Papillary Lesions of the Breast
Papillary Lesions of the Breast
Papillary Lesions of the Breast
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The Complexities <strong>of</strong> <strong>Papillary</strong><br />
<strong>Lesions</strong> <strong>of</strong> <strong>the</strong> <strong>Breast</strong><br />
F.A. TAVASSOLI, MD<br />
YALE UNIVERSITY SCHOOL OF<br />
MEDICINE, NEW HAVEN<br />
<strong>Papillary</strong> <strong>Lesions</strong> <strong>of</strong> <strong>the</strong> <strong>Breast</strong><br />
• Papilloma<br />
• Papilloma with DIN 1<br />
Clinical<br />
Features<br />
Solitary<br />
Papillomas<br />
Multiple<br />
Papillomas<br />
Subareolar (%) 90-95 20-25<br />
Discharge (%) 75-80 20-25<br />
Bilateral (%) 1.5-4.0 15-25<br />
Mean Age (yr) 48 40<br />
Palp. Mass (%) 98 55<br />
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Myoepi<strong>the</strong>lial Cells<br />
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Sclerosing Papilloma (Ductal adenoma)<br />
No. <strong>of</strong> cases: 15<br />
Age: 22-77 yrs, med. 60 yrs<br />
Clinical presentation: Lump 12<br />
Bloody Discharge 2<br />
Diffuse nodularity 1<br />
Duration <strong>of</strong> symptoms: 10 days- 4 mo, med. 1.9 mo<br />
Size, clinical: 0.6-6 cm<br />
Metaplastic changes: Apocrine, several cases<br />
Chondroid, one case<br />
Pseudoinfiltrative pattern: 13/15 cases<br />
Follow-up 1-14 yr, N. E. D.<br />
(Mod. Pathol. 1993;6:660-2)<br />
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Pseudoinvasion<br />
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Pseudo- Invasion<br />
AE1/AE3<br />
<strong>Papillary</strong> <strong>Lesions</strong> <strong>of</strong> <strong>the</strong><br />
<strong>Breast</strong><br />
I. Benign<br />
1. Papillomas: Central, solitary<br />
2. Papillomatosis: Peripheral, multiple,<br />
arises in TDLU<br />
p63<br />
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<strong>Papillary</strong> DIN 1-3<br />
(<strong>Papillary</strong> Intraductal Ca)<br />
♦ Solitary, central, grossly visible<br />
♦ Multifocal, peripheral, microscopic<br />
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FVIII<br />
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DIN1, <strong>Papillary</strong> type with<br />
subnuclear vacuoles<br />
(<strong>Papillary</strong> DCIS)<br />
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What is your interpretation?<br />
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DIN 1-3, <strong>Papillary</strong> type<br />
(<strong>Papillary</strong> Intraductal Ca)<br />
♦ Solitary, central, grossly visible<br />
♦ Multifocal, peripheral, microscopic<br />
Intracystic/Solid Variants<br />
• Presentation: Mass, Nipple Discharge<br />
• Mammographically: Rounded, Lobulated,<br />
Well-Defined<br />
• Macroscopic: Well Defined, may be >5cm<br />
• Microscopic: ME cells may be present or<br />
absent around <strong>the</strong> duct wall<br />
• Recurrences depend on <strong>the</strong> presence <strong>of</strong> DIN<br />
(DCIS/AIDH) in <strong>the</strong> surrounding mammary<br />
tissue (Carter, 1983)<br />
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<strong>Papillary</strong> <strong>Lesions</strong> <strong>of</strong> <strong>the</strong> <strong>Breast</strong><br />
• Papilloma<br />
• