Origin and extension of intraductal papillomas of the breast: a three-dimensional reconstruction study

Nonneoplastic and neoplastic sclerosing lesions of the breast

Sclerosing lesions of the breast encompass a spectrum of benign and malignant entities and often pose a diagnostic challenge. Awareness of key morphologic features and pitfalls in the assessment of morphology and immunophenotype is essential to avoid over- or underdiagnosis and ensure optimal clinical management. This review summarizes nonneoplastic sclerosing lesions such as radial scar/complex sclerosing lesion, sclerosing adenosis, sclerosing intraductal papilloma, sclerosing variants of ductal adenoma and nipple adenoma, and fibroadenoma with extensive sclerosis, including their clinical presentation, characteristic morphology, differential diagnostic considerations, appropriate immunohistochemical work-up, when needed, and the clinical significance. In addition, atypical or neoplastic entities (such as atypical ductal hyperplasia, ductal carcinoma in situ, low-grade adenosquamous carcinoma, and fibromatosis-like metaplastic carcinoma) that can involve these sclerosing lesions are also briefly discussed.

A Preliminary Investigation into Search and Matching for Tumor Discrimination in World Health Organization Breast Taxonomy Using Deep Networks

Breast cancer is one of the most common cancers affecting women worldwide. It includes a group of malignant neoplasms with a variety of biological, clinical, and histopathologic characteristics. There are more than 35 different histologic forms of breast lesions that can be classified and diagnosed histologically according to cell morphology, growth, and architecture patterns. Recently, deep learning, in the field of artificial intelligence, has drawn a lot of attention for the computerized representation of medical images. Searchable digital atlases can provide pathologists with patch-matching tools, allowing them to search among evidently diagnosed and treated archival cases, a technology that may be regarded as computational second opinion. In this study, we indexed and analyzed the World Health Organization breast taxonomy (Classification of Tumors fifth ed.) spanning 35 tumor types. We visualized all tumor types using deep features extracted from a state-of-the-art deep-learning model, pretrained on millions of diagnostic histopathology images from the Cancer Genome Atlas repository. Furthermore, we tested the concept of a digital "atlas" as a reference for search and matching with rare test cases. The patch similarity search within the World Health Organization breast taxonomy data reached >88% accuracy when validating through "majority vote" and >91% accuracy when validating using top n tumor types. These results show for the first time that complex relationships among common and rare breast lesions can be investigated using an indexed digital archive.

Spectrum of Papillary Breast Lesions According to World Health Organization Classification of Papillary Neoplasms of Breast

Introduction Papillary breast lesions are segregated into benign and malignant based on the presence or absence of myoepithelial cells in the papillary cores. Papillary breast lesions are further classified into: intraductal papilloma, papilloma with atypical ductal hyperplasia (ADH)/ductal carcinoma in situ (DCIS), papillary DCIS, solid papillary carcinoma in situ, solid papillary carcinoma with invasion, invasive solid papillary carcinoma, encapsulated papillary carcinoma and encapsulated papillary carcinoma with invasion. In this study, we evaluated the spectrum of papillary breast lesions in resection specimens of the breast according to the latest World Health Organization (WHO) classification of breast tumors. Methods This was a retrospective cross-sectional study, and was conducted at Liaquat National Hospital for a period of six years, from January 2012 till December 2017. Data of patients that underwent surgeries for breast tumors were included in the study. All specimens were grossed, according to defined protocols, and representative sections were taken after inking resection margins. Hematoxylin and eosin-stained sections were examined by experienced histopathologists, and myoepithelial stains (p63 and myosin) were done in selected sections of all tumors. Histopathological classification of papillary tumors was performed according to WHO classification of breast tumors. Results The study involved 190 excision specimens of papillary breast lesions. Mean age of the patients was 45.6±17.1 years. Most of the lesions were between two and five centimetres (69.1%). For invasive carcinomas (n = 76), the most frequent grade was II (52.6%). For in situ and invasive carcinomas (n = 129), lymphovascular invasion and axillary metastasis were noted in 5.4% and 9.3% cases, respectively. Among papillary breast lesions, 36.8% were benign (intraductal papilloma, solitary or multiple) while 63.2% harbored ADH, DCIS, or invasive carcinoma. Invasive papillary carcinoma was the most frequent malignant papillary lesion (20%), followed by solid papillary carcinoma with invasion (12.6%). We found significant associations between patient's age and tumor size with histological type of papillary lesion as benign papillary lesions had smaller size and younger age compared to malignant papillary lesions. Conclusion We noted a high frequency of malignancy in papillary breast lesions. Moreover, malignant papillary lesions were significantly associated with higher age and larger tumor size.

