gland was
not observed. Mammography depicted the tumor as a partially
lobulated mass. The margin of the mass was almost clear.
Breast computed tomographic (CT) scans showed a homogeneously
enhanced lesion (17 16 mm in size) with a clear
margin. Regional lymph nodes or distant metastases were not
detected by whole-body CT scans. The aspiration specimen
taken from the lesion showed atypical cells with prominent
nucleoli and abundant intracellular secretory material, suggesting
that the tumor was possibly an SC. A core needle
biopsy (CNB) specimen revealed that the neoplastic cells
formed glands and nests with abundant clear intracytoplasmic
material, which was positive for the periodic acid Schiff
(PAS) reaction. The background of the lesion was associated
with prominent hyalinized fibrous tissue. Another characteristic
feature was the presence of extracellular Alcian bluepositive
secretory mucosubstance. The patient was subsequently
given a definitive diagnosis of SC (T1N0M0 Stage I).
Using mammography, we confirmed that the extent of the
patient’s mammary gland was comparable with that of adults.
She underwent total mastectomy with sentinel lymph node
biopsy by means of a double-mapping method. Total mastectomy
was performed in an identical manner to that for adults.
We removed two hot nodes as sentinel nodes and two swollen
lymph nodes which were adjacent to the sentinel nodes.
The initial diagnosis of the tumor using FNAC and CNB
wasconfirmedonpermanenthistopathological examination
(Fig. 1a). The lesion was surrounded by a thick wall and its
margin status was negative. Metastases were not observed in
the sentinel lymph nodes and two adjacent nodes. The
estrogen receptor (ER) was weakly positive (Fig. 1b) and the
progesterone receptor was negative. Human epidermal
growth factor receptor 2 (HER-2) expression was also negative.
Immunohistochemistry revealed weak basal differentiation
[CK5/6(þ), vimentin(þ) and epidermal growth factor
receptor (EGFR) (þ)] (Fig. 2a–c). The antibodies that we
used were as follows: anti-ER (SP1, Predilute: Roche, Basal,
Switzerland); anti-PgR (1E2, Predilute: Roche); anti-Her2
(Rabbit polyclonal 1:300: Dako, Carpinteria, CA, USA);
anti-CK5/6 (D5/16B4, 1:100: Dako); anti-vimentin (V9,
1:100: Dako); anti-EGFR (EGFR25, 1:50: Leica
Microsystems, Bannockburn, IL, USA).
In order to confirm the diagnosis, we needed to detect the
ETV6 (exon 5) and NTRK3 (exon 13) fusion gene
t(12;15)(p13;q25) of 511 bp using the reverse transcription–
polymerase chain reaction (RT–PCR) method. This gene is
specific to SC. We extracted total RNA from snap-frozen
tissue. PCR was carried out to amplify the ETV–NTRK3
fusion gene using 5 0 -TCCTCCGAGTCCCACCCGAAG-3 0 as
a forward primer and 5 0 -CATCGCCGCACACTCCATA
GAA-3 0 as a reverse primer. We detected the PCR products
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Figure 2. Immunohistochemically stained tumor section showing weak basal differentiation (a) CK5/6(þ) (D5/16B4, Dako), (b) vimentin(þ) (V9, Dako) and
(c) EGFR(þ) (EGFR25, Leica Microsystems). EGFR, epidermal growth factor receptor.
Figure 3. (a) Tumor section showing polymerase chain reaction (PCR) products. PCR products of 511 bp can be seen between the marker fragments of 400
and 600 bp. The presence of the ETV6–NTRK3 fusion gene was confirmed using agarose gel electrophoresis (lane 1, size marker; lane 2, current case). (b)
Direct sequencing revealed fusion of ETV6 (exon 5) and NTRK3 (exon 13) using Big Dye Terminator ver. 3.1.
of 511 bp using agarose gel electrophoresis. PCR products of
511 bp can be seen between the marker fragments of 400
and 600 bp (Fig. 3a). We then confirmed the PCR product as
the fusion of the ETV6 (exon 5) and NTRK3 (exon 13)
genes by direct sequence using Big Dye Terminator ver. 3.1
(Life Technologies Japan, Tokyo, Japan) (Fig. 3b).
