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Neither Russell nor Magenta bodies: A cytological dilemma in breast fine needle aspiration cytology

A 90yearold lady presented with right breast discomfort and a firm lump in the upper inner quadrant of breast. Mammography revealed a 2 × 1.8 cm, welldefined mass, and she was referred to our institute with a diagnosis of plasmacytoma on fine needle aspiration (FNA). Positron emission tomography– computed tomography confirmed a heterogeneously enhancing right breast lesion measuring 2 × 1.8 cm (SUV max 3.6) with associated perilesional fat stranding. A repeat FNA was performed by palpation guidance from this breast lump for cytological smears and cell block preparation. The smears were highly cellular, and showed a predominantly dispersed population, single file pattern, and few cohesive clusters of tumour cells. These tumour cells exhibited plasmacytoid morphology and contained occasional eosinophilic cytoplasmic inclusions (Figure 1). Mitosis was infrequent and no necrosis was evident. The morphological differentials were plasmacytoma versus infiltrating lobular carcinoma. The cell block was cellular with tumour cells arranged in nests and trabecular pattern. On immunohistochemistry, these tumour cells were negative for MUM1 ruling out plasmacytoma and diffusely positive for pancytokeratin and GATA3 proving primary invasive breast carcinoma. Ecadherin showed strong circumferential membranous staining confirming infiltrating ductal carcinoma (Figure 2). Oestrogen receptor and progesterone receptor were strongly positive (Allred score: 8/8). HER2neu immunostain was negative whereas the Ki67 proliferating index was around 5%. Based on this immunoprofile, the tumour belonged to Luminal A subtype of breast cancer. In view of the morphological features and intermediateNottingham grade, neuroendocrine (NE) markers were performed. Synaptophysin and chromogranin were expressed in >50% of tumour cells, confirming the neuroendocrine differentiation (Figure 3). Thus, the cytoplasmic inclusions which posed a diagnostic dilemma seem to be neurosecretory granules rather than Russel bodies in plasma cell neoplasm or Magenta bodies in invasive lobular carcinoma. The patient underwent wide local excision in a private hospital. A diagnosis of mixed invasive ductal carcinoma (IDC) with neuroendocrine tumour was offered based on the current criteria as per the World Health Organization (WHO) classification of breast tumours (2019).