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.

Challenging diagnosis of male intraductal papilloma masquerading as eccrine hidradenoma in the breast: Case report

RATIONALE

This article presents a challenging case involving an elderly male patient with a misdiagnosed intraductal mammary papilloma initially identified as a sweat adenoma through ultrasound imaging. The study aims to explore the histopathology, clinical presentations, and sonographic features of both conditions, emphasizing the contributing factors to the diagnostic misstep.

PATIENT CONCERNS

A 61-year-old male reported a persistent left breast mass, along with pain and swelling, spanning a 6-month duration.

DIAGNOSES

Ultrasound examination indicated a deep, square, mixed-echo mass in the left nipple, initially suggestive of a sweat adenoma. However, subsequent pathological analysis following resection under general anesthesia confirmed an intraductal papilloma.

INTERVENTION

The patient underwent surgical resection of the left breast mass under general anesthesia.

OUTCOME

Post-surgery, the patient exhibited satisfactory recovery; however, regrettably, he was lost to follow-up.

LESSONS

This study underscores the challenge in differentiating between clear cell sweat adenoma and male intraductal mammary papilloma solely based on ultrasonic characteristics. It emphasizes the susceptibility of ultrasound-based diagnoses to misinterpretation, highlighting the critical need for a comprehensive pathological examination to establish a definitive diagnosis.

Treatment Strategy for Breast Benign Intraductal Papilloma: A Meta-Analysis

Currently, the optimal treatment approach for breast benign intraductal papilloma (IDP) diagnosed via biopsy remains uncertain. There is ongoing debate regarding the feasibility of clinical follow-up and the criteria for selective surgical excision. This study aims to conduct a meta-analysis to determine the rate of upgrade from breast benign IDP and identify predictive factors associated with the conversion of benign IDP to high-risk lesions or carcinoma, which could guide healthcare practitioners in selecting the appropriate clinical treatment strategy. We conducted a comprehensive search across multiple databases (PubMed, Web Of Science, Cochrane Library, and Embase) for studies published between 2012 and 2023 that evaluated upgrade rates and predictive factors of breast benign IDP diagnosed via biopsy. In addition, we included studies that reported on the clinical follow-up of patients with breast benign IDP. In total, 32 studies comprising 7371 cases of biopsy-diagnosed breast benign IDP were included. Among these cases, 720 demonstrated an upgrade to high-risk lesions or carcinoma, resulting in an upgrade rate of 6.94% [95% confidence interval (CI): 3.0-8.0%]. A subgroup of 1713 patients was clinically followed up, demonstrating an average follow-up duration of 30.95 months. Among them, 26 cases experienced an upgrade to high-risk lesions or carcinoma, yielding an upgrade rate of 1.51% (95% CI 0.00-2.00). Furthermore, we identified nine predictive factors associated with the upgrading of breast benign IDP, which included age at diagnosis, personal history of breast cancer, family history of breast cancer, multiple IDPs, lesion size ≥ 10 mm, palpable mass, calcification, and the presence of mass and asymmetry in mammographic findings. Although the conversion rate of breast benign IDP to high-risk lesions or carcinoma is relatively low, timely identification of predictive factors associated with benign IDP upgrades may help selecting the optimal clinical treatment strategy, such as surgery for patients with benign IDP presenting one or more predictive factors, while clinical follow-up for those without specific risk factors.

Intraductal papilloma with atypical ductal hyperplasia and neuroendocrine differentiation as a possible precursor lesion of solid papillary carcinoma

Breast papillary neoplasms include a wide range of tumor types, and their pathological diagnosis is sometimes difficult. Furthermore, the etiology of these lesions is still not fully understood. We report the case of a 72-years-old woman referred to our hospital with bloody discharge from the right nipple. An imaging study detected a cystic lesion, including a solid component contiguous with the mammary duct, in the subareolar region. The lesion was then removed by segmental mastectomy. Pathological examination of the resected specimen revealed an intraductal papilloma with atypical ductal hyperplasia. Moreover, the atypical ductal epithelial cells expressed neuroendocrine markers. The presence of an intraductal papillary lesion with neuroendocrine differentiation suggests solid papillary carcinoma. Thus, this case suggests that intraductal papilloma could be a precursor of solid papillary carcinoma.