Unusual recurrent metastasizing benign breast papilloma: a case report

BACKGROUND

Papillary breast lesions may be benign, atypical, and malignant lesions. Pathological and clinical differentiation of breast papillomas can be a challenge. Unlike malignant lesions, benign breast papillomas are not classically associated with lymph node and distant metastasis. We report a unique case of a recurrent, benign breast papilloma presenting as an aggressive malignant tumor.

CASE PRESENTATION

Our patient was a 56-year-old postmenopausal African American woman who was followed in the breast clinic with a long history of multiple breast papillomas. She underwent multiple resections over the course of 7-9 years. After being lost to follow-up for 2 years, she once again presented with a slowly enlarging left breast mass. Subsequent imaging revealed a predominantly cystic mass in the left breast, as well as a suspicious hypermetabolic internal mammary node and a hypermetabolic nodule in the pretracheal space. Biopsy of the internal mammary node demonstrated papillary neoplasm with benign morphology and immunostains positive for estrogen receptor, progesterone receptor, and human epidermal growth factor receptor 2/Neu. Due to the clinical picture concerning for malignancy, the patient was then started on endocrine therapy with palbociclib and letrozole before surgery. She then underwent simple mastectomy and sentinel lymph node dissection with negative nodes and pathology once again revealing benign papillary neoplasm. She underwent adjuvant chest wall radiation for 6 weeks and received letrozole following completion of her radiation therapy. She was without evidence of disease 30 months after surgery.

CONCLUSIONS

We present an unusual case of multiple recurrent peripheral papillomas with entirely benign histologic features exhibiting malignant behavior over a protracted period of many years, with an invasion of pectoralis musculature and possibly internal mammary and mediastinal nodes. Her treatment course included multiple surgeries (ultimately mastectomy), radiation therapy, and endocrine therapy.

Benign Breast Tumours - Diagnosis and Management

With improvements in breast imaging, mammography, ultrasound and minimally invasive interventions, the detection of early breast cancer, non-invasive cancers, lesions of uncertain malignant potential, and benign lesions has increased. However, with the improved diagnostic capabilities comes a substantial risk of false-positive benign lesions and vice versa false-negative malignant lesions. A statement is provided on the manifestation, imaging, and diagnostic verification of isolated benign breast tumours that have a frequent manifestation, in addition to general therapy management recommendations. Histological evaluation of benign breast tumours is the most reliable diagnostic method. According to the S3 guideline and information gained from analysis of the literature, preference is to be given to core biopsy for each type of tumour as the preferred diagnostic method. An indication for open biopsy is also to be established should the tumour increase in size in the follow-up interval, after recurring discrepancies in the vacuum biopsy results, or at the request of the patient. As an alternative, minimally invasive procedures such as therapeutic vacuum biopsy, cryoablation or high-intensity focused ultrasound are also becoming possible alternatives in definitive surgical management. The newer minimally invasive methods show an adequate degree of accuracy and hardly any restrictions in terms of post-interventional cosmetics so that current requirements of extensive breast imaging can be thoroughly met.

Mutational Analysis of AKT1 and PIK3CA in Intraductal Papillomas of the Breast with Special Reference to Cellular Components

The pathologic feature of intraductal papillomas is defined as a papillary structure composed of a fibrovascular stromal core lined by luminal epithelial cells and myoepithelial cells. We used droplet digital PCR for the mutational analysis of AKT1 (E17K) and PIK3CA (H1047R, E542K, and E545K) in 60 papillomas. AKT1 and PIK3CA mutations were detected in 12 (20%) and 17 (28%) of the papillomas, respectively. In five tumors harboring mutations, mutational analysis of AKT1 or PIK3CA was performed separately using luminal epithelial cells and myoepithelial cells sorted using anti-cytokeratin 19 antibody and anti-α smooth muscle actin antibody. The two types of cells from a given papilloma had the identical mutation. Three patients with the PIK3CA mutation-positive papilloma developed breast cancers at the resection site of the papilloma, but none of these subsequent breast cancers had the PIK3CA mutation. These results indicate that a papilloma stems from a bipotent progenitor cell that contains the AKT1 or PIK3CA mutation and proliferates and differentiates to form the papilloma. Papilloma can be a risk factor for developing breast cancer but is unlikely to be its obligate precursor.

