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CASE PRESENTATION
BY
Salma Tarek Mahmoud
Assistant Fellow at Ahmed Maher Teaching Hospital
A 22 ys old female patient complaining
of left breast mass.
 Excision was done

Gross examination
•A fairly

defined rubbery mass measured
10x7x7 mm.
•Cut section was homogenous grayish white
Microscopic examination
PAS staining was done
Cytokeratin
c
Diagnosis
Granular cell tumor
Granular cell tumor( GCTs)
Uncommon tumor thought to be derived from
schwann cells.
 Abrikossoff first described this tumour in 1926 as
‘‘granular cell myoblastoma’’, assuming it was of
myogenic origin; some even refer to the lesion as
‘‘Abrikossoffoma’’.
 Considered benign, only rare reports of malignant
variants
Incidence
 Occur in any age but are most common in
fourth, fifth and sixth decades of life, rare in
children.
 It is about twice as common in women as in men.

Site


Arise in any organ as solitary painless nodule



Most frequently in oral cavity typically the tongue



Internal organs, particularly larynx, bronchus, stomach
and bile duct.

Clinically


Approximately 10–15% of patients have lesions at
multiple sites.



Multiple lesions may appear synchronously or over a
period of many years.

Gross picture



Poorly circumscribed nodule less than 3 cm
Cut section pale yellow-tan or gray.
Microscopically








Infiltrating compact
nests or sheets
Bland looking large
polygonal to spindle
cells
Eosinophilic
cytoplasmic granules
Nuclei are small dark
monotypic
+/- vacoulization and
clearing


Pseudoepitheliomatous
hyperplasia of the overlying
squamous epithelium, should
not be mistaken for squamous
cell carcinoma.



In close proximity to peripheral
nerve bundles
Special Stains and
Immunohistochemistry










S-100 protein: highlights cytoplasmic
granularity with strong cytoplasmic and
nuclear staining
Carcinoembryonic antigen (CEA): diffuse
immunoreactivity
Cytokeratin and (EMA) are negative
Myoglobin negative
(ER) and (PR) are negative
PAS positive diastease resistant cytoplasmic
granules
GCTs in breast
Incidence
 5%- 6% in breast.
 Premenopausal women in 40’s, reported in
adolescents, elderly women and men
 May be more common in African-American women
Site
 Superior medial quadrant (course of supraclavicular nerve)
Clinical features
 Usually solitary unilateral, rarely multiple
 Painless firm mass, may be associated with skin
retraction and nipple inversion
Gross
 Cut surface is fairly
defined white - gray to
yellow
 Less than 3 cm but
reported up to 9 cm.
Radiologically
X-ray
 Mammography
Suggestive of
malignancy due
to apparent
infiltration, stellate
mass without
calcification

Differential Diagnosis
D.D
Reactive

histocytic lesion
Invasive breast carcinoma
 Apocrine carcinoma
 Myoblastomatoid, Lobular carcinoma
histocytic variant
Alveolar soft part sarcoma
Metastatic malignant melanoma
Metastatic renal cell carcinoma
Reactive Histocytic lesions


Dispersed
histocytes with
mixed population of
inflammatory cells
Apocrine carcinoma







Older age
Usually in outer
quadrant
large cells with
pleomorphic nuclei,
prominent nucleoli,
mitosis
Typically associated with
intra-ductal component
IHC: Positive for
cytokeratin, GCDFP-15
Myoblastomatoid invasive lobular
carcinoma, histocytic variant
Older age
 Associated with
infiltrative
component
 Loosely cohesive
tumor cells
 IHC: Positive for
cytokeratin

Alveolar soft part sarcoma
•
•

•

•
•
•

Deep soft tissue
Pleomorphic cells
Cells are divided into
packets by thin walled
vessels
Alveolar pattern if cells
discohesive
Vascular invasion
common
IHC: Positive for
Myoglobin
Metastatic malignant melanoma
Old age
 History of primary
elsewhere
 Nuclei usually show




nucleoli
 Cytoplasmic pseudoinclusions
 Melanin pigments

IHC: Positive HMB- 45
Metastatic renal cell tumor









History of primary
elsewhere
Nests, separeted by
sinasoids
Well defined cell
membrane
Nuclear
pleomorphism
Prominent nucleoli in
high grades
Clearing of
cytoplasm
IHC: positive for
EMA
Take home message










GCTs is an uncommon tumor occur in any age.
5%-6% incidence in breast, inner upper quadrant.
Pose a real diagnostic challenge for physicians.
Clinically and radiologically misdiagnosed as carcinoma
Preoperative diagnosis with core needle biopsy is
important because treatment is with wide excision , rather
than mastectomy.
Less than 1% of all GCTs, including mammary
lesions, are malignant.
The prognosis for benign GCT of the breast is excellent.
Recurrence occurs in 2-8% of individuals after excision
with wide margins
A case of granular cell tumor