The patient received no adjuvant therapy including radiotherapy
and is currently disease free at 12 months after
surgery. Genetic testing was not performed because her
mother refused permission. The parents have discussed the
timing of plastic surgery with us. We are planning two
future plastic surgeries, the first during the patient’s adolescence
and the second at adulthood. We intend to follow the
patient up for at least 20 years.
DISCUSSION
Age is an important factor in the diagnosis and management
of breast tumors. The majority of breast masses in children,
such as fibroadenoma in girls and gynecomastia in boys, are
Jpn J Clin Oncol 2011 Page 3 of 4
benign. Murphy et al. (9) reported that the average age of
children with primary breast cancer was 11 years, with a
range of 3–19 years. Tanimura and Konaka documented
breast cancer in a 5-year-old Japanese girl (10).
Approximately 80% of breast cancers in children are SC
(10). Age at presentation with SC varies from 3 to 87 years
(11,12). The present patient was one of the youngest SC
cases reported in Japan. SC is often located near the areola
and has an indolent clinical course. One of the characteristic
biological features of juvenile SC is negative hormone
receptor status, suggesting that this type of tumor is not
influenced by sex hormones in juvenile patients (9,13,14).
ER-positive cases have been reported in invasive ductal
carcinoma and invasive lobular carcinoma (14). However,
the majority of SCs tend to be ER- and PR- negative and do
not show HER-2 overexpression (15). The present case
exhibited weakly positive ER expression, although the
patient had not gone through menarche. The association
between sex hormones and juvenile SCs should be investigated
in the future. Typical pathologic features for this
cancer have been reported previously (14). In the present
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Page 4 of 4 Secretory carcinoma in a 9-year-old girl
study, immunohistochemistry revealed weak basal differentiation
in SC and that the lesion was positive for CK5/6,
vimentin and EGFR. These are considered typical genomic
features of SC (5–7). The ETV6 (exon 5) and NTRK3 (exon
13) fusion gene was detected using the RT–PCR method,
which is considered specific for SC. Richard et al. (16) conducted
a literature review of 33 reported cases with
follow-up in adult females and reported that 33% of the
patients who underwent less extensive treatment than simple
mastectomy demonstrated local recurrence.
Juvenile SC usually follows a favorable prognosis. The
overall incidence of axillary lymph node infiltration is
around 30% in children and adults regardless of gender
(16,17). Although lymph node metastases are rarely observed
in female patients with SC tumors of ,2 cmindiameter,
nodal metastases might occur more frequently in male
patients with smaller tumors (18). Axillary metastases rarely
involve more than three lymph nodes (19). Lymphedema,
which is a serious life-long problem, occurs in 6–30% of
the patients treated by axillary dissection (17,20). Sentinel
node biopsy procedures have been successfully applied in a
few cases of juvenile SC (10,14). Even though there are
currently no data on sentinel node biopsy followed by
back-up axillary dissection in children, it is likely that
sentinel node biopsy would be a valuable tool for breast
cancer, just like it is in adults. Post-operative radiotherapy
(17,21) and adjuvant chemotherapy (21,22) have been used
on at least two occasions. However, there is at present insufficient
evidence to recommend either approach in the
management of SC (23). Post-operative radiotherapy is not
advised for children due to possible secondary effects such
as fibrosis of the lung, rib damage and the consequent asymmetry
of the rib cage (3,22).
Adverse prognostic features previously reported were
tumors that were larger than 2 cm in diameter, lack of gross
circumscription and infiltrative margins (16).
Recurrencehasbeenreportedtooccuratupto20years
after the initial treatment (24). Thus, it is desirable to follow
juvenile patients with SC over at least this time period (24).
Distant metastases from SC are extremely rare and only five
cases have been reported (23).
In conclusion, even though breast cancer is extremely rare
in children and adolescents, it is important to confirm the
pathology of the breast tumors that are found.
Immunohistological examination demonstrated that ER was
weakly positive in the tumor of the case involved in our
study. It did not exhibit pathological features that are typical
of SC. However, it was possible using the RT–PCR method
and direct sequencing to diagnose the tumor as SC, due to
detection of the ETV6 (exon 5) and NTRK3 (exon 13)
fusion gene which is considered to be specific to SC.
Conflict of interest statement
None declared.
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