PAPILLARY LESIONS

PAPILLARY LESIONS
Maria J Merino MD
National Cancer Institute
WHO New edition
Papillary lesions
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Intraductal Papilloma,
Atypical Papiloma
Papillary Carcinoma
Intracystic Papillary Carcinoma
Nipple Adenoma
Papillomatosis
• Multiple Papillomas or Florid Hyperplasia
• Juvenile Papillomatosis
• Micropapillary DCIS
• Micropapillary invasive cancer
PAPILLARY TUMORS
• PAPILLOMA
• Nipple discharge or
mass
• Central
• 2 Cell Types,
Myoepithelial cells present
• APOCRINE changes
• Complex patterns
• ‘Entrappment’
PAPILLOMA
PAPILLOMA
SMA
p63
Problems , biopsy and core
**Frozen Section…..Do not do it if you can
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ADH, DCIS
Sclerosis
Squamous metaplasia
Necrosis
Infarction
CORE BIOPSY
Papilloma
SMA
SCLEROTIC PAPILLOMA
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Presents as calcified mass
Marked distortion of ducts
Central or peripheral
Entrapment
Keloid like collagen
Retains 2 cell layers –p63, calponin
OVERDIAGNOSIS ON SCNB
SCLEROTIC PAPILLOMA
SCLEROTIC PAPILLOMA
PAPILLOMA WITH CENTRAL ENTRAPMENT
Atypical Papilloma
Atypical Papilloma
Papilloma with ADH and DCIS
• Focal areas with morphological
and cytol. features of ADH.
• Few myoep. cells in the areas
• < 3mm Pap with ADH
• > 3mm Pap with DCIS
• 30% or 90%???
• WHO WG says Size should be
used.
• 4x increased risk of invasive
carcinoma compared to
papillomas without atypia
Myoepithelial cells present
Papillary DCIS
Recommendations
Samples diagnosed as papilloma may not
require excision provided that the size of
the papilloma is concordant with the size
and appearance of imaging findings.
Suspicious or malignant features,
excision
• Middleton et al
LCIS
INTRACYSTIC…….ENCAPSULATED
PAPILLARY CARCINOMA
Intracystic papillary carcinoma of the breast.
After mastectomy, radiotherapy or excisional
biopsy alone. Carter, Orr and Merino, 1983 Cancer
Intracystic papillary carcinoma of the breast (IPC) was distinguished
from the more common papillary intraductal carcinoma (DCIS) and
infiltrating duct carcinoma with a papillary pattern. IPC was defined as a
solitary tumor with a pattern recognizable as carcinoma which is
confined to a dilated duct. A series of 41 such cases was collected from
three institutions. Twenty-nine patients underwent mastectomy; 11 of
them had axillary dissections. None of these patients had metastatic
disease in the axillary lymph nodes or recurrence in the follow-up period
which averaged five years. Eleven patients did not have mastectomy or
radiotherapy. Eight of these patients (followed for an average of ten
years) had no recurrence. The only patients who developed invasive
carcinoma were those with DCIS as well as IPC in the excisional biopsy.
The data suggest that IPC is much more likely to be cured by local
treatment than is IPC accompanied by DCIS.
IPC
• ALONE
68 CASES
• WITH DCIS
52 CASES
• WITH INVASIVE CA
39 CASES
IPC ALONE
• ELDERLY PATIENTS
• 2% OF BREAST CA
• MAY OR NOT HAVE NIPPLE
DISCHARGE
• CENTRAL OR PERIPHERAL
• NO RECURRENCE
Intracystic Papillary Carcinoma
41 cases
Gross:
Micro:
Circumscribed
Papillary
Papillary
Cribriforme
Necrosis
Solid
81%
40%
100%
56%
32%
37%
Associated DCIS: 19/41=46%
INTRACYSTIC PAPILLARY
CARCINOMA
IPC HISTOLOGY
IPC WITH INVASION
IPC WITH INVASION
IPC
IPC WITH DCIS
IPC WITH DCIS
• 52 CASES
• 3/52 (6%) HAD INVASIVE CA
• NO RECURRENCES
IPC WITH INVASIVE CARCINOMA
• 39 CASES
• 9 ( 23% ) RECURRED AS INVASIVE
CARCINOMA
• 3/9 WITH AXILLARY LYMPH NODE
BIOPSY HAD METASTASES
Treatment of IPC
• ALONE
CONSERVATIVE TREATMENT:
ELDERLY PATIENT WITH
CIRCUMSCRIBED LESION AND
NEGATIVE MARGINS
• WITH DCIS
TREAT AS DCIS
• WITH INVASIVE CA
TREAT AS INVASIVE CA
BENIGN NIPPLE TUMORS
• NIPPLE ADENOMA
ADENOMA OF NIPPLE
• MOST COMMONLY OVERDIAGNOSED
LESION OF NIPPLE
• ATYPIA, SOME MITOTIC FIGURES
• MUSCLE INVASION
• SQUAMOUS MORULES
• EXTENDS ONTO EPIDERMIS
• ADENOMYOEPITHELIA
• NON-NECROTIC
ADENOMA
FOLLOWUP ADENOMA
• 51 CASES
• 7 IPSILATERAL CARCINOMAS
2 ARISING FROM ADENOMA (FP)
4 SEPARATE INVASIVE
1 WIDESPREAD DCIS
• 3 CONTRALATERAL
• ROSEN & CACCIO
IPC ALONE