Bloody nipple discharge due to intraductal papilloma in an adolescent girl

An early adolescent girl was referred to our breast surgery clinic with multiple right-sided breast masses and several months of unilateral bloody nipple discharge. MRI demonstrated multiple enhancing masses in the right breast with intrinsic hypertensive T1 signal of the ducts extending to the nipple. A biopsy showed partially sclerosed intraductal papillomas without atypia or malignancy. Following extensive counselling with the patient and her family, two palpable breast masses and a single central breast duct responsible for bloody nipple discharge were fully excised. Histopathological analysis showed unique overlapping features of resembling intraductal papilloma, nipple adenoma and fibroadenomas. The patient has had resolution of her bloody nipple discharge and excellent cosmetic outcomes post-surgery. Intraductal papilloma is rare in the adolescent population and the risk of concurrent and future malignancy is not well established. Thus, a tailored approach to the work-up and management of paediatric breast masses is essential.

[A Case of Intraductal Papilloma of the Male Breast]

Male breast cancer accounts for approximately 1% of the overall incidence of breast cancer. We report a rare case of intraductal papilloma(intracystic papilloma)in a 73-year-old man, which was suspected to be breast cancer as it presented as an approximately 6 cm mass below the left nipple in various imaging studies. The patient was aware of a mass measuring a few millimeters below the left nipple for 5 years, but had not sought treatment. He visited our department 3 months after redness and pain were noted around the nipple; the mass had enlarged. Palpation revealed a 6 cm smooth-surfaced mass as well as nipple retraction; diagnostic imaging showed a cystic tumor with a solid internal structure. Fine-needle aspiration cytology and core needle biopsy did not indicate a definitive diagnosis, and a left mastectomy and sentinel lymph node biopsy were performed based on a preoperative diagnosis of breast cancer. Pathological examination confirmed the diagnosis of intraductal papilloma, based on findings such as infarction-induced hemorrhagic necrosis, stromal and epithelial proliferation, apocrine metaplasia, and squamous epithelial metaplasia. Reports of a large-diameter intraductal papilloma(intracystic papilloma)suspicious for breast cancer in men are rare; therefore, surgical resection and detailed histopathological exploration of the whole tumor were required.

Upgrade rate of intraductal papilloma diagnosed on core needle biopsy in a single institution

The management of intraductal papilloma (IDP) diagnosed on core needle biopsy (CNB) is controversial due to the variable upgrade rates to breast carcinoma (BC) on subsequent surgical excision reported in the literature. The purpose of our study was to investigate the upgrade rate of IDP diagnosed on CNB to BC in subsequent surgical excision and the impact of clinical, pathologic, and radiologic variables. This is a retrospective cohort of all women who had a diagnosis of IDP on a CNB between 2005 and 2018 in a tertiary academic center with subsequent surgical excision. Upgrade was defined as ductal carcinoma in situ (DCIS) and invasive carcinoma on surgical excision. Statistical analyses included Pearson's chi-square, Wilcoxon rank-sum, and logistic regression. A total of 216 women with IDP in a CNB were included. Nineteen patients (8.8%) upgraded to BC in the overall cohort, including 14 DCIS and 5 invasive carcinomas. An upgrade rate of 27% was found in atypical IDP (14 of 51 cases), while only 3% of pure IDP upgraded to BC (5 of 165 cases). Older age (>53 years) at the time of biopsy (odds ratio [OR] = 1.05, 95% confidence interval [CI] = 1.01-1.09, p = 0.027) and concomitant atypical ductal hyperplasia (ADH) (OR = 9.69, 95% CI = 3.37-27.81, p < 0.0001) were significantly associated with upgrade. Our results support surgical excision of IDP on CNB when associated with ADH or diagnosed in women aged older than 53 years. The low surgical upgrade rate of 3% for pure IDP on CNB in younger women should be part of the management discussion.

