Papillary lesions of the breast - bdiap.orgbdiap.org/wp-content/uploads/2017/04/Cecily_Quinn.pdf ·...
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Papillary lesions of the breast
Cecily Quinn Irish National Breast Screening Programme & St. Vincent’s University Hospital, Dublin
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Papillary lesions of the breast
Central, solitary Classical
Sclerosing
Complications
Variants
Central, solitary, Classical (intracystic) ? In situ ? Invasive
Solid
Invasive
Peripheral, multiple Peripheral, multiple
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Benign intraduct papilloma
• Large ducts
• Solitary
• Female • 30 – 50 years • Symptomatic
– Nipple discharge – Lump
• Mammographic lesion
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Intraduct papilloma
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Intraduct papilloma
Microscopy
• Intraductal lesion
• FV cores covered by epithelial & myoep. cells
p63, calponin, actin, sm. myosin
• Apocrine metaplasia 20%
• Epithelial hyperplasia Cytokeratin 5/6 (HMW) useful
• Myoepithelial hyperplasia
p63
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Papillomatosis (Peripheral papillomas)
Microscopy
• Papillary fronds supported by fibrovascular stalks in multiple TDLUs
• Epithelial & myoep. cell layer present
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Complications of papilloma
Sclerosis •Entrapment of tubules in duct wall •Overdiagnosis of malignancy
Infarction •Spontaneous •Post core biopsy •Squamous metaplasia •Cytologic atypia •Difficulty in diagnosis
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Sclerosing papilloma
• Papilloma that has become sclerotic
• TDLUs affected by sclerosing adenosis surround & invaginate duct
taking a covering of epithelial and myoepithelial cells into the lumen - broad papillae containing glandular structures
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Sclerosing papilloma
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Variants of papilloma
Ductal adenoma Adenomyoepithelioma Pleomorphic adenoma
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Papilloma with atypical intraduct epithelial proliferation (AIDEP)
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Papilloma with AIDEP
• Papilloma with ADH or non HG DCIS < 1/3 of lesion
= Atypical papilloma
• Papilloma with non high grade DCIS >1/3 and <90% or Papilloma with high grade DCIS
= Papilloma with DCIS
• Papilloma with DCIS > 90% of lesion
= Papillary carcinoma (in situ)
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Papilloma with AIDEP
• Papilloma with ADH = Papilloma with ADH!
• Papilloma with DCIS = Papilloma with DCIS!
• Biological course most likely determined by
pathology in the surrounding breast tissue
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Classical papillary carcinoma Epidemiology
• Large ducts
• Central
• Female • 50-70 years • Symptomatic
– Nipple discharge – Subareolar lump
• Mammographic lesion
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Classical papillary carcinoma
• Friable bosselated mass within a cystic space • ? Dilated duct / ? Thick capsule
• Intracystic papillary carcinoma (descriptive term)
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Classical papillary carcinoma Microscopy
• Circumscribed
• Thick capsule
• Complex papillary architecture
• ‘Falling apart’
• Haemorrhage
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Classical papillary carcinoma Microscopy
• Papillae slender cores
• May be fibrotic
• Covered by atypical epithelial cells
• May be multilayered
• Cytokeratin 5/6 negative
• No myoepithelial cells within the lesion
p63
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Classical papillary carcinoma Dimorphic variant
• No me cells on fv cores
• Epithelial cells in direct contact with cores morphologically different ‘globoid’
• May mimic ME cells – ME marker negative
– Cam 5.2 positive
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Myoepithelial cells were completely absent in 33/40 (82%) IPCs and only focal in the remaining 7/40 (18%).
IPC constitutes a spectrum of in situ and invasive carcinoma with a predominance of the latter. IPC carries a very good prognosis.
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Classical papillary carcinoma ? True nature
• Traditionally regarded as in situ lesion
• Recent studies - no peripheral ME cell layer
• Case reports of ipsilateral LN metastases
• Indolent biological course
p63
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Solid papillary carcinoma Epidemiology
• Female • 60-80 years • Symptomatic
– Nipple discharge – Subareolar lump
• Mammographic lesion
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Solid papillary carcinoma Microscopy
• Nodular
(one or more)
• Well circumscribed
• May be fibrous
capsule
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Solid papillary carcinoma Microscopy
• Uniform population of epithelial cells
• Mild to moderate atypia
• Solid growth pattern
• Interrupted by narrow FV cores – scaffolding
• No classical papillae
• No ME cells within lesion
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Solid papillary carcinoma Microscopy
• Cells have granular eosinophilic cytoplasm
• Cytokeratin 5/6 neg.
• Focal chromogranin & synaptophysin pos.
• Endocrine DCIS Azzopardi JG and colleagues.
Histopathology 1985
Chromogranin
Grimelius
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Invasive papillary carcinoma Microscopy
• Papillary architecture
• Infiltrative outline
• Rare
• Conventional IDC adjacent to ‘papillary carcinoma’ more common
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Papillary carcinomas low histological grade, IHC markers consistent with luminal type,
lower rate of lymph node metastases & less genomic aberrations than grade and ER matched IDCs
Papillary carcinomas are part of the spectrum of ER positive breast cancers.
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Papillary DCIS Microscopy
• Malignant equivalent of papillomatosis
• Variant of usual type ductal carcinoma in situ
• Multiple small to medium sized ducts involved
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Papillary lesions Diagnosis on needle
core biopsy
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Papillary lesion on NCB
B3a B3b
Guidelines for non operative diagnosis and reporting in breast cancer screening. NHSBSP UK June 2001
It is anticipated that the majority of papillary lesions will be designated B3
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Papillary lesion on NCB
• Assess H& E Are there ME cells on papillae? Associated epithelial proliferation Benign or atypical? • Immunohistochemistry ME cell markers – p63, calponin Epithelial proliferation - Cytokeratin 5/6
• Check radiology Size of lesion Any unusual features
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Papillary lesions Non-operative diagnosis
B2 B3 B4 B5
Histopathology only one part of the diagnostic process Talk to our multidisciplinary colleagues
And LISTEN!!
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Relationship of papilloma to carcinoma?
Concurrent risk Pathology heterogeneous
Subsequent risk Increased
Accompanying changes (atypia or DCIS) within the lesion or surrounding tissue main risk determinant
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Predictive value of NCB diagnoses of lesions of uncertain malignant potential in abnormalities
detected by mammographic screening
• 124 patients NCB diagnosis of papilloma
• Malignancy in 13 patients (10%)
El-Sayed ME, Rakha EA, Reed J, et al. Histopathology 2008;53:650-657
Atypia on NCB in 9/25 patients (36%)
No atypia on NCB in 4/99 patients (4%)
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Can we reduce surgical excision
rate for B3 papillary lesions ?
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Mammotome biopsy
Papillary lesion
No atypia Atypia
No further action Excise or observe
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