national cancer institute · papillary lesions •intraductal papilloma, •atypical papiloma...

PAPILLARY LESIONS

Maria J Merino MD

National Cancer Institute

WHO New edition

Papillary lesions

• 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

• ADH, DCIS

• Sclerosis

• Squamous metaplasia

• Necrosis

• Infarction

**Frozen Section…..Do not do it if you can

Papilloma SMA

CORE BIOPSY

SCLEROTIC PAPILLOMA

• 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: Circumscribed 81%

Papillary 40%

Micro: Papillary 100%

Cribriforme 56%

Necrosis 32%

Solid 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