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Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."
Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011
Dr. Shankar P.R.
"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."
Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011 Anuradha
Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.
Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020
Original article / research
Full Version
Metaplastic Carcinoma of Breast: A Rare Pathological Entity- A Study of 10 Cases from Tertiary Care Centre in Northern India
Correspondence Address :
Dr. Chiranjeev Kumar Gathwal,
B 27, Doctors Enclave, BPS GMC Campus, Khanpur, Sonipat-131305, Haryana, India.
E-mail: drchiranjeev@gmail.com
Introduction: Metaplastic Carcinoma of Breast (MCB) is a rare heterogeneous neoplasm characterised by a mixture of adenocarcinoma with dominant areas of spindle cells, squamous and other mesenchymal differentiation. The reported incidence is 0.2% of all breast cancers.
Aim: To study the clinicopathological presentation, pathologic features and differential diagnosis of MB.
Materials and Methods: This retrospective cross-sectional descriptive study included 10 cases of MCB who underwent mastectomy and biopsies at BPS GMC Khanpur Kalan, Sonipat, Haryana, India from March 2013 to February 2020. Data were analysed by Microsoft Office Excel Datasheet 2019.
Results: Out of 10 cases, five cases were MCB Not Otherwise Specified (NOS) type, four cases were MCB with mesenchymal differentiation and one case showed rhabdomyosarcomatous differentiation. The right breast was involved in nine cases. The mean size of tumour was 8 cm with range of 3 to 16 cm. Five patients were treated by modified radical mastectomy and axillary dissection, four patients had lumpectomy and one patient underwent mastectomy. Half of the patients were below 40 years with the mean age being 36.8 years and range of 21-60 years. On Immunohistochemistry (IHC), 90% (9/10) cases were triple negative.
Conclusion: The MCB, although rare has to be diagnosed and excised at the earliest as the prognosis is predicted to be worse similar to other triple negative breast carcinomas. Ductal Carcinoma in Situ (DCIS) at the tumour periphery and co-expression of vimentin and cytokeratin would help to clinch the diagnosis in difficult situations.
Carcinosarcoma, Mastectomy, Neoplasm, Osteosarcoma, Rhabdomyosarcoma
In 1973, Huvos AG et al., first described the metaplastic carcinoma of the breast (1). It is a rare and histologically a diverse subtype of breast carcinoma. There has been limited research as it was not recognised as a distinct subtype until 2000. It accounts for less than 1% of all breast cancers (1),(2),(3). Multiple types of MCB have been described, in 2012 World Health Organisation (WHO) Classification of Tumours of the Breast, broadly as: a) No special type- low-grade adenosquamous carcinoma, fibromatosis like metaplastic carcinoma, squamous cells carcinoma, and spindle cell carcinoma; b) With mesenchymal differentiation- (chondroid, osseous and other mesenchymal differentiation); and c) Mixed metaplastic carcinoma (4).
Clinicopathological features: The MCB is often seen in 5th or more decade women and present as a palpable breast mass (1),(4). These are characterised by large size and rapid growth. The imaging characterisitcs of lesions can be simliar to Invasive Ductal Carcinoma (IDC) and benign lesions on mammography, sonography, and Magnetic Resonance Imaging (MRI). The imaging spectrum can be from circumscribed, round or oval shapes lesions on mammogram to lobular, circumscribed, hypoechoic solid mass with posterior acoustic enhancement on ultrasound with MRI T2 hyperintensity (5). These lesions usually show Oestrogen Receptor (ER), Progesterone Receptor (PR), and Human Epidermal growth factor Receptor 2 (HER2neu) negativity. Axillary lymph nodes can be invoved in 8-40% of cases (6). Comparing with IDC, MCB shows poor prognosis with 5-year survival rates as 49-68% (7).
In this study, authors have discussed clinicopathologic presentation, pathologic features and differential diagnosis of this rare type of breast cancer.
This was a retrospective cross-sectional descriptive study done in Pathology Department of BPS GMC Khanpur Kalan, Sonipat, Haryana, India from March 2013 to Feburary 2020, analysis of the data was done in March 2020. Institutional Ethical Commitee (BPSGMCW/RC/180/IEC/16) permission was taken. Considering the descriptive observational study of this rare subtype of breast carcinoma, convenient sampling of 10 cases (as total revcieved) of MCB who underwent mastectomy and biopsies during the study duration was taken.