Treatment and Outcome of 341 Papillary Breast Lesions

BACKGROUND

Papillary breast lesions constitute a pathological heterogeneous group and display diverse clinical and imaging features. This study was conducted to analyze the upgrade rate of intraductal papilloma diagnosed on core needle biopsy and to assess the possible risk factors associated with upgrade to higher-risk lesions. We also examined the long-term outcomes in patients who received resection of the papillary lesions.

MATERIALS AND METHODS

The clinical and pathology records of 324 female patients who were diagnosed with papillary lesions based on core needle biopsy (CNB) from February 2010 to October 2016 at our institution were retrospectively analyzed. Patients were grouped by initial diagnosis into two groups (papilloma with or without atypia) and followed-up for long-term outcomes. For the upgrade to higher-risk lesions after excision, upgraded lesions were compared with benign papillomas for the collected variables.

RESULTS

A total of 341 lesions were included for final analysis, and all were available for follow-up. Papillomas with or without atypia diagnosed by CNB were found in 9 and 332 lesions, respectively. Papillomas without atypia on CNB were treated by open excision (n = 265) or vacuum-assisted biopsy (VAB) (n = 67), which yielded similar event-free rate (p = 0.19). The upgrade rate of this group to higher-risk lesions was 9.9%. Peripheral (p = 0.011) lesions in postmenopausal (p = 0.001) or older (p = 0.001) patients with papillomas without atypia based on CNB showed significantly higher upgrade rates. Papillomas with atypia on CNB were all managed by open excision, and concurrent malignancy was found in two lesions.

CONCLUSION

In conclusion, our results support benign papillary lesions based on CNB require further treatment. Peripheral lesions occurring in older or postmenopausal women are at higher risk for upgrade.

Intraductal papilloma arising from the accessory parotid gland: A case report and literature review

RATIONALE

Intraductal papillomas of the accessory parotid glands are extremely rare benign tumors that are most commonly derived from minor salivary glands and are easily misdiagnosed as other diseases. Studying these lesions by pathology and immunohistochemistry can raise awareness of the disease, reduce the rate of misdiagnosis, and provide more precise treatments.

PATIENT CONCERNS

A 35-year-old man first presented to our hospital with a 6-month history of a painless mass on his left parotid gland.

DIAGNOSES

The patient was diagnosed with intraductal papilloma of the accessory parotid gland by pathology and immunohistochemistry.

INTERVENTIONS

The mass was completely resected.

OUTCOMES

After 2 years of postoperative follow-up, the patient recovered well without recurrence.

LESSONS

Intraductal papilloma of the accessory parotid gland is very rare, and can easily be misdiagnosed as sialadenoma papilliferum, inverted ductal papilloma, or papillary cystadenoma, among others. It is necessary to analyze its pathology and immunohistochemistry in comparison with other diseases. Early excision and long-term follow-up are necessary to provide optimal treatment and to better understand the pathological processes of intraductal papilloma.

Papillary Breast Lesions: Association with Malignancy and Upgrade Rates on Surgical Excision

Intraductal papilloma falls under the category of benign breast mass. However, recent studies show that it can harbor occult carcinoma. The management of benign intraductal papilloma remains controversial because of its nonspecific radiologic and histological findings, as well as its association with surrounding malignant pathology. The purpose of this study is to investigate upgrade rates of a benign intraductal papilloma on surgical excision and the need for surgical excision of papillary lesions diagnosed at core needle biopsy. A retrospective review of a single institution's pathology database between 2011 and 2015 identified 43 core biopsies with benign papilloma. We followed the upgrade rates of these lesions on surgical excision. There were 90 biopsies with the diagnosis of benign intraductal papilloma. The average age was 55.2 (range from 24-87 years old). Forty-three had benign intraductal papilloma; 28 of the 43 core biopsies had surgical excision. Two (7.1%) had an upgrade from benign intraductal papilloma to intraductal papilloma with atypia. One (3.6%) had an upgrade to ductal carcinoma in situ. None had invasive cancer. Surgical findings were in agreement with core biopsies in 25 (89.3%) of 28 cases (κ = 0.80, P < 0.0001). Core biopsies have a statistically significant correlation with pathologies on surgical excision in detecting atypia in breast lesion as demonstrated by κ = 0.80. However, the study shows benign intraductal papillomas on core biopsy have an upgrade rate of 10.7 per cent after undergoing surgical excision. As such, we recommend a more aggressive approach including surgical excision of all benign intraductal papillary lesions.