Papillary Lesions of the Breast: An Update

CONTEXT

-Papillary lesions of the breast, characterized by the presence of arborescent fibrovascular cores that support epithelial proliferation, constitute a heterogeneous group of neoplasms with overlapping clinical manifestation and histomorphologic features, but may have divergent biological behavior. These lesions are exclusively intraductal neoplasms, although an invasive carcinoma may rarely have a predominantly papillary architecture. Although recognition of a papillary architecture is typically not challenging, the histologic distinction of these entities is not always straightforward. Historically, different terminologies and variable criteria have been proposed for a given entity by various authorities. The difficulty in classifying these lesions has been further confounded by the scarcity of data and the heterogeneity across different studies with regard to the molecular genetic characteristics of this group of lesions.

OBJECTIVE

-To provide an overview focusing on the current concepts in the diagnosis and classification of papillary lesions of the breast incorporating recent molecular genetic advances.

DATA SOURCES

-Data were obtained from pertinent peer-reviewed English-language literature.

CONCLUSIONS

-The recent evolution of molecular techniques has enhanced our knowledge of the pathogenesis of papillary carcinomas of the breast. This, along with emerging outcome studies, has led to prognosis-based reclassification of some of these entities. Additional studies focusing on the molecular signatures are needed to identify potential decision tools to further stratify these lesions with respect to prognostic significance.

A Case of Intraductal Papilloma of the Breast With High 18F-FDG Uptake on PET/CT

We present a case of intraductal papilloma in the right breast of a 51-year-old woman with high F-FDG uptake. Its maximum standardized uptake value increased from 10.2 on early (1 h) PET/CT scan to 12.2 on delayed (2 h) PET/CT scan suggesting a primary breast cancer. However, histopathology proved it to be an intraductal papilloma. Immunohistochemically, strong expression of glucose transporter-1 and weak expression of hexokinase-II were noted in the papilloma. With the detection of a subareolar intracystic mass with high F-FDG uptake, intraductal papilloma should be included in the differential diagnosis.

Tissue proteomics of the human mammary gland: towards an abridged definition of the molecular phenotypes underlying epithelial normalcy

Our limited understanding of the biological impact of the whole spectrum of early breast lesions together with a lack of accurate molecular-based risk criteria for the diagnosis and assignment of prognostic significance to biopsy findings presents an important problem in the clinical management of patients harboring precancerous breast lesions. As a result, there is a need to identify biomarkers that can better determine the outcome of early breast lesions by identifying subpopulations of cells in breast premalignant disease that are at high-risk of progression to invasive disease. A first step towards achieving this goal will be to define the molecular phenotypes of the various cell types and precursors - generated by the stem cell hierarchy - that are present in normal and benign conditions of the breast. To date there have been very few systematic proteomic studies aimed at characterizing the phenotypes of the different cell subpopulations present in normal human mammary tissue, partly due to the formidable heterogeneity of mammary tissue, but also due to limitations of the current proteomic technologies. Work in our laboratories has attempted to address in a systematic fashion some of these limitations and here we present our efforts to search for biomarkers using normal fresh tissue from non-neoplastic breast samples. From the data generated by the 2D gel-based proteomic profiling we were able to compile a protein database of normal human breast epithelial tissue that was used to support the biomarker discovery program. We review and present new data on the putative cell-progenitor marker cytokeratin 15 (CK15), and describe a novel marker, dihydropyriminidase-related protein 3 (DRP3) that in combination with CK15 and other well known proteins were used to define molecular phenotypes of normal human breast epithelial cells and their progenitors in resting acini, lactating alveoli, and large collecting ducts of the nipple. Preliminary results are also presented concerning DRP3 positive usual ductal hyperplasias (UDHs) and on single cell layer columnar cells (CCCs). At least two bona fide biomarkers of undifferentiated ERα/PgR negative luminal cells emerged from these studies, CK15 and c-KIT, which in combination with transformation markers may lead to the establishment of a protein signature able to identify breast precancerous at risk of progressing to invasive disease.

