Sonographically-guided 14-gauge core needle biopsy for papillary lesions of the breast

Objective

We wanted to assess the need for surgical excising papillary lesions of the breast that were diagnosed upon sonographically guided 14-gauge core needle biopsy.

Materials and Methods

Sixty-nine women (age range: 25-74 years, mean age: 51.7 years) with 69 papillary lesions (4.9%) were diagnosed and followed after performing sonographically guided 14-gauge core needle biopsies. Surgical excision was performed for 44 (64%) of 69 papillary lesions, and 25 lesions were followed with imaging studies (range: 6-46 months, mean: 17.9 months). The histologic findings upon core biopsy were compared with the surgical, imaging and follow-up findings.

Results

Core needle biopsies of 69 lesions yielded tissue that was classified as benign for 43 lesions, atypical for 18 lesions and malignant for eight lesions. Of the 43 lesions that yielded benign papilloma upon core needle biopsy, one had intraductal papillary carcinoma found upon surgery. An immediate surgical biopsy was recommended for this lesion because of the imaging-histologic discordance. No additional carcinoma was found during the imaging follow-up. Surgical excision was performed for 17 atypical papillary lesions, and this revealed intraductal (n = 6) or invasive (n = 2) papillary carcinoma in 8 (47%) lesions. Of the seven intraductal papillary carcinomas, surgery revealed invasive papillary carcinoma in one (14%).

Conclusion

Our results suggest that papillary lesions of the breast that are diagnosed as benign upon sonographically guided 14-gauge core needle biopsy can be followed when the results are concordant with the imaging findings.

Intraductal papilloma of the parotid gland in a child

Intraductal papillomas are rare benign tumors, most commonly encountered in minor salivary glands and rarely in major salivary glands. They are cystic, solitary neoplasm that arise from ductal epithelium and produce painless swelling. We report a case of intraductal papilloma of the parotid gland in a child.

Breast Papillomas in the Era of Percutaneous Needle Biopsy

BACKGROUND

The significance of breast papillomas detected on core needle biopsy (CNB) remains unclear. While those associated with malignancy or atypia are excised, no clear solution exists for benign papillomas. We sought to determine the indication for surgical excision, incidence of malignancy, significance, and natural history.

METHODS

In this retrospective review, patients were divided into benign, atypical, or malignant cohorts based on initial results. While patients with malignant or atypical features were encouraged to undergo surgical excision, no standard recommendation was given for benign papillomas. Mammographic features, method of initial diagnosis, pathology results, and follow-up data were analyzed.

RESULTS

Between January 1994 to December 2005, 5,257 CNBs were performed at our tertiary level medical center. 206 patients were diagnosed with 215 breast papillomas. 174 (81%) papillomas were benign, 26 (12%) were associated with atypia, and 15 (7%) were associated with malignancy. Two benign papillomas (1.1%) developed into cancer over an average of 53 months. Average follow-up of those patients not undergoing excision for benign papilloma was 41 months; we had 92 patients with greater than two year follow-up and 57 patients with greater than four year follow-up. Of patients with atypia or malignancy associated with papilloma, there was a 26% and 87% associated rate of malignancy, respectively.

CONCLUSIONS

Benign breast papillomas diagnosed by CNB have a low risk of malignancy and do not need excision. However, they should be considered high risk lesions which require serial radiographic monitoring. Papillomas associated with atypia or malignancy should continue to be excised.

Papilomas intraductales de mama en paciente afectada de síndrome de Costello

Costello syndrome is a multisystemic congenital disorder with a very low prevalence. The pathogenesis remains unclear and predisposes to the development of tumors of ectodermal origin. Diagnosis is clinical, based on findings of mental and growth retardation and a characteristic phenotype. We report the case of a patient with Costello syndrome who was referred to our unit with a suspected diagnosis of intraductal papilloma based on the presence of various episodes of nipple discharge. Postoperative histopathological study confirmed the diagnosis of multiple intraductal papilloma. We review the literature on the topic and discuss the advisability of aggressive surgical therapy, given the predisposition of these patients to develop both benign and malignant tumors.

