Intracystic papillary carcinoma of breast: interrelationship with in situ and invasive carcinoma and a proposal of pathogenesis: array comparative genomic hybridization study of 14 cases

Papillary lesions of the breast - review and practical issues

Papillary lesions of the breast represent a heterogeneous group of neoplasm featuring fibrovascular cores covered by epithelial cells with or without intervening myoepithelial cells. According to the World Health Organization classification of breast tumors, papillary lesions of the breast are further classified into intraductal papilloma (including intraductal papilloma with atypical ductal hyperplasia /ductal carcinoma in situ), papillary ductal carcinoma in situ, encapsulated papillary carcinoma, solid papillary carcinoma (in situ and invasive) and invasive papillary carcinoma. The overlapping morphological features and immunohistochemical profiles make accurate diagnosis of breast papillary lesion a challenge for pathologists. In this review, the morphological and relevant immunohistochemical features of papillary lesions are discussed, with further emphasis on some commonly encountered practical diagnostic issues. A simple diagnostic algorithm will be established. The relevant molecular characteristics will be discussed as well.

rare cancer in an unexpected ectopic

Accessory Breasts can occur anywhere along the milk line extending from the axilla to the groin. In view of cosmetic reasons, accessory breasts are removed. We present three cases of accessory breasts with intra-cystic papillary carcinoma in them. Intra-cystic papillary carcinoma is a rare carcinoma that has finger like projections. It has a good prognosis and hence a simple excision biopsy is enough for these patients.

Papillary lesions of the breast

Papillary lesions of the breast represent a heterogeneous group of lesions including benign papillomas, papillomas with focal epithelial atypia, fully fledged ductal carcinoma in situ (DCIS) or lobular neoplasia, papillary DCIS, encapsulated papillary carcinomas without or with invasion, solid papillary carcinomas, and invasive papillary carcinomas. A micropapillary pattern characterized by lack of fibrous stalks within the papillae is observed in micropapillary DCIS and invasive micropapillary carcinoma. In addition, a variety of other rare breast lesions reveals a papillary architecture such as tall cell carcinoma with reversed polarity (TCCRP) and mucinous cystadenocarcinoma, adenomyoepithelioma, and secretory carcinoma. In addition, benign lesions such as usual ductal hyperplasia, apocrine metaplasia, gynecomastia, and juvenile papillomatosis may show a papillary or micropapillary architecture. Fragments of a benign papilloma in a breast biopsy are considered a lesion of uncertain malignant potential (B3 in the European classification) and excision is mostly recommended. Although the knowledge about molecular pathology of papillary breast lesions has increased, there is not sufficient evidence for diagnostically useful molecular features, yet. The aim of this review is to provide an update on papillary and micropapillary lesions with emphasis on problematic areas for daily diagnostic work including biopsies.

Next-generation sequencing revealed recurrent ZFPM1 mutations in encapsulated papillary carcinoma of the breast

Encapsulated papillary carcinoma (EPC) of the breast is a rare subtype of tumor. To date, the genetic abnormalities underlying EPC remain elusive. The purpose of this study was to gain further insight into EPC mutation profile. Forty-one EPCs diagnosed from 2015 to 2018 were included. Twenty-six EPCs were submitted to whole-exome sequencing (WES), and a 185 gene-targeted sequencing panel was designed to validate the results of the 26 EPCs that underwent WES and 15 additional cases. Recurrently mutated genes were further confirmed by Sanger sequencing. Our study revealed multiple recurrently mutated genes including PI3K-AKT-mTOR pathway genes (PIK3CA, AKT1, ULK1, MAP3K1, MAP2K4, RHOA, and PTEN) (27/41, 65.8%) and chromatin modification genes (ZFPM1, GATA3, CTCF, and KMT2C) (21/41, 51.2%) in EPC. Importantly, somatic ZFPM1 mutations existed in 9/41 (21.9%) of the EPCs. The frequency of ZFPM1 mutations in the EPCs was significantly higher than that of other tumor types. Of the nine ZFPM1 mutations, seven were frameshift mutations, and the remaining two were nonsense mutations. Moreover, a significant concurrence of ZFPM1 and PI3K-AKT-mTOR mutations were revealed in the EPCs. Of note, no TP53 mutations were detected in our EPCs, whereas it was detected in a considerable proportion of the luminal A invasive ductal carcinomas of no special type (IDC-NSTs) from TCGA. We reveal that recurrent somatic ZFPM1 mutation is characteristic of EPC and concurred with mutations in the PI3K-AKT-mTOR pathway. The distinctive genetic features of EPC might underlie its special histological structures and indolent behavior.