Papillary neoplasms of the breast: a review

CONTEXT

Interpretation of papillary lesions of the breast remains a challenging task because of the wide morphologic spectrum encountered in the benign, atypical, and malignant subtypes. Data on clinical significance and outcome of papillary lesions, with superimposed atypia or areas similar to ductal carcinoma in situ partially replacing the benign elements, are sparse. Furthermore, complete excision of even a fully developed papillary carcinoma confined to a dilated or cystic duct is associated with an excellent prognosis, whereas a complex papilloma extending into multiple branches of a duct may ultimately recur as a carcinoma because of incomplete excision of microscopic foci. This makes an outcome-based classification difficult.

OBJECTIVE

An arbitrary yet practical approach to classification is outlined, with discussion of methods to circumvent the various diagnostic difficulties. The limitations in precise diagnosis of papillary lesions in aspirates are addressed, and the implications of finding papillary lesions in core biopsies are discussed. Although the focus is on intraductal lesions, associated invasive carcinomas and invasive micropapillary carcinoma are also presented.

DATA SOURCES

The literature on papillary lesions and invasive micropapillary carcinoma is reviewed.

CONCLUSIONS

It would be prudent to completely excise any papillary lesion that has not been entirely removed by the initial core biopsy. The optimal management of localized papillary lesions is complete excision with a small rim of uninvolved breast tissue without any prior needle instrumentation if and when the papillary nature can be determined by imaging. Thus managed, most of these lesions behave indolently, and outcome is usually excellent.

[Most common benign epithelial breast diseases: diagnosis, treatment and cancer risk]

As a consequence of breast imaging development and increased interventional radiology, benign epithelial breast diseases (BEBD) represent a growing percentage of breast pathology diagnoses. BEBD include numerous entities such as cysts, fibrosis, adenosis, duct ectasia, which require neither surgery nor follow-up. Some BEBD have to be individualized (radial scars, papillomas, complex sclerosing adenosis, lobular intraepithelial neoplasia, flat epithelial atypia, atypical hyperplasia), being preinvasive lesions or markers of increased breast cancer risk, or being associated with suspect radiological aspect. BEBD should be managed in a pluridisciplinar way and correctly diagnosed by percutaneous biopsies or surgical specimens. The goals of surgery vary according to lesions. It always allows a complete surgical specimen analysis and therefore a search for atypical or cancerous cells. Surgery can also have a preventive role by reducing the risk of potential malignant transformation. Finally, it enables in some cases the excision of a radiologically suspect mass. So the aim of this review is to give a clinical and morphological description of most common BEBD, underlying their cancer risk, specific diagnosis, therapeutic, follow-up and psychological repercussions.

Identification of a subset of breast carcinomas characterized by expression of cytokeratin 15: relationship between CK15+ progenitor/amplified cells and pre-malignant lesions and invasive disease

Recently, we presented evidence--based on the analysis of benign hyperproliferative lesions of the breast--for the presence of cells that express the stem cell marker cytokeratin (CK) 15 in combination with CK19, a protein widely expressed by mammary epithelial cells. Here we report the finding of a subset of breast carcinomas characterized by expression of CK15. CK15 expressing tumors constituted 5% (6 out of 120; 4 of ductal type and 2 of lobular type) of the high-risk breast carcinomas examined by gel-based proteomics and immunohistochemistry. Five out of the six CK15+ carcinomas were CK15+/CK19-. The remaining tumor was mainly composed of cells expressing both CK15 and CK19 (CK15+/CK19+), but it also contained invasive areas with cells expressing only one of these makers (CK15+/CK19- and CK15-/CK19+ cells). To address the relationship between putative luminal progenitor/amplified CK15+ cells and malignant disease, and to determine whether cells/lesions lose expression of CK15 as a result of tumour initiation and/or progression, we searched among our sample set for carcinomas in which invasive tumor areas co-existed with non-malignant cells and hyperproliferative and known pre-malignant lesions. Only one such tumour was found (T71), a CK15-/CK19+/p53+ carcinoma that contained p53 negative non-malignant epithelial cells exhibiting a variety of, CK15/CK19 cellular phenotypes (CK15+/CK19+; CK15+/CK19-; CK15-/CK19+; CK15-/CK19-), often associated with simple columnar cells. Single layers of epithelial cells exhibiting all four CK15/CK19 phenotypes were observed contiguous to areas of atypical ductal hyperplasia that contained p53 positive cells that lost CK15 expression (CK15-/CK19+) and had a very similar phenotype to those of the neighboring ductal carcinoma in situ (DCIS) and invasive cells. The undifferentiated CK15+/CK19+ cells, which had the phenotype CK15+/CK19+/CK14+/CK8+ and -/ER-/PgR-/AR-/CD44+ (weak)/CK17-/p63-/vimentin+/Ki67-/Bcl-2+ (weak)/GATA-3-/p53-, most likely correspond to lineage-restricted luminal progenitor cells able to generate the other more differentiated CK15/CK19 cellular phenotypes, thus giving rise to the daunting intratumour heterogeneity displayed by carcinoma T71. Cells with a very similar phenotype to the CK15+/CK19+ progenitor cells were observed in a juvenile fibroadenoma as well as in the large collecting ducts of the breast. The latter, however, expressed in addition CK14 and had a phenotype (CK15+/CK19+/CK14+/CK8+ (weak)/ER-/PgR-/AR-/CD44+ (weak)/CK17-/p63-/vimentin-/Ki67-/Bcl-2+/GATA-3-/p53-) that resembled that of the putative normal adult breast stem cells as inferred from published data. Further molecular characterization of these progenitor cells as well as unraveling of the signaling pathways that regulate their growth and differentiation may prove invaluable for developing novel therapeutic strategies that target cancer at an early stage.