Myoepithelial cells in solid variant of intraductal papillary carcinoma of the breast: a potential diagnostic pitfall and a proposal of an immunohistochemical panel in the differential diagnosis with intraductal papilloma with usual ductal hyperplasia

We examined myoepithelial status in intraductal papillary carcinoma (IPC) along with the expression of high-molecular weight cytokeratin (HMWK) and neuroendocrine markers, with special reference to the differential diagnosis of solid intraductal papillary carcinoma(SIPC) and intraductal papilloma with usual ductal hyperplasia (IP-UDH). Twenty-six (93%) of the twenty-eight intraductal papillomas (IP) had myoepithelial cells in >70% of the epithelial-stromal interface of the intraluminal proliferating component. Six (29%) of twenty-one SIPC had almost complete myoepithelial layer like IP-UDH at the epithelial-stromal interface. HMWK (34 beta E-12) was diffusely positive in 14 (93%) of 15 IP-UDH, but 16 (76%) of 21 SIPC were completely negative for HMWK. Neuroendocrine markers were positive in 14 (67%) of SIPC, but all 28 IPs were completely negative. If only the presence of myoepithelial cells is emphasized as a benign hallmark, about 30% of SIPCs may be underdiagnosed as IP-UDH. However, by using a combination of myoepithelial markers, HMWK, and neuroendocrine markers, all of the 36 solid intraductal papillary lesions were properly classified as benign and malignant. Solid intraductal papillary lesions meeting at least two of the following criteria are highly likely to be malignant: (1) absence of myoepithelial cells(<10% of epithelial-stromal interface of intraluminal proliferating component), (2) negative HMWK(<10%), (3) positive neuroendocrine markers (>10%).

Transnipple pyramidectomy in pathological nipple discharge: an original minimal surgery technique in a series of 80 cases

Pathologic nipple discharge presents a diagnostic dilemma as no one diagnostic test has proven clearly superior to any other in the differentiation of benign versus malignant conditions. This is a clinical study of 80 patients with unilateral suspicious nipple discharge whose complete investigation included histological evaluation. A transnipple approach was used to identify, get to and excise the breast tissue suspicious of having caused the pathological discharge, with a pyramide-shaped tissue dissection (pyramidectomy). Specimens satisfactory for histological evaluation were obtained in all cases. Breast cancer was detected in six cases, papillomatosis in four, papillomas in 30, fibrocystic changes in five, ductal ectasia in 31 and non specific findings in four cases. There were no intraoperative complications and functional and healing-esthetic recovery was very good in all cases. It is concluded that transnipple pyramidectomy is a useful technique for a reliable diagnosis of pathologic nipple discharge.

Multiple papillomas of the breast: Is current management adequate?

Multiple papillomas (MP) are subject to debate in terms of their clinical and pathological significance and management. To date the ideal management is still not well established. The Royal Perth Hospital Multidisciplinary Breast Service has prospectively accrued clinical and pathological data on over 9000 patients since 1994. The database was interrogated and all pathology reports retrospectively reviewed. A total of 23 cases with the diagnosis of MP were retrieved from the database between 1994 and 2004. Of these 23 cases, 13 (56.5%) were diagnosed by core biopsy, nine (39.1%) on excision biopsy, and one (4.4%) on a mastectomy specimen. The average age of patients was 56.4 years (range 44-74 years). The average duration of follow up is 4.1 years (range 1-10 years). In our series a close association with malignancy was noted for MP, which was also associated with a spectrum of proliferative breast disease. Contemporary guidelines should be developed for this controversial condition. We recommend that all patients with MP, especially when associated with atypia, undergo wide excision of the lesion with clear margins of at least 10mm and that these patients be monitored closely with annual imaging.

[Clinical features and prognosis of intraductal papillary mucinous neoplasms of pancreas: analysis of 38 cases]

OBJECTIVE

To explore the diagnosis, clinical manifestation, treatment, and prognosis of intraductal papillary mucinous neoplasms (IPMNs) of pancreas.

METHODS

The clinical data of 38 patients with IPMNs, 23 males and 15 females, aged 64.1 +/- 10.7 (41 - 81), were analyzed respectively.