Papillary Lesions of Breast

INTRODUCTION

Papillary breast lesions constitute a pathological heterogeneous group and are characterized by growth in the milk ducts. In this study, we aimed to present in view of literature patients who underwent lumpectomy due to breast mass and with papillary lesion in histopathological examination.

MATERIAL METHOD

The pathology records and informations of 42 patients who were operated between 2006-2014 in our clinic and considered to have papillary lesion in histopathological examination were examined retrospectively. The patients were evaluated for age, gender, complaints, lesion localizations, performed surgery, histopathological type, follow-up period and the lesions occurring during follow-up.

FINDINGS

The excisional biopsy in the form of lumpectomy was made to 34 patients who were reported as benign papillary lesion in coreneedle biopsy performed. The lesion in 11 patients were marked preoperatively by radiology clinic. 33 patients who had benign papillary lesion in excisional biopsy were followed. Modified radical mastectomy was performed to a total of 9 patients including 1 patient with malignant papillary lesion in excisional biopsy and 8 patients with malignant papillary lesion in coreneed lebiopsy.

RESULT

Histopathological diagnosis should be confirmed by performing definitely excisional biopsy in patients who detected benign papillary lesions by coreneedle biopsy and strict clinical follow-up should be made for developing malignancies in patients who detected benign papillary lesions.

[A woman with a large mass in the breast]

A 45-year-old woman presented with a palpable mass in the right breast. Ultrasound and mammography showed a cystic mass measuring 5 cm, with a solid component. The diagnosis 'intraductal papilloma' was made, based on the histological findings after biopsy. We performed lumpectomy and the diagnosis was confirmed by immunohistochemistry. Six months later, there were no signs of recurrence.

Intraductal papillary lesions of the breast: clinical and pathological correlation

Papillary lesions of the breast range from a spectrum of benign intraductal papillomas with and without atypia to papillary carcinoma. Distinction between benign and malignant lesions on core needle biopsy (CNB) is difficult without surgical excision. We examined if clinical findings in patients with benign intraductal papillomas (IP) on CNB correlate with pathology at surgical excision. Between 1998 and 2011, 103 patients were identified with a papillary lesion on CNB. Clinical variables were studied to determine if there was clinical correlation with pathological outcomes at final surgical excision. Of the 103 patients, 59 (57%) patients had IP on initial CNB and were included in our analysis. On final pathology, 17 (29%) of these were upstaged to intraductal papilloma with atypia and six (10%) were found to have carcinoma. A clinically palpable mass was the only significant predictor of upstaging to malignancy (P<0.05). No radiographic findings were found to be significant predictors of pathological upstaging. In conclusion, surgical excision is still recommended for benign papillary lesions diagnosed on CNB because the correlation with clinical and radiological findings does not assure benign pathology.

The accuracy of the 'triple test' in the diagnosis of papillary lesions of the breast

BACKGROUND AND OBJECTIVE

The literature on fine-needle aspiration (FNA) cytology for papillary lesions presents a very mixed picture. Many authors advocate mandatory excision of these lesions. This recommendation is largely based on the 'atypical' nature of the FNA report. The aim of this work is to see if breast papillomas can be treated conservatively.

STUDY DESIGN

We report a retrospective study of outcomes for patients with a provisional diagnosis of a 'papillary breast lesion' based on assessment by palpation (no clinically suspicious features), sonography (benign or probably benign according to the Breast Imaging Reporting and Data System 'BI-RADS®'), and FNA (benign cytological category with a papillary architecture) findings from one integrated breast service.