Papillary lesions of the breast: a review

Papillary lesions comprise a wide spectrum of lesions in terms of their clinical presentation, morphologic appearance, malignant potential, and clinical behavior. Their defining feature is that of a fibrovascular stromal core lined by epithelial and myoepithelial cells, attached to the wall of the duct and extending into the duct lumen. Papillary lesions are often diagnostically challenging both on core biopsy and in excision specimens. Much of the difficulty arises from the many different terminologies that are used to describe the various entities that are included under the umbrella term of papillary lesions. Separation of papillary lesions into categories with a meaningful clinical outcome is most appropriate; however, there is a relative paucity of well-designed outcome studies with substantial cohort numbers to provide information in this regard. We use a pragmatic approach to the classification of papillary lesions in our practice, as we will outline in this review. We will also discuss controversies surrounding papillary lesions and focus on management of these lesions on core biopsy and in excision specimens.

Les tumeurs papillaires non malignes du sein : quelle prise en charge après diagnostic percutané ?

PURPOSE

To assess the reliability of percutaneous breast biopsies in diagnosing and managing non malignant papillary lesions and determine if subsequent excision must be systematic. MATERIALS AND METHODS. Retrospective review of 2233 breast biopsies over a 43 months period (September 2001 to March 2005): sonographically guided core biopsies (n = 836), ultrasound (n = 346) or stereotactic (n:1051) guided vacuum biopsies. 86 non malignant papillary tumors were diagnosed (core biopsy:28, US:38 and stereotactic guided vacuum biopsy:20). A larger sample was systematic after core biopsy: lumpectomy (n = 19) or vacuum biopsy (n = 9). Surgical excision followed vacuum biopsy (n = 18) in case of atypia or sampling excision. Alternatively, yearly follow-up was advised (n = 40). Correlation with surgical findings (n = 37) or mammographic follow-up (n = 49) is presented. The influence of various factors on the risk of underestimation was analysed.

RESULTS

Surgical resection revealed an underestimation of 5/37 (13.5%): 4/19 with core- and 1/18 with vacuum-assisted biopsy corresponding to 4 low grade ductal carcinoma in situ and a microinvasive ductal carcinoma in situ. It was higher for core biopsies and related to age and size: higher when women<50 years and when radiological image>1 cm. The influence of the other factors was not significant. Of the 9 non operated papillomas after core biopsy, vacuum biopsy revealed an additional underestimation (low-grade ductal carcinoma in situ). Of the 49 papillary lesions that were not surgically biopsied, 40 were monitored at 2-42 months (average: 19 months). No carcinoma was detected during this follow-up.

CONCLUSION

Percutaneous biopsy is an accurate technique in managing papillary tumors. A larger histologic specimen is necessary after core biopsy. Vacuum biopsy is an attractive alternative to surgery for smaller papillomas (<1 cm), but in spite of nonsignificant results we advise subsequent excision in case of multiple papillomas, atypia or residual tumor.

PAPILOMATOSE MÚLTIPLA E RECORRENTE UNILATERAL: AVALIAÇÃO PELOS MÉTODOS DE IMAGEM

Papilomas múltiplos são tumores benignos de pacientes jovens, que se caracterizam por risco aumentado de recorrência e predisposição a desenvolver câncer de mama subjacente. Os autores relatam um caso de papilomatose múltipla unilateral, no qual se realizou excisão de 21 papilomas, com o objetivo de demonstrar os principais aspectos de imagem dessa entidade, incluindo os achados mamográficos, ecográficos e da ductogalactografia.