RESULTS

The main symptoms included abdominal pain and jaundice. Pancreaticoduodenectomy was performed on 32 patients, total pancreatectomy on 1 patient, distal pancreatectomy on 3 patients; and pancreatic biopsy on 2 patients. One patient died during the peri-operational period. Pathology showed 15 cases of main-duct type, 14 cases of branch-duct type, 1 case of mixed type, and 8 cases being un-differentiated, all with dilatation of pancreatic duct at different degrees 4.6 mm in diameter on average. There were 30 cases of invasive IPMNs, with significantly higher level of carbohydrate antigen 19-9 (CA19-9), and 8 non-invasive. The median survival time was 18.5 months in general. In the invasive IPMN group the general median survival time was 16.1 months, and the 1, 2, and 5-year survival times were 54%, 31%, and 21% respectively; and in the non-invasive IPMN group the median survival time was 24.3 months, and the 1, 2, and 5-year survival times were 58% and 38% respectively; without significant differences in the survival times between these 2 groups. TMN staging showed 6 cases of stage 0, 15 cases of stage I, 9 cases of stage II, and 4 cases of stage III among the 34 patients of malignant IPMNs. The median survival times of the patients of the stages 0, I, II, and III were 31.3, 27, 9.1, and 8.9 months respectively with significant differences among them (P = 0.0124).

CONCLUSION

IPMN of pancreas has no specific clinical manifestation. Dilatation of pancreatic duct is a manifestation in imaging examination characteristic of IPMN. The serum CA19-9 level is significantly higher in the patients with invasive IPMN. There are significant differences in survival rate among different groups according to TMN staging.

International consensus guidelines for management of intraductal papillary mucinous neoplasms and mucinous cystic neoplasms of the pancreas

Non-inflammatory cystic lesions of the pancreas are increasingly recognized. Two distinct entities have been defined, i.e., intraductal papillary mucinous neoplasm (IPMN) and mucinous cystic neoplasm (MCN). Ovarian-type stroma has been proposed as a requisite to distinguish MCN from IPMN. Some other distinct features to characterize IPMN and MCN have been identified, but there remain ambiguities between the two diseases. In view of the increasing frequency with which these neoplasms are being diagnosed worldwide, it would be helpful for physicians managing patients with cystic neoplasms of the pancreas to have guidelines for the diagnosis and treatment of IPMN and MCN. The proposed guidelines represent a consensus of the working group of the International Association of Pancreatology.

Significance of Papillary Lesions at Percutaneous Breast Biopsy

BACKGROUND

The management of nonpalpable papillary lesions found in specimens obtained by percutaneous breast biopsy is controversial. We reviewed the treatment of patients found to have papillary lesions by stereotactic, sonographic, or fine-needle aspiration breast biopsy to identify indications for surgical excision.

METHODS

Consecutive patients with intraductal papilloma, atypical papilloma/papilloma with atypical ductal hyperplasia, papillary neoplasm, and papillomatosis according to percutaneous breast biopsy were identified from radiology records. The charts were reviewed to identify patients who had subsequent surgical excision, and the pathologic findings were correlated with the biopsy method and indications for surgery.

RESULTS

Papillary lesions were found in 120 biopsy samples from 109 patients. Malignancy was found at operation in 19 (24%) of 80 lesions that underwent surgical excision: 12 (63%) were ductal carcinoma-in-situ, 4 (21%) were infiltrating ductal carcinoma, 2 (11%) were infiltrating papillary carcinoma, and 1 (5%) was intracystic papillary carcinoma. Malignancy was found in 9 (30%) of 30 fine-needle biopsy papillary lesions, 6 (35%) of 17 core biopsy papillary lesions, and 4 (12%) of 33 stereotactic biopsy papillary lesions. Malignancy was missed significantly less frequently with stereotactic biopsy (P<.05).

CONCLUSIONS

Malignancy is frequently found at surgical excision for papillary lesions found on percutaneous breast biopsy. Malignancy is missed significantly less frequently with stereotactic biopsy.

