Papillary neoplasms of the breast including upgrade rates and management of intraductal papilloma without atypia diagnosed at core needle biopsy

Malignant upgrade rate and associated clinicopathologic predictors for concordant intraductal papilloma without atypia: A systematic review and meta-analysis

Previously reported upgrade rates for benign breast intraductal papilloma (IDP) are widely variable. However, many previous studies have failed to consider radiologic-pathologic discordance of lesions. This review aims to synthesize malignant upgrade data for benign, concordant IDP at surgical excision. Thirteen studies were included in our meta-analysis. The pooled estimate for percentage underestimation of carcinoma was 1.4% (95% CI: 0.8%-2.0%). We conclude that these lesions can be safely managed by active surveillance.

Invasive papillary carcinoma of the breast

Invasive papillary carcinoma is a rare form of breast cancer that is more likely to occur in postmenopausal women. Previous studies have been limited to case reports and small retrospective studies, leading to low awareness of this type of tumor and difficult clinical management. According to the available literature, invasive papillary carcinoma exhibits unique pathological features and biological behaviors. Invasive papillary carcinoma is mostly luminal type, with a low rate of lymph node metastasis, which underlies its favorable prognosis. The effectiveness of adjuvant therapy in reducing tumor burden and improving prognosis in patients with invasive papillary carcinoma remains uncertain. Due to the rarity of the lesion, conducting prospective clinical trials is impractical. The use of biological models, such as organoids, can help alleviate the impact of the scarcity of this condition on research. In addition, invasive papillary carcinoma is affected by specific genomic events, and more extensive studies of gene expression profiling may provide molecular-level insights to make optimal therapeutic decisions.

Diagnostic Pitfalls in Breast Cancer Pathology With an Emphasis on Core Needle Biopsy Specimens

CONTEXT.—

Breast pathology has many mimics and diagnostic pitfalls. Evaluation of malignant breast lesions, particularly in the biopsy setting, can be especially challenging, with diagnostic errors having significant management implications.

OBJECTIVE.—

To discuss the pitfalls encountered when evaluating ductal carcinoma in situ and invasive breast carcinomas, providing histologic clues and guidance for appropriate use and interpretation of immunohistochemistry to aid in the correct diagnosis.

DATA SOURCES.—

Data were obtained from review of pertinent literature of ductal carcinoma in situ and invasive breast carcinomas and from the experience of the authors as practicing breast pathologists.

CONCLUSIONS.—

Awareness of the pitfalls in diagnosing breast cancers is important when creating a differential diagnosis for each breast lesion evaluated. This review will cover some of these scenarios to aid in the diagnostic process.

Axillary chest wall solid-papillary carcinoma: A case report on presentation and management

Papillary breast carcinomas comprise <1% of all breast cancers. They are notorious among surgical pathologists for posing diagnostic difficulty, especially with small sample sizes, such as a core-needle biopsy and carry potential for overtreatment. Solid-papillary carcinoma is a subtype of papillary breast carcinomas that affects elderly females and generally has a favorable diagnosis in its in-situ form. This report focuses on the unique and clinically aggressive presentation and treatment of invasive solid-papillary carcinoma that was discovered along the axillary chest wall after an ipsilateral mastectomy for multifocal ductal carcinoma in situ.

Contrast-enhanced ultrasound combined with ultrasonic elastography to diagnose encapsulated papillary carcinoma: A case report

Encapsulated papillary carcinoma is a rare malignant breast tumor with low malignancy, and is most commonly found in postmenopausal women. On ultrasound, encapsulated papillary carcinoma has an envelope, and anechoic areas inside the lesion. Contrast-enhanced ultrasound shows marked enhancement without size expand, and ultrasonic elastography suggests soft parenchyma in the lesion. However, it is often challenging to differentiate between encapsulated papillary carcinoma and other breast tumors, especially some benign lesions. Here, we reported a case of encapsulated papillary carcinoma in a 65-year-old female patient who discovered a breast mass three years ago and presented with nipple discharge and pain six months before. This case report demonstrated the ability of multimodal ultrasound to diagnose encapsulated papillary carcinoma.

Upgrade Rates of Intraductal Papilloma with and without Atypia Diagnosed on Core Needle Biopsy and Clinicopathologic Predictors

Surgical excision of breast intraductal papilloma (IDP) without atypia diagnosed on core needle biopsy (CNB) is controversial as the risk of upgrade to malignant lesions is not well established. This study investigates upgrade rates of benign and atypical IDP to ductal carcinoma in situ (DCIS) and invasive carcinoma (IC) and clinicopathologic predictors. We identified 556 cases of IDP diagnosed on CNB at a single institution from 2010-2020 after excluding patients with a history of breast carcinoma, ipsilateral high-risk lesion, radiologic/pathologic discordance, or less than 2 years of follow-up if no excision within one year. Of these, 97 biopsies were consistent with atypical IDP and 459 were benign IDP. Surgical excision was performed for 318 (57.2%), and the remaining 238 (42.8%) underwent active monitoring. The upgrade rate for IDP without atypia was 2/225 (0.9%; 1 DCIS and 1 IC). Of 93 surgically excised atypical IDPs, 19/93 (20.4%) upgraded (14 DCIS and 5 IC). Of 238 non-excised IDPs followed clinically (range 24-140 months, mean 60 months), there was no subsequent breast cancer diagnosed at the IDP site on follow-up. Mean age of patients was 56 yr±12.6sd without upgrade, 63 yr±10.6sd (p value=0.027) with DCIS, and 61 yr±10.8sd (p value=0.35) with IC. Atypical IDP was more likely to upgrade if biopsied by stereotactic guidance (8/19, 42.1% p=0.035). At our institution, we had an exceedingly low upgrade rate for benign IDP. Overall, patients with upgrade to DCIS were older. For atypical IDP, upgrade was seen in higher proportions of stereotactic biopsies.

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.

Papillary Neoplasms of the Breast: Diagnostic Features and Molecular Insights

Papillary neoplasms of the breast are a heterogeneous group of tumors characterized by fibrovascular cores lined by epithelium, with or without myoepithelial cells. Papillary neoplasms include benign, atypical, and malignant tumors that show varying histopathologic features and clinical outcomes. Appropriate pathologic classification is crucial to guide clinical treatment. Classification of papillary neoplasms is largely based on morphology, with immunohistochemistry playing an ancillary role to establish diagnoses. Recent molecular studies have provided insight into the genomics of these lesions. This review summarizes the histologic, immunohistochemical, and molecular features of papillary neoplasms of the breast that are important for diagnosis and treatment.

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.

Galactography Combined with Sonogalactography for Improving the Evaluation of Pathological Nipple Discharge

Diagnosing patients with pathological nipple discharge (PND) is controversial, and therefore a standardized diagnosis algorithm is needed. The objective of this study was to investigate the usefulness of galactography (GL) combined with sonogalactography (SGL) for the evaluation of PND patients. A retrospective study was conducted of 51 patients with PND who were evaluated with GL and SGL. The findings from the galactograms of the patients in this study were assigned to different categories of the Galactogram Image Classification System. Additionally, the sensitivity, specificity, and the positive predictive values and negative predictive values of the GL and SGL tests were calculated, considering the gold standard of pathology diagnosis. The results obtained show that GL combined with SGL improved the diagnostic efficiency of ductal lesions, especially for borderline and malignant lesions. Papilloma was diagnosed in 19 cases, and ductal carcinoma in situ in 8 patients. Conclusions: To the best of our knowledge, this is the first study in which the combination of GL and SGL improves the diagnostic efficiency of ductal lesions of patients with PND. A diagnosis algorithm is recommended for women with PND.