C, John S. B, George M. F. A Simple Approach to Nipple Discharge

Evaluation and management of patients with nipple discharge (ND) aims to identify carcinoma when present, and in benign cases, stop the discharge when bothersome. We reviewed our recent experience with ND to develop a simple and effective algorithm to manage these patients. Records of all patients with ND evaluated from December 1996 through June 1999 were reviewed. Patients were liberally offered duct excision for a clinical suspicion of malignancy (persistent clear or bloody fluid) or to stop bothersome discharge. Patients with breast imaging abnormalities (mammography or ultrasound) related to their ND underwent biopsy and were considered separately. Of 104 patients with ND, 11 underwent biopsy as a result of mammographic findings; three of these cases proved malignant. The remaining 93 patients were evaluated with 55 tests that did not demonstrate malignancy, including ductography, discharge fluid cytology, serum prolactin and thyroid-stimulating hormone levels, and image-guided breast or nipple biopsy. Thirty-nine patients underwent duct excision with only a single patient demonstrating malignancy. Clinical follow-up has not identified malignancy in any patient managed nonoperatively. When diagnostic breast imaging is negative, malignancy related to ND is uncommon. Patients with ND should have diagnostic breast imaging and, if it is negative, should be offered duct excision. There is little role for ductography, cytology, or laboratory studies in evaluating these patients.

Incidental treatment of nipple discharge caused by benign intraductal papilloma through diagnostic Mammotome biopsy

OBJECTIVE

The purpose of this study was to evaluate imaging-guided vacuum-assisted mammotome biopsy as a minimally invasive method of obtaining a satisfactory diagnosis and eliminating the bothersome symptoms in patients presenting with nipple discharge.

MATERIALS AND METHODS

Forty-nine women who presented with nipple discharge and who had final pathologic diagnoses of papillary lesions were retrospectively identified. Fifty-six lesions were biopsied in this group. The examinations included mammography, ductography, sonography, and, if possible, percutaneous biopsy. All lesions were centrally located and most were superficial. Of this study group, four patients with five lesions proceeded to sonographically guided automated core biopsy, and 38 patients with 44 intraductal lesions identified by sonography advanced to sonographically guided biopsy with an 11-gauge mammotome probe. One patient underwent stereotactic 11-gauge mammotome biopsy. Patients not advancing to sonographically guided biopsy were those with masses either in the nipple or nipple-areolar complex (five patients), one patient with no identifiable lesion at sonography, and one directly referred for open surgical biopsy.

RESULTS

In all biopsied patients, satisfactory tissue for diagnosis was obtained. In patients biopsied with the mammotome probe, follow-up at a mean time of 13 months revealed resolution of the presenting problematic discharge in 97.2% of patients. Complications were mild and infrequent. Only one of 50 percutaneously biopsied lesions was not benign and required subsequent surgery.

CONCLUSION

Papilloma excision with percutaneous biopsy allows safe and accurate tissue analysis and a high probability of terminating the symptomatic nipple discharge.

Breast-conserving surgery for invasive cancer: a principle based on segmental anatomy

As the incidence of breast cancer increases in Japan, breast-conserving surgery becomes an important issue in the light of quality of life. We have demonstrated by 3-D reconstruction studies that ductal carcinoma in situ (DCIS) originates from the terminal duct-lobular unit (TDLU). Normal mammary epithelium anatomically located in the TDLU was shown to be biologically associated with cancerous change, particularly in specimens from patients who subsequently developed invasive carcinoma. Atypical ductal hyperplasia as well as DCIS expressed breast cancer associated antigen, providing further biological evidence that the atypical lesion at the TDLU are premalignant. Intraductal spread of carcinoma was defined as "DCIS was present clearly extending beyond the TDLU, or present prominently within the large ducts," and was classified into 3 grades according to the distribution of carcinoma in the duct-lobular system. We have developed a breast-conserving surgery consisting of quadrantectomy and regional lymph node dissection and immediate volume replacement using lateral tissue-flap (LTF). The quadrantectomy was employed on the basis of segmental anatomy of the duct-lobular system in which breast carcinoma originates. Fairly good cosmetic outcome as well as local control were obtained in the patients who underwent the immediate volume replacement using LTF. It must be emphasized that the quadrantectomy is a radical procedure in the sense that it aims at removal of all the carcinoma cells of the primary tumor.