Intraductal papilloma in a reconstructed breast: mammographic and sonographic appearance with pathologic correlation

The usual abnormal mammographic and sonographic findings encountered after reconstruction with autologous myocutaneous flaps for breast carcinoma, include fat necrosis, calcifications, lymphedema, and locally recurrent carcinoma. This case report describes a case of an intraductal papilloma occurring in a reconstructed breast in a 48-year-old woman who underwent a left-sided mastectomy for recurrent ductal carcinoma in situ followed by immediate reconstruction with a supercharged transverse rectus abdominal muscle flap. The role of imaging in the detection and management of occult or clinically palpable abnormalities in reconstructed breasts is discussed.

[Application of microdebritor in the treatment of the juvenile onset recurrent respiratory papillomatosis]

OBJECTIVE

To evaluate the treatment methods and improve the curative effects of the juvenile onset recurrent respiratory papillomatosis.

METHOD

Fourteen patients with juvenile onset recurrent respiratory papillomatosis were treated from 2002 to 2003 by using microdebritor.

RESULT

Among the 14 cases, eight cases had no recurrence after three to six operations within six month follow up and were decannulated,the other six cases had recurrence postoperatively.

CONCLUSION

It is demonstrated that microdebritor surgery is an ideal therapy for the treatment of juvenile onset recurrent respiratory papillomatosis.

Intraductal papilloma with "comedo-like" necrosis, a diagnostic pitfall

Necrosis in the breast is more frequently associated with malignancies than benign conditions. In the latter, it may be diffuse as seen in infarcts, postpartum changes, and after anticoagulant therapy, or focal as in florid adenosis and juvenile papillomatosis. The goal of this study was to find other benign entities associated with necrosis. Using our pathology database from January 1994 to March 2003, we identified 10 cases of florid duct hyperplasia associated with luminal necrosis. Clinical information was collected and all slides were reviewed. The age of the patients ranged from 36 to 94 years (mean, 53.2 years). All patients underwent an initial excisional biopsy except for one who had a core biopsy. Patients presented with a palpable mass (6 cases) a radiographic density (3 cases), or nipple discharge (1 case). Findings correlated with the presence of an intraductal papilloma with adjacent or associated florid duct hyperplasia. Within the central luminal spaces of the florid duct hyperplasia, cellular debris associated with necrosis was present and was morphologically identical to that seen in comedo intraductal carcinoma. In fact, in two of the four consultation cases, these lesions were initially diagnosed as comedo carcinoma. Re-excision performed in three cases showed no atypia or malignancy. It is important to recognize the presence of comedo-like necrosis in florid duct hyperplasia associated with or adjacent to intraductal papillomas of the breast and not to misinterpret these findings as intraductal carcinoma. The necrosis may be secondary to reactive changes within the intraductal papilloma.

Intraductal biopsy for diagnosis and treatment of intraductal lesions of the breast

BACKGROUND

Bloody nipple discharge is a significant clue in the detection of ductal carcinoma of the breast. In the past, pathologic diagnoses were obtained exclusively via excision, but recently developed mammoscopic techniques have been found to yield valuable information relating to the diagnosis of intraductal lesions.

METHODS

Mammary duct endoscopy (i.e., mammoscopy) was performed a combined total of 407 times for 295 patients who experienced nipple discharge. Intraductal breast biopsy (IDBB) under mammoscopic observation was performed in 193 intraductal papillomas (from a total of 107 patients) and 30 ductal carcinomas (from a total of 27 patients); IDBB was performed a combined total of 36 times in the 27 patients who had breast carcinoma and yielded 21 diagnostic specimens (58.3%). In addition, the therapeutic value of IDBB was assessed in 70 patients with intraductal papilloma who had undergone more than 3 years of follow-up; these 70 patients harbored a combined total of 75 intraductal papillomas.

RESULTS

IDBB correctly identified the presence of carcinoma in 9 of 27 patients (33.3%); 7 other lesions (25.9%) were placed in the suspected carcinoma (i.e., atypical papillary lesion) category, and 5 (18.5%) were identified as intraductal papillomas. Using IDBB, it was difficult to collect diagnostic specimens from patients with breast carcinoma, because of the location and weak tissue cohesiveness of these lesions compared with intraductal papillomas. The 193 intraductal biopsies performed on intraductal papillomas yielded only 20 specimens that were insufficient for diagnosis. IDBB exhibited therapeutic efficacy in 54 of 70 patients with intraductal papilloma (77.6%) who had more than 3 years of clinical follow-up. Therapeutic results tended to be less favorable for patients who had intraductal lesions in multiple duct lobular units.