Data from clinical history, imaging and operative details of histopathologically proven MCB cases was retrieved from medical record section as available for study inclusion. Cases data with patient history of previous exposure to chemotherapy or radiotherapy was excluded from the study. Histopathology blocks and IHC slides of panel comprising of ER and PR, HER2/neu as done in all cases and cytokeratin, vimentin, p63, S100 and desmin as done in different respective cases were retrieved from histopathology section of Pathology department. WHO Classification of Tumour of the Breast, 2012 has been used for characterisation of cases (4). Data was studied, associated and summarised.
Statistical Analysis
Mean and median were calculated. Data were analysed by Microsoft Office Excel Datasheet 2019.
Right breast was involved in nine out of the ten cases. The lesions ranged from 3-16 cm with mean as 8 cm and the duration of lesion was upto six months in most of the cases. Half of the patients were below 40 years with mean age being 36.8 years and age range of 21-60 years. Two patients were postmenopausal and others had normal menstrual history and none of the patient had family history of carcinoma breast. The Ultrasonography (USG) of lesions (as available) showed well defined, homogenous, round to hypoechoic lesions with internal vascularity on Doppler mimicking benign lesions (Table/Fig 1)a,b (Case No. 10). Five patients were treated by modified radical mastectomy and axillary dissection, one patient was treated by mastectomy with axillary clearance and four patients underwent lumpectomy. Grossly, the large MCB cases showed ulceration and cut surface showed infiltrative grey white tumour with areas of necrosis and firm glistening cartilaginous and bony areas (Table/Fig 2)a,b, (Case No 3 and 6). Cases No 1-5, 6-9 and 10 were of MCB, NOS type, MCB with mesenchymal differentiation and with rhabdomyosarcomatous differentiation respectively (Table/Fig 3).
On histological examination, four cases (Case No. 1-4) of MCB NOS type contained malignant IDC component, histological grade III admixed with high-grade spindle sarcomatoid elements with giant cells (Table/Fig 4)a. Case No. 5 showed tumour composed of polygonal cells with increased N/C ratio, hyperchromatic nuclei, eosinophilic cytoplasm and at places showed keratinisation and intercellular bridges (Table/Fig 4)b,c. Four cases (Case No. 6-9) showed MCB with mixture of heterologous myxoid and chondroid elements and large areas of necrosis. Case No. 6-8 showed MCB with chondrosarcomatous areas (Table/Fig 4)d and Case No. 9 showed osteosarcomatous tumour area with osteoid production (Table/Fig 5)a. Case No. 10 showed MCB with rhabdomyoblastic differentiation (Table/Fig 5)b-d. The detailed immunohistochemical profile of the subtypes is shown in (Table/Fig 6).
There are major challenges in classification of MCB and its differentials due to the rarity and histological diversity (5). Though actual pathogenesis of MCB is still unknown but few theories clarified the histomorphological diversity of this tumour, including genetic and non genetic mechanisms with reports suggested origin from cancer stem cells or myoepithelial progenitors (8). Few reports also suggested the theory of epithelial to mesenchymal transition causing transformation of the carcinomatous component into the sarcomatous component (9).