RESULTS

Thirty-six cases were identified over a period of 6 years. Thirty-four of the patients had surgical excision. All of the 34 surgical cases were confirmed to be benign in nature on histopathology (intraduct papilloma). The remaining 2 cases were stable on follow-up.

CONCLUSION

We believe that a policy of mandatory excision of papillary lesions of the breast is unnecessarily cautious.

Enlarging unilateral breast mass in an adolescent male: an unusual presentation of intraductal papilloma

Breast masses presenting in adolescent boys are rare and are almost uniformly owing to gynecomastia. Although surgical referral for breast masses in adolescent boys is common, intervention is typically for cosmesis. We report the case of a 14-year-old boy who presented with an enlarging unilateral breast mass, which was found to be owing to an intraductal papilloma at the time of surgical excision.

Carcinoma within solitary ductal papilloma of the breast

BACKGROUND

Solitary ductal papilloma of the breast, traditionally considered a benign disorder, was recently found to have malignant potential, especially when associated with atypical ductal hyperplasia.

METHODS

All patients diagnosed with solitary ductal papilloma at a tertiary medical center from 1994 to 2004 were identified by a database search. Background, clinical and pathological data were collected for those with a carcinoma within the papilloma, and their pathological specimens were revised.

RESULTS

Of the 3849 breast biopsies performed in our medical center during the study period, 77 (2%) yielded a solitary ductal papilloma. In 12 cases (15.6% of all solitary ductal papillomas; 0.3% of all breast biopsies), a carcinoma was found within the papilloma. Ten were diagnosed as carcinoma in situ and 2 as microinvasive carcinoma.

CONCLUSION

In the present series, the incidence of carcinoma within solitary ductal papilloma was 15.6%, indicating that solitary ductal papillomas have malignant potential.

SUMMARY

Carcinoma within solitary ductal papilloma of the breast was found in 15.6% of all papillomas. This seems to indicate a malignant potential of papillomas and the need for surgical excision.

Pancreatic intraductal papillary mucinous neoplasms: a paradigmatic case. A case report and review of the literature

Pancreatic intraductal papillary mucinous neoplasms constitute an increasingly frequent clinical entity. The definition and clinical behaviour of these tumours are still a subject of debate. As a consequence, their clinical management is also presents controversial aspects ranging from follow-up to the advisability or otherwise of an aggressive surgical approach, even in the case of small non-malignant lesions. In 2002 we observed a patient affected by a large pancreatic mass with the endoscopic and radiological features of an intraductal papillary mucinous tumour. Over a 20-year clinical history the patient had been considered and treated as affected by chronic pancreatitis. In spite of the tumour size and possible vascular infiltration, surgical exploration was considered. Total pancreatectomy was performed and final histology revealed a non-invasive papillary mucinous carcinoma of the pancreas. Twenty-six months after surgical resection the patient is alive and free of disease. In the present paper we re-assess the clinical history of this patient and review the most recent literature on such tumours.

[A comparison of localization by ductoscopy-guided wire and conventional methods in terminal duct excision for women with pathological nipple discharge]

OBJECTIVE

To evaluate and compare localization by ductoscopy-guided wire with localization by conventional methods in the terminal duct excision for women with pathological nipple discharge.

METHODS

Breast terminal duct excision were performed in 174 consecutive patients with intraductal lesions diagnosed by mammary ductoscopy. Sixty-eight of those underwent ductoscopy-guided wire localization for more accurate ductal excision. The patients received mammary ductoscopy and a hooked wire was anchored at the intraductal lesions under endoscopic surveillance just before the operation. Then a biopsy resection of wire-guided terminal duct and frozen section were done. Tbe other 106 patients received terminal duct excision under localization with conventional methods without ductoscopy either by puncturing a needle or injection of blue dye through the duct with pathological discharge.