CONCLUSIONS

Mammoscopy can contribute not only to the diagnosis of cases of nipple discharge but also to the treatment of intraductal papilloma.

Calcifying obstructive pancreatitis: a study of intraductal papillary mucinous neoplasm associated with pancreatic calcification

BACKGROUND AND AIMS

We have observed intraductal papillary mucinous neoplasm (IPMN) associated with pancreatic calcification. The aim of this study is to describe the profile of IPMN associated with calcification and gain insights into the pathogenesis of calcification in IPMN.

METHODS

We identified 10 patients with IPMN with pancreatic calcification, of whom 7 underwent pancreatic resection. We reviewed demographic data, history of previous pancreatitis, and radiological and histological features of these patients.

RESULTS

In patients with IPMN with calcification (mean age, 65 +/- 12 yr; 50% men), a diagnosis of chronic calcifying pancreatitis was entertained in 5 of 10 patients; 2 patients had undergone previous endoscopic therapy for stone removal. There was no previous history of pancreatitis in 9 of 10 patients. Radiologically, calcifications were seen diffusely throughout the gland in 8 of 10 patients and interpreted as chronic calcific pancreatitis. Although 1 of the 7 patients who underwent resection had diffuse IPMN throughout the gland, 6 patients had IPMN confined to the head or uncinate process (mean size, 2.75 cm; range, 1.1-5 cm). Histologically, 6 of 7 IPMNs were adenomas, and 1 patient had invasive cancer. No patient had intratumoral calcification. All 7 patients had calcification within the main pancreatic duct and/or side branches, often within inspissated mucus.

CONCLUSIONS

IPMN associated with pancreatic calcification can lead to misdiagnosis and inappropriate treatment for chronic calcifying pancreatitis. In the absence of intratumoral calcification or a previous history of long-standing chronic pancreatitis, calcification in IPMN likely represents a unique and hitherto unrecognized form of calcifying obstructive pancreatitis caused by prolonged partial obstruction of the pancreatic duct.

[Malignancy risk in some benign mammary lesions]

We analyzed retrospectively 821 patients operated on in our clinic for benign mammary lesions and for breast cancer. Histopathology identified in some cases associated benign and malign lesions. Atypical hyperplasia is considered significant risk factor for malignancy. Women in this category need close surveillance.

Microdochectomy in women aged over 50 years

Management of a spontaneous single duct nipple discharge without associated mass and normal mammography remains controversial. Our study examined the pathological results of 52 women of all ages treated with microdochectomy for single duct nipple discharge. Malignant or premalignant lesions were identified in 1 patient under 50 years of age and 2 patients over 50 years. Papilloma was the most frequently identified pathology in both age groups (60% of patients under 50 years and 73% over or equal to 50 years of age). Our results suggest that microdochectomy is a safe effective treatment in women aged over 50 years.

The role of ERCP and pancreatoscopy in cystic and intraductal tumors

ERCP and pancreatoscopy may establish a diagnosis of IPMT and differentiate it from a pseudocyst or cystic neoplasm of the pancreas. These techniques may also assess risk of malignancy, extent of disease, allow tissue sampling, and provide therapeutic intervention.

Surgery of cystic neoplasms

Neoplastic cysts of the pancreas have been recognized since the nineteenth century, and although differences between neoplastic and proliferative cysts were acknowledged, they were treated similarly, first by marsupialization and later by internal drainage. Increased awareness of the malignant potential of neoplastic cysts, as well as advances in surgical techniques, made excision the preferred treatment for these lesions as early as the 1940s, but errors in diagnosis were frequent, and even to this date, continue to account for cases of pancreatic cystic tumors treated by drainage.

Percutaneous endoscopy of an intracystic papilloma of the breast

We present a new endoscopic procedure for the evaluation of intracystic papilloma of the breast. We suggest that the method is a potential alternative to open surgery.