Different distributions of immunoreactive S100-alpha and S100-beta protein expression in human breast cancer

BACKGROUND AND OBJECTIVES

Although the localization of S100 protein in breast carcinoma has previously been studied, the immunohistochemical expression of the S100-alpha and -beta subunits has not been examined.

METHODS

Immunohistochemical staining for S100-alpha and S100-beta proteins was performed on 72 benign breast lesions and 72 infiltrating ductal carcinoma of the breast. Noncross-reactive anti-S100-alpha and anti-S100-beta antibodies purified by affinity chromatography were used in the studies.

RESULTS

More than 30% of the epithelial cells comprising all the benign lesions were either S100-alpha or S100-beta positive. In breast carcinoma cases, however, >30% of malignant cells were S100-alpha positive in 70/72 cases (97.2%), whereas the number of S100-beta positive cells exceeded 30% in only 3/72 cases (4.0%).

CONCLUSIONS

Immunohistochemical staining for S 100-alpha and S100-beta proteins may help to differentiate benign proliferative breast lesions from breast cancers in difficult cases.

Subsequent breast carcinoma risk after biopsy with atypia in a breast papilloma

BACKGROUND

Risk of breast cancer after biopsy demonstrating a papilloma has long been variously interpreted on the basis of histologic pattern of multiplicity of papillomas.

METHODS

A nested case control study was performed on women with surgical breast biopsies evidencing papillomas; cases who subsequently developed invasive carcinoma were compared with controls who did not. Presence of atypical hyperplasia (AH) within the papilloma as well as areas of AH in the surrounding parenchyma were evaluated in both cases and controls. The entire cohort (not tested) was separately evaluated for all variables except for atypia within papillomas.

RESULTS

The relative risk of invasive carcinoma for women with papillomas containing AH was > 4x that of papillomas without AH within or surrounding the papilloma. This risk may be greater with added atypical hyperplasia outside the papilloma and most strikingly, most of the subsequent invasive carcinomas developed in the same breast and probably near the site of the original papilloma. However, ordinary patterns of epithelial hyperplasia lacking specific features of AH within the papilloma do not add to the risk of subsequent carcinoma development over papillomas without hyperplasia.

CONCLUSIONS

This study indicates that women having papillomas with AH have a similar or greater cancer risk than others with specifically defined patterns of atypical hyperplasia within the breast parenchyma (4-5x relative risk). Most importantly, this risk is largely local in the region of the original papilloma.

Management of ductal carcinoma in situ with nipple discharge. Intraductal spreading of carcinoma is an unfavorable pathologic factor for breast-conserving surgery

BACKGROUND

Surgical management of ductal carcinoma in situ (DCIS) has been a controversial issue in the selection of breast-conserving surgery as a method of treatment. The definition of intraductal spreading of carcinoma becomes an important factor in the decision making process, but little is known about how much intraductal extension influences the spreading of tumor in the whole breast. To define any unfavorable pathologic factors existing in limited surgery for patients with DCIS, the authors investigated histopathologic characteristics using a sequential slicing of tissues.

METHODS

Duct-lobular segmentectomy, a limited surgery, was performed on 110 patients with a bloody nipple discharge. Six patients with invasive carcinoma and 17 patients with DCIS subsequently received a total mastectomy. The specimens obtained by segmentectomy and mastectomy were histopathologically examined. Using subserial sections, the authors examined the relationship between intraductal spreading of carcinoma in the segmentectomy specimens and carcinoma residue in the mastectomy specimens.

RESULTS

Among 16 mastectomy specimens, the authors found residual DCIS in 6, and atypical ductal hyperplasia in 4. Intraductal spreading of carcinoma was detected in 8 of 16 segmentectomy specimens. Six of eight patients with intraductal spreading had residual DCIS. The other two patients had atypical hyperplasia in breasts. No residual DCIS was detected in the other eight patients without intraductal spreading. Among 12 patients under observation who did not have a mastectomy, invasive carcinoma subsequently developed in 3. Two of three patients had intraductal spreading in segmentectomy specimens. Only 1 of 10 patients without intraductal spreading, however, developed carcinoma.

CONCLUSIONS

Intraductal spreading of carcinoma is an unfavorable pathologic factor in breast-conserving surgery for patients with ductal carcinoma in situ with nipple discharge.