RESULTS

Of the 68 patients with ductoscopy-guided duct excision, 64 had intraductal papillomas and 4 duct carcinoma in situ proved by pathology. All the lesions in these 68 patients were completely resected during biopsy without extra extended resection, and the concordance rate of the pathological result with ductoscopic diagnosis was 100.0%. None of them developed a postoperative breast distortion. In the conventional method localization group, there were 96 intraductal papilloma, 6 duct carcinoma in situ and 4 adenosis. Only 77.4% of the lesions were excised in the primary biopsy, and 22.6% needed extended resection. The concordance rate of the pathological diagnosis with ductoscopic diagnosis was 96.2%. Twenty-six patients had a deformed breast postoperatively.

CONCLUSION

Ductoscopy-guided wire localization is superior to the conventional localization method in the surgical terminal duct excision for women with spontaneous nipple discharge. It is not only helpful for more accurate localization and resection as well as pathologic sampling, but also is minimally invasive. Further studies are still required and this method may deserve to be popularized.

[Breast intraductal lesion resection under breast fiberoptic ductoscopy]

OBJECTIVE

To explore the feasibility and to sum up the experience of breast intraductal neoplasm resection under breast fiberoptic ductoscopy (FDS).

METHODS

FDS was performed on 548 patients with nipple discharge from Sep.2004 to Nov.2006. The clinical data of breast intraductal neoplasm found by FDS in patients who underwent tumor resection were analyzed, and the breast intraductal neoplasm image characteristics, diagnosis, operative type and postoperative pathological results were analyzed.

RESULTS

Of the 548 patients with nipple discharge, intraductal neoplasm was found in 187 cases (34.1%), intraductal papilloma in 159 cases (29.0%), intraductal papillomatosis in 12 cases (2.2%), and breast carcinoma in 16 cases (2.9%). One hundred thirty-five patients were operated on in our hospital, of whom 91 were performed tumor resection or segmentectomy under the localization by FDS, and the other 44 were performed segmentectomy after breast duct infusion of methylene blue. The diagnostic rate under FDS in the FDS group (97.8%) was higher than that in the breast duct infusion methylene group (86.4%) (chi2=6.96, P=0.008).

CONCLUSION

FDS is not only an accurate diagnosis for breast intraductal lesion, but also an assistance to localize the breast intraductal neoplasm and to remove them in the operation.

[Risk evaluation for malignant transformation breast intraductal papilloma]

AIM

To evaluate the risk evaluation for malignant transformation breast intraductal papiloma.

MATERIALS AND METHODS

277 women with pathologic nipple discharge were evaluated and operated on during 1994-2005. Nipple discharge was unilateral in 217 patients and bilateral in 60. The main diagnostic methods were clinical examination, ductography, discharge cytology. Cytologycal test was of greatest evidence. All 277 women were with small multiple papillomes. We found carcinoma in only 3 cases--1 intraductal and 2 invasive ductal carcinomas.

CONCLUSION

According to our results 1.1% of our patient were with malignant potential.

[Benign papilloma: is US-guided vacuum-assisted breast biopsy an alternative to surgical biopsy?]

The purpose of this study is to assess the value of US guided vacuum-assisted breast biopsy compared to surgery for management of intraductal papilloma. This retrospective study included 13 patients with hypoechoic nodular lesion corresponding to small benign intraductal papillomas on biopsy and visible by US. The lesions were removed using US-guided vacuum-assisted biopsy and all tissue material was reviewed at histology. The mean size of papillomas was 9.3 mm (5-16 mm). Vacuum-assisted tumor removal was considered total for all 13 lesions. Maximum follow-up was 57 months. Two patients had tumor recurrence at 22 and 28 months respectively. In one case, atypical ductal hyperplasia was present at the periphery of the papilloma, requiring complementary surgery. US-guided vacuum-assisted excision of small benign tumors such as solitary intraductal papillomas appears to be an alternative to surgical biopsy. Because of the large volume of tissue removed, total tumor excision is possible allowing detection of incidental associated lesions.