Molecular analysis of encapsulated papillary carcinoma of the breast with and without invasion

Encapsulated papillary carcinomas (EPCs) of the breast are a unique variant of papillary carcinoma confined to a cystic space with absent or attenuated myoepithelial cell layer. Although staged as an in situ lesion, it can be associated with invasive ductal carcinoma (IDC). We sought to compare the genomic characteristics of pure EPC and EPC with associated invasive carcinoma (EPCi) at the genomic level. All cases of EPCi harbored recurrent hotspot mutations in PIK3CA. PIK3CA, KMT2A, and CREBBP deleterious somatic events were found across both tumor groups, irrespective of invasion status. At the whole transcriptomic level, EPCi cases displayed remarkably similar mRNA profiles when compared to EPC. When EPCi cases were compared with their corresponding IDC, despite significant overlap, we identified differential gene expression in 39 genes with enrichment of multiple pathways including extracellular matrix regulation, cell adhesion, and collagen fibril organization. Despite morphologic, genotypic, and transcriptomic overlap between pure EPC and EPCi, the latter tumors are likely advanced lesions with PIK3CA activating mutations and enrichment of stromal-related genes implicated in the switch to IDC.

Papillary lesions of the breast: a review

Papillary breast lesions are rare breast tumors that comprise a broad spectrum of diseases. Pathologically they present as mass-like projections attached to the wall of the ducts, supported by fibrovascular stalks lined by epithelial cells. On mammogram they appear as masses that can be associated with microcalcifications. Ultrasound is the most used imaging modality. On ultrasound papillary lesions appear as homogeneous solid lesions or complex intracystic lesions. A nonparallel orientation, an echogenic halo or posterior acoustic enhancement associated with microcalcifications are highly suggestive of malignancy. MRI has proven to be useful to establish the extent of the lesion. Core needle biopsy is the gold standard for diagnosis. Surgical excision is usually recommended, although treatment for papillomas without atypia is still controversial.

The standard form of CD44 as a marker for invasion of encapsulated papillary carcinoma of the breast

Encapsulated papillary carcinoma (EPC), a rare variant of papillary carcinoma of the breast, is regarded as a transition form between carcinoma in situ and invasive carcinoma. Here, we tried to identify differences in immunohistochemical phenotype between 10 EPCs with invasive properties (EPC with invasion) and 17 non-invasive EPCs (EPC). We immunohistochemically assessed the expression of hormone receptors, matrix metalloproteinase (MMP) 2 and MMP9, vascular endothelial growth factor (VEGF), CD31, and D2-40, markers of tumor-associated macrophages (CD163, CD206), Ki-67 and stem cell markers (CD44 and CD24). The frequency of MMP9-positive cases and the number of tumor-associated macrophages infiltrating into the fibrous capsule were significantly higher in EPC with invasion than in EPC. The expression of the standard form of CD44 (CD44s) was significantly stronger in EPC with invasion than in EPC (P = 0.0036) and was correlated with MMP2 expression and M2-like macrophage infiltration. A multivariate logistic model analysis showed that CD44s expression in tumor cell and infiltration of CD163 positive macrophage in EPC capsule showed an independent odds ratio for invasion of EPC. Thus, CD44s may be a potential marker predicting invasive potential of EPC and could play an important role in progression to the invasive phase of EPC.

The genetic architecture of breast papillary lesions as a predictor of progression to carcinoma

Intraductal papillomas (IDP) are challenging breast findings because of their variable risk of progression to malignancy. The molecular events driving IDP development and genomic features of malignant progression are poorly understood. In this study, genome-wide CNA and/or targeted mutation analysis was performed on 44 cases of IDP, of which 20 cases had coexisting ductal carcinoma in situ (DCIS), papillary DCIS or invasive ductal carcinoma (IDC). CNA were rare in pure IDP, but 69% carried an activating PIK3CA mutation. Among the synchronous IDP cases, 55% (11/20) were clonally related to the synchronous DCIS and/or IDC, only one of which had papillary histology. In contrast to pure IDP, PIK3CA mutations were absent from clonal cases. CNAs in any of chromosomes 1, 16 or 11 were significantly enriched in clonal IDP lesions compared to pure and non-clonal IDP. The observation that 55% of IDP are clonal to DCIS/IDC indicates that IDP can be a direct precursor for breast carcinoma, not limited to the papillary type. The absence of PIK3CA mutations and presence of CNAs in IDP could be used clinically to identify patients at high risk of progression to carcinoma.