In present study, authors had evaluated 10 MCB cases for their clinicopathological and immunohistochemical profile. Half of the patients were below 40 years with mean age being 36.8 years and age range of 21-60 years. In contrast Western series reported MCB in women older than 50 years of age (6),(10),(11). Young age group shows spindle cell proliferation and warrants differential diagnosis of rare sarcoma. It is difficult to differentiate low-grade spindle cell metaplastic carcinoma with key morphologic features as irregularly fat infiltration, entrapped ducts with variable atypia and plump atypical spindle cell nuclei exhibiting cytokeratin immunoreactivity on IHC (12). In this study, irregular infiltration of fat and breast parenchyma was observed as showm in MCB squamous cell carcinoma and rhabdomyoblastic differentiation cases. DCIS was also observed in two cases. Several antibodies like High Molecular Weight Cyto-Keratin (HMW CK) (34bE12), CK5/6, smooth muscle actin, muscle-specific actin and p63 have been described useful in supporting the diagnosis and hypothesis of derivation from myoepithelial cells with p63 expression may be seen in both epithelial and spindle cell components (5),(6),(13). Moderate atypical metaplastic carcinomas is to be distinguished from malignant phyllodes tumour and sarcoma as the treatment and prognosis both differ significantly (12),(14). Certain features as Leaf like architecture, stromal cell CD34 expression and lack of cytokeratin expression favours diagnosis of phyllodes tumour (8). Immunohistochemical panel as proposed by Hicks DG and Tang P consisting ER, PR, HER2, Epidermal Growth Factor Receptor (EGFR) and cytokeratin 5/6 (CK 5/6) as a surrogate for molecular classification was widely accepted in identifying breast carcinomas with basal-like immunophenotype and categorisation of MBC (9),(10),(13). A 90% cases were found to be Triple
Negative Breast Carcinomas (TNBC) and didn’t exhibited positivity to ER, PR or HER2 and only one case showed immunopositivity with ER and HER2 neu while negative for PR. These findings were in concordance with previous studies (Table/Fig 7) (15),(16),(17),(18),(20); concluding that rare nuclear reactivity MCB for ER and PR hormone receptors in range of 0 to 17% (11),(17),(18),(19),(20),(21). The rate of HER2 overexpression has been shown variable in different studies ranging from 4-19.6% and up to 72% in one of the study (21),(22). Triple negative features of MCB in range from 77-96 % have been described in few studies. The p63 positivity in majority of squamous cell carcinoma cases and EGFR overexpression in up to 80% of cases of MCB have been reorted in few studies (22),(23),(24),(25). The axillary lymph nodal metastasis in MCB has been reported lower than that of IDC as incidence being 15-36% (20). In this study, out of four MRM specimens with lymph node dissection, two showed lymph node metastasis.
There are still lot of controvesies regarding prognosis of MCB; however most of the studies showed its more aggressive behaviour than IDC (7). In a study comparing 29 cases of MCB with 4,851 cases of IDC, Park HS et al., found comparable survival rates of stage I-III of MCB to those of IDC wth incidence of MCB stage IV disease at the diagnosis and recurrence being higher (26). In present study, two cases of matrix producing MCB showed recurrence within six month. Younger age presentation, skin invasion, squamous cell carcinoma subtype and nodal spread have been described as poor prognostic factors of MCB. Few studies reported insignificant role of subtypes in MCB prognosis (2). Association of phenotypic diversity of breast cancer with differences in risk factors, biological behaviour, clinical outcome, histologic grades and response to therapy has been described by Perou CM et al., (8). However, few believed in role of subtypes in prognosis describing more favourable outcome for fibromatosis-like spindle cell tumours and low likelihood of axillary metastasis in tumours with predominantly sarcomatous morphology (12),(18). Mastectomy and radiation therapy has been recommended for MCB equal or larger than 5 cm or with 4 or more metastatic axillary lymph nodes (irrespective of size of the tumour). Adjuvant radiation should always be considered as part of the multimodality therapy for MCB irrespective of the its subtype (7).
Limitation(s)
Though authors have studied maximum number of cases comparing previous studies in past, limitation of rarity of this disease further warrants advanced scientific exploration to have more light in the unexposed perspective of this rare pathlogical entity.
Divergent differentiation and histogenesis of metaplastic carcinoma of the breast have been described which is a rare histological subtype of breast cancer with aggressive nature and poor prognosis. It should always be included in the differentials of breast carcinomas with spindle cell subtype. Extensive sampling of tumour tissue should be done to rule out the presence of adjoining focus of DCIS, fat infiltration with IHC being quite helpful in the narrowing the differentials.
10.7860/JCDR/2021/48854.15086
Date of Submission: Feb 04, 2021
Date of Peer Review: Mar 01, 2021
Date of Acceptance: Jun 04, 2021
Date of Publishing: Jul 01, 2021
AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? No
• For any images presented appropriate consent has been obtained from the subjects. No
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