Fine needle aspiration biopsy for preoperative workup of pancreatic cystic neoplasms: report of 4 cases

BACKGROUND

Cystic neoplasms of the pancreas comprise a pathologically heterogeneous group of lesions that usually present with similar, nonspecific clinical features. Based on the diagnosis, treatment varies from watchful observation of the lesion to total surgical resection of the pancreas. Therefore the importance of a precise and accurate diagnosis on fine needle aspiration (FNA) biopsy cannot be overemphasized from the patient management standpoint. There is debate regarding the accuracy of FNA diagnosis of cystic lesions of the pancreas. We report 4 cases and review the literature to explore and highlight the cytologic findings and diagnostic pitfalls that may help the cytopathologist accurately distinguish mucinous cystic neoplasm (MCN), intraductal papillary mucinous neoplasm (IPMN), serous cystadenoma (SCA) and ductal adenocarcinoma (DAC).

CASES

We present 4 cases of patients with abdominal masses who underwent either computed tomography (CT)-guided or endoscopic ultrasound (EUS)-guided FNA biopsy as preoperative workup. Based on the cytologic diagnosis, the patients underwent surgery.

CONCLUSION

Our cases illustrate the cytologic criteria that help the cytopathologist distinguish among MCN, IPMN, SCA and DAC. Correlation with clinical and radiologic findings is strongly advocated for accurate diagnosis. We describe the diagnostic pitfalls frequently encountered in these cases and how to avoid them.

Breast cancer from the excisional scar of a benign mass

Breast cancer developing from a surgical scar is rare; this type of malignancy has been reported in only 12 cases to date. Herein, we report on a 52-year-old female who developed infiltrating ductal carcinoma in a surgical scar following excision of a benign mass. Two years previously, the patient underwent surgery and radiotherapy for invasive ductal carcinoma of the contralateral breast. The initial appearance of the scar was similar to fat necrosis; it was observed to be progressively shrinking on follow-up sonography. On the two year follow-up ultrasound, the appearance changed, an angular margin and vascularity at the periphery of the scar were noted. A biopsy and subsequent excision of the scar were performed; the diagnosis of infiltrating ductal carcinoma of the scar was confirmed.

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.

[Stereotactic vacuum core biopsy of clustered microcalcifications classified as B1-RADS 3]

PURPOSE

Evaluation of stereotactic vacuum core biopsy of clustered microcalcifications categorized as BI-RADS 3.

MATERIAL AND METHODS

86 patients with microcalcifications BI-RADS 3 (probably benign, < 3% malignant) underwent a stereotactic vacuum core biopsy (Mammotome, Fa. Ethicon Endo-Surgery Breast Care) using a digital stereotactic unit (Mammotest, Fa. Fischer Imaging). The removal of the calcifications was judged by two radiologists in consensus and classified as complete (100%), major (55-99%) or incomplete (< 50%).

RESULTS

4/86 patients could not be evaluated by vacuum core biopsy due to the localization of the microcalcifications close to the skin or lack of detection. In 40/82 cases a complete, in 38/82 a major, and in 4/82 a incomplete removal was achieved. Histology revealed 67 cases of fibrocystic changes, 4 papillomas, 4 fibroadenomas, 4 cases of atypical ductal hyperplasia (ADH), and 3 ductal carcinomas in situ (DCIS), one of these with a minimal-invasive tumor component. Patient with ADH were advised to undergo surgical biopsy. Histology revealed complete removal. 7 patients had complications or side-effects.

CONCLUSIONS

Percutaneous vacuum core biopsy is a reliable minimal-invasive diagnostic method to come to the final diagnosis in patients with clustered microcalcifications categorized BI-RADS 3. However, if malignancy is proven (about 4% of our cases) an open biopsy is necessary.

Sebaceous gland metaplasia in intraductal papilloma of the breast

We report here the first case of sebaceous gland metaplasia arising within an intraductal papilloma of the breast of a 70-year-old female. Several lobules and nests composed of clear cells closely resembling sebaceous glands of the skin were discovered within an intraductal papilloma of the breast. Squamous metaplasia was also noted in certain areas of the tumor. Immunohistochemically, the cells of the lobules and nests stained positively for monoclonal antibodies anti-cytokeratin 14 and epithelial membrane antigen. This study confirms a novel type of metaplasia of the breast.