Surgical and mammographic follow-up of papillary lesions and atypical lobular hyperplasia diagnosed with stereotactic vacuum-assisted biopsy

The purpose of this study was to assess the accuracy of stereotactic vacuum-assisted biopsy (SVAB) for the diagnosis of high-risk lesions, which include papillary lesions and atypical lobular hyperplasia (ALH). Retrospective review was performed of 212 consecutive SVABs at our institution between May 1, 2000 and February 28, 2001. Biopsies were performed using an 8-gauge SVAB probe, with the patient prone on a dedicated stereotactic table. Eleven to 17 cores (mean 12.4) were harvested from each lesion. Radiography of core specimens was performed in cases in which the targeted lesion contained microcalcifications. Six of the lesions (2.8%) demonstrated intraductal papilloma, 1 (16.7%) of which had features suggestive of a radial scar, and 7 (3.3%) demonstrated ALH. Surgical excision was performed on 3 of the 6 (50%) papillomas and all 7 (100%) cases of ALH. Histopathologic analysis at surgical excision demonstrated benign breast tissue in 1 of the papillomas (33.3%), radial scar in 1 (33.3%), and atypical ductal hyperplasia (ADH) in 1 (33.3%). One papilloma not surgically excised underwent repeat mammography at 6 months and demonstrated no change. Of the surgically excised lesions with ALH, 4 (57.1%) retained the diagnosis of ALH, though one of these (25%) also demonstrated a coexisting radial scar. One lesion (14.3%) demonstrated ductal carcinoma in situ (DCIS), 1 (14.3%) demonstrated lobular carcinoma in situ (LCIS), and 1 (14.3%) demonstrated fibrocystic change. Lesions diagnosed as papillomas at SVAB did not demonstrate malignancy, but 2 (66.7%) were found to contain high-risk lesions that may impact surveillance or prophylactic therapy (i.e., tamoxifen). Because of the relatively small series reported, additional studies are necessary to further assess the accuracy of SVAB in the diagnosis of benign papillary lesions. ALH diagnosed with SVAB that underwent subsequent surgical excision demonstrated cancer in 1 of 7 lesions (14.3%). This rate of cancer underestimation is similar to that seen with ADH diagnosed with SVAB, which warrants surgical excision to rule out malignancy. Therefore we recommend that lesions demonstrating ALH at SVAB be considered for surgical excision to rule out malignancy.

Suspicious node found at the time of reduction mammaplasty

A case of a patient with a suspicious glandular node found during reduction mammaplasty is described. The preoperative search for such nodes, the management of cases on which a suspicious node is found intraoperatively, and a situation on which the diagnosis of breast cancer is made during histology are discussed. When a suspicious small node (with a diameter up to 2 cm) is detected during a cosmetic breast surgery, lumpectomy can be performed. It may be a definite surgical treatment, depending on stage and tumor type. In the case presented, histology revealed intraductal papilloma, a benign tumor, therefore lumpectomy was a suitable procedure with an acceptable cosmetic result. With the increased incidence of breast cancer, this situation will happen more often and technical options for the management of such cases deserves the attention of plastic surgeons.

Benign tumors of the breast with multinucleated stromal giant cells. Immunohistochemical analysis of six cases and review of the literature

The authors present six cases of benign tumors of the breast with numerous multinucleated stromal giant cells (MSGC). All six patients were women aged 37-70 years (mean 48 years), presenting clinically with a breast mass 1.0-3.8 cm in size (mean 1.9 cm; median 1.5 cm). By standard H&E examination, all cases showed the presence of numerous MSGC haphazardly dispersed within the tumor stroma. Three cases revealed MSGC merging into the surrounding adipose tissue simulating infiltrative growth. The MSGC appeared to have multiple nuclei (5 to 25) with fine chromatin and sporadic small nucleoli. Their cytoplasm was inconspicuous. The MSGC expressed vimentin only and to lesser extent CD34. These cells were negative for muscle markers, keratins, S-100 protein, vascular markers, CD68 and hormone receptors. Interestingly, the majority of MSGC and mononuclear stromal cells showed reactivity for p53 protein and Ki-67 proliferation antigen. All patients were treated by simple excision and remain free of recurrence (mean 70 months, median 48 months.). The reactivity of p53 in MSGC and mononuclear stromal cells may play a key role in linking these two cell types. Nonetheless, the presence of MSGC does not alter prognosis of otherwise typical benign lesions.