Mucosal inflammation in Candida esophagitis has distinctive features that may be helpful diagnostically

The diagnosis of Candida esophagitis can be challenging when the epithelium containing Candida filamentous forms is not readily seen or is entirely sloughed away. Mucosal inflammation could be helpful diagnostically, if distinctive. However it is thought to be nonspecific in Candida esophagitis. The goal of this retrospective study was to identify features of mucosal inflammation helpful in alerting a pathologist to the possibility of Candida esophagitis when Candida mycelia are not readily observed. The study group consisted of 99 consecutive cases of Candida esophagitis and a control group of 64 consecutive cases of reflux esophagitis diagnosed at our institution from 2008-2016. Band-like superficial intraepithelial neutrophils and increased intraepithelial lymphocytes were observed in 75 and 67% of Candida esophagitis cases, respectively and only in 14 and 19% of reflux esophagitis cases, respectively (p < .0001). Intraepithelial lymphocytes were peripapillary or CD4-predominant in 75% of Candida esophagitis cases with increased lymphocytes, in contrast to 17% of reflux esophagitis cases (p = .0011). Concurrent presence of intraepithelial neutrophils and increased lymphocytes showed increased specificity for Candida esophagitis and was observed in 61% of patients with Candida esophagitis and only in 2% of patients with reflux esophagitis (p < .0001). In addition, superficial band-like neutrophils were observed concurrently with increased peripapillary lymphocytes or CD4-predominant lymphocytes in 35 and 50% of Candida esophagitis cases, respectively, in contrast to no reflux esophagitis cases. Basal cell hyperplasia and elongation of stromal papillae were frequent in both groups. The data suggest that when Candida microorganisms are not readily observed, concurrent presence of superficial band-like neutrophils and increased lymphocytes may be indicative of Candida etiology of active esophagitis.

Diagnosis, treatment, and outcomes of encapsulated papillary carcinoma: a single institution experience

Background.

Encapsulated papillary carcinoma (EPC) is a rare entity of breast cancer accounting for approximately 1–2% of all breast tumours. There are no evidence-based guidelines for the treatment of EPC.

Materials and methods.

From the database of the National Centre of Pathology (NCP), we obtained pathology reports of 19 patients with histologically confirmed EPC, who were treated at the National Cancer Institute (NCI) in Vilnius, Lithuania, between July 2009 and July 2015. Demographic, diagnostic and treatment data were collected from medical records retrospectively.

Results.

During the indicated period, 19 patients with EPC were treated at the NCI. Three of them had pure EPC, they were 74 to 81 years of age at the time of diagnosis (mean 76.7 years, median 75 years); all of them are still alive and no disease progression has been observed. Seven patients had EPC associated with carcinoma in situ. Nine patients had EPC associated with invasive breast ductal carcinoma. All patients underwent surgery, in most cases – wide local excision. Only one patient died.

Conclusions.

EPC is a rare form of breast cancer and usually presents with an invasive breast carcinoma or carcinoma in situ in postmenopausal women. Tumours have an excellent prognosis in the cases of pure EPC and in both EPC associated with carcinoma in situ (CIS) and invasive carcinoma.

A possible role of FANCM mutations in male breast cancer susceptibility: Results from a multicenter study in Italy

INTRODUCTION

Breast cancer (BC) in men is a rare disease, whose etiology appears to be associated with genetic factors. Inherited mutations in BRCA1/2 genes account for about 10-15% of all cases. FANCM, functionally linked to BRCA1/2, has been suggested as a novel BC susceptibility gene. Our aim was to test if FANCM germline mutations could further explain male BC (MBC) susceptibility.

METHODS

We screened the entire coding region of FANCM in 286 MBCs by a multi-gene panel analysis, and compared these data with available whole exome sequencing data from 415 men used as population controls. Moreover, we genotyped the two most frequent FANCM mutations (c.5101C>T and c.5791C>T) in 506 MBCs and 854 healthy male controls.

RESULTS

Two FANCM truncating mutations, the c.1432C>T (p.Arg478Ter) and c.1972C>T (p.Arg658Ter), were identified in two MBC cases (0.7%). When specifically considering cases at increased genetic risk for BC, FANCM mutation frequency raises up to 1%. One mutation, the c.2201_2202delCT (p.Ser734Terfs), was found among controls (0.24%). Mutation frequency in cases was higher than in controls, however this difference was not statistically significant. FANCM c.5101C>T was not present in any of the cases and controls analyzed, whereas FANCM c.5791C>T was found in two controls (0.23%).

CONCLUSION

Rare FANCM truncating mutations, other than c.5101C>T and c.5791C>T, may have a role in MBC susceptibility. The inclusion of FANCM in gene panels for research purpose would allow for the identification of a higher number of mutation carriers, thus helping estimate BC risk associated with FANCM mutations.