An original stereomicroscopic analysis of the mammary glandular tree

In the 1970s, Wellings developed and reported extensively on a technique for a three-dimensional (3D) analysis of breast lesions. Drawbacks of this subgross sampling technique were that it was laborious, rather time-consuming and only allowed prospective studies. Furthermore, the stereomicroscopic aspect of the lesions studied was not diagnostic and each sample had to be studied histologically after paraffin embedding to determine the diagnosis. The present study introduces an original method enabling the exploration of the 3D structure of the mammary glandular tree from a paraffin-embedded sample. This procedure is quicker than the Wellings' technique, permits retrospective study and enables a 3D analysis of previously identified histological structures. Stereomicroscopic aspects of non-malignant lesions such as single multiple or metaplastic cysts, adenosis, ductal-lobular hyperplasia and malignant in situ neoplasms are illustrated. Our results confirm Wellings' concept that most minimal lesions arise in the terminal ductulo-lobular units. We also show that ductal carcinoma in situ may grow continuously by extending through the glandular tree but may also have a multifocal or stepwise progression in some cases.

The operative management of intraductal papilloma of the breast

Intraductal papillary tumors of the breast exhibit bloody nipple discharge with often no evidence of a palpable tumor, making discrimination between benign and malignant lesions sometimes difficult for pathologists and surgeons. However, appropriate surgical management requires correct differentiation between these lesions. According to previously reported 3-dimensional analyses of intraductal papillary lesions, solitary papilloma originates in the large ducts while multiple papilloma originates in the peripheral ducts and often coexists with intraductal carcinoma. We performed selected ductolobular segmentectomy on both solitary and multiple intraductal papilloma, and even on small foci of intraductal carcinoma which were found inadvertently. The favorable results of this surgery include a fine cosmetic appearance, functional breast feeding and no recurrence of papilloma during the 2 to 7 year follow-up period. In this article, the operative method of selected ductolobular segmentectomy is described.

Microdochectomy for single-duct discharge from the nipple

Microdochectomy has been the accepted treatment for single-duct nipple discharge. Review of 97 consecutive patients undergoing microdochectomy between 1980 and 1987 revealed a total of eight patients with ductal carcinoma in situ. All of these had pre-operative mammography, results of which were highly suspicious of malignancy in six patients. Tiny foci of ductal carcinoma in situ were found in the two patients with normal mammograms. We suggest an expectant policy in cases where the mammogram is normal, omitting routine microdochectomy.

Three-dimensional reconstruction of semi-gross biostructures using 'macroserials'--1-mm-thick serial organ slices

A method for reconstructing a gross or semi-gross organ structure was developed in a pathological analysis of liver lobes surgically excised from patients with bile duct carcinoma, where the extent of the tumour was to be demonstrated three-dimensionally. Fixed material was serially sliced with a ham-slicer, producing flawless slices as thin as 1 mm. Prior to slicing, the material was temporarily 'embedded' in gelatine to hold it in shape throughout slicing. These slices ('macroserials') could be directly brought into macroscopic 3-D reconstruction, but in the case of bile duct carcinoma, microscopic examination of the slices was indispensable in determining the extent of carcinoma and precarcinomatous (dysplastic) changes. Slices 1 mm thick were embedded in paraffin using a special holder made of plywood plates which kept a slice in a flat, extended state through the dehydration process. This method of preparing thin slices not only allows the reconstruction of a gross organ structure with less effort than before, but also ensures a certain amount of accuracy in the reproduction of submacroscopic structures.

Possible cancerous change of intraductal papillomas of the breast. A 3-D reconstruction study of 25 cases

Surgical specimens from 25 patients with intraductal papilloma were subjected to 3-dimensional (3-D) reconstruction studies of their mammary ducts. Papillomas of the multiple type (15 cases) always originated in the terminal duct lobular units (TDLU), whereas all papillomas of the solitary type (10 cases) originated in the large ducts except for one. In 6 of the 25 (24%) patients ductal carcinomas were accidentally found during specimen reconstruction. Two of the six patients harbored microscopic carcinoma as small as 3 mm or less. Three-D reconstructions revealed that carcinomas with multifocal origins in the TDLUs were connected with peripheral papilloma. Papilloma preceding carcinoma was of the multiple type in five patients, and of the solitary type in one. This study also showed that 6 of the 16 (37.5%) patients with papilloma originating in the periphery had carcinomas, whereas none of the nine patients originating in the center did. This observation strongly suggests that the peripheral papilloma is highly susceptible to cancerous change.