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A case of granular cell tumor

  • 1. CASE PRESENTATION BY Salma Tarek Mahmoud Assistant Fellow at Ahmed Maher Teaching Hospital
  • 2. A 22 ys old female patient complaining of left breast mass.  Excision was done 
  • 3. Gross examination •A fairly defined rubbery mass measured 10x7x7 mm. •Cut section was homogenous grayish white
  • 5.
  • 6.
  • 7.
  • 9.
  • 11. c
  • 12.
  • 14. Granular cell tumor( GCTs) Uncommon tumor thought to be derived from schwann cells.  Abrikossoff first described this tumour in 1926 as ‘‘granular cell myoblastoma’’, assuming it was of myogenic origin; some even refer to the lesion as ‘‘Abrikossoffoma’’.  Considered benign, only rare reports of malignant variants Incidence  Occur in any age but are most common in fourth, fifth and sixth decades of life, rare in children.  It is about twice as common in women as in men. 
  • 15. Site  Arise in any organ as solitary painless nodule  Most frequently in oral cavity typically the tongue  Internal organs, particularly larynx, bronchus, stomach and bile duct. Clinically  Approximately 10–15% of patients have lesions at multiple sites.  Multiple lesions may appear synchronously or over a period of many years. Gross picture   Poorly circumscribed nodule less than 3 cm Cut section pale yellow-tan or gray.
  • 16. Microscopically      Infiltrating compact nests or sheets Bland looking large polygonal to spindle cells Eosinophilic cytoplasmic granules Nuclei are small dark monotypic +/- vacoulization and clearing
  • 17.  Pseudoepitheliomatous hyperplasia of the overlying squamous epithelium, should not be mistaken for squamous cell carcinoma.  In close proximity to peripheral nerve bundles
  • 18. Special Stains and Immunohistochemistry       S-100 protein: highlights cytoplasmic granularity with strong cytoplasmic and nuclear staining Carcinoembryonic antigen (CEA): diffuse immunoreactivity Cytokeratin and (EMA) are negative Myoglobin negative (ER) and (PR) are negative PAS positive diastease resistant cytoplasmic granules
  • 19.
  • 20. GCTs in breast Incidence  5%- 6% in breast.  Premenopausal women in 40’s, reported in adolescents, elderly women and men  May be more common in African-American women Site  Superior medial quadrant (course of supraclavicular nerve) Clinical features  Usually solitary unilateral, rarely multiple  Painless firm mass, may be associated with skin retraction and nipple inversion
  • 21. Gross  Cut surface is fairly defined white - gray to yellow  Less than 3 cm but reported up to 9 cm.
  • 22. Radiologically X-ray  Mammography Suggestive of malignancy due to apparent infiltration, stellate mass without calcification 
  • 24. D.D Reactive histocytic lesion Invasive breast carcinoma  Apocrine carcinoma  Myoblastomatoid, Lobular carcinoma histocytic variant Alveolar soft part sarcoma Metastatic malignant melanoma Metastatic renal cell carcinoma
  • 25. Reactive Histocytic lesions  Dispersed histocytes with mixed population of inflammatory cells
  • 26. Apocrine carcinoma      Older age Usually in outer quadrant large cells with pleomorphic nuclei, prominent nucleoli, mitosis Typically associated with intra-ductal component IHC: Positive for cytokeratin, GCDFP-15
  • 27. Myoblastomatoid invasive lobular carcinoma, histocytic variant Older age  Associated with infiltrative component  Loosely cohesive tumor cells  IHC: Positive for cytokeratin 
  • 28. Alveolar soft part sarcoma • • • • • • Deep soft tissue Pleomorphic cells Cells are divided into packets by thin walled vessels Alveolar pattern if cells discohesive Vascular invasion common IHC: Positive for Myoglobin
  • 29. Metastatic malignant melanoma Old age  History of primary elsewhere  Nuclei usually show   nucleoli  Cytoplasmic pseudoinclusions  Melanin pigments IHC: Positive HMB- 45
  • 30. Metastatic renal cell tumor        History of primary elsewhere Nests, separeted by sinasoids Well defined cell membrane Nuclear pleomorphism Prominent nucleoli in high grades Clearing of cytoplasm IHC: positive for EMA
  • 31.
  • 32.
  • 33.
  • 34. Take home message         GCTs is an uncommon tumor occur in any age. 5%-6% incidence in breast, inner upper quadrant. Pose a real diagnostic challenge for physicians. Clinically and radiologically misdiagnosed as carcinoma Preoperative diagnosis with core needle biopsy is important because treatment is with wide excision , rather than mastectomy. Less than 1% of all GCTs, including mammary lesions, are malignant. The prognosis for benign GCT of the breast is excellent. Recurrence occurs in 2-8% of individuals after excision with wide margins

Editor's Notes

  1. Gross Cystic Disease Fluid Protein 15