Comparative genomic hybridization and transcriptome sequencing reveal that two genes, OsI_14279 (LOC_Os03g62620) and OsI_10794 (LOC_Os03g14950) regulate the mutation in the γ-rl rice mutant

We previously established the genetic locus of the rolled-leaf mutant, γ-rl, to chromosome 3. In this study, we performed a comparative genomic hybridization (CGH) analysis to identify the genes responsible for the γ-rl mutant phenotype. This was combined with RNA transcriptome sequencing (RNA-seq) to analyze differences in the mRNA expression in seeds 12 h after germination. Using the reference genome of the "indica type" rice from GenBank, we created a chip with 386,000 high density DNA probes designed to target chromosome 3. The genomic DNA from γ-rl and Qinghuazhan (the wild-type) was used for hybridization against the chip to compare signal differences. We uncovered 49 regions with significant differences in hybridization signals including deletions and insertions. RNA-seq analysis between γ-rl and QHZ identified 1060 differentially expressed genes, which potentially regulate numerous biological activities. Moreover, we identified 72 annotated genes in the 49 regions discovered in CGH. Among these, 44 genes showed differential expression in RNA-seq. qRT-PCR validation of the candidate genes confirmed that seven of the 44 genes showed a significant change in their expression levels. Among these, four genes [OsI_10125 (LOC_Os03g06654), OsI_14045 (LOC_Os03g62490), OsI_14279 (LOC_Os03g62620) and OsI_14326 (LOC_Os03g63250)] were down regulated and three genes [(OsI_10794 (LOC_Os03g14950), OsI_11412 (LOC_Os03g21250) and OsI_14152 (LOC_Os03g61360)] were up regulated with a fold change ≥2.0 and a P value ≤ 0.01. Finally, we constructed transgenic plants to study the in vivo functions of these genes. RNAi knock down of LOC_Os03g62620 resulted in rolled-leaf, lower seed-setting and decreased seed growth phenotypes. Transgenic plants with LOC_Os03g14950 over-expression showed dwarf plants with a shortened leaf phenotype. Our results, LOC_Os03g62620 and LOC_Os03g14950 as the essential genes responsible for creating the γ-rl mutant phenotypes suggested that these genes may play crucial roles in regulating rice leaf development and seed growth.

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.

Pathological criteria and practical issues in papillary lesions of the breast - a review

Papillary lesions of the breast include a broad spectrum of lesions, ranging from benign papilloma, papilloma with atypical ductal hyperplasia (ADH) or ductal carcinoma in situ (DCIS) to papillary carcinoma. The accurate diagnosis of mammary papillary lesions is a challenge for pathologists, owing to the overlapping features among these lesions. In this review, some of the diagnostic criteria of papillary lesions are discussed, with special emphasis on some key morphological features, namely fibrovascular cores, epithelial proliferation in a solid pattern, intraductal papilloma complicated by ADH or DCIS, and invasion and its mimics. The roles of immunohistochemistry, and the interpretation of myoepithelial cell markers, hormone receptors, and high molecular weight cytokeratin, are addressed. Finally, novel biomarkers and genetic aberrations in papillary lesions are summarized.

Practical Considerations in Breast Papillary Lesions: A Review of the Literature

Context.—Diagnosis of papillary breast lesions, especially in core biopsies, is challenging for most pathologists, and these lesions pose problems for patient management. Distinction between benign, premalignant, and malignant components of papillary lesions is challenging, and the diagnosis of invasion is problematic in lesions that have circumscribed margins. Obtaining a balance between overtreatment and undertreatment of these lesions is also challenging.

Objectives.—To provide a classification and a description of the histologic and immunohistochemical features and the differential diagnosis of papillary breast lesions, to provide an update on the molecular pathology of papillary breast lesions, and to discuss the recommendations for further investigation and management of papillary breast lesions. This review provides a concise description of the histologic and immunohistochemical features of the different papillary lesions of the breast.

Data Sources.—The standard pathology text books on breast pathology and literature on papillary breast lesions were reviewed with the assistance of the PubMed database (http://www.ncbi.nlm.nih.gov/pubmed).

Conclusions.—Knowledge of the clinical presentation, histology, immunoprofile, and behavior of papillary breast lesions will assist pathologists with the diagnosis and optimal management of patients with papillary breast lesions.

Intracystic Papillary Carcinoma in Male Breast with High Nuclear Grade: A Case Report

Intracystic papillary carcinoma (IPC) in men is an extremely rare disease that accounts for less than 1% of all malignancies with only a few case presentations published so far. This report presents a case of 53-year-old male, who presented a painless swelling of his left breast. The left breast mass was 6 cm maximally and was found to be non-invasive IPC. The tumour is consistently positive for GCDFP-15, ER or PR and negative for HER-2. It consists of predominantly fibrovascular stromal lined by monotonous epithelial cells retaining intermediate to high histological grade with a high nuclear cytoplasmic ratio. In addition, increased numbers of mitotic figures were also seen. Chest X-ray, liver ultrasound and bone centigram showed no evidence of distant metastases. In short, this is the first case report from Saudi Arabia of a male having IPC, with increased number of mitotic figures and high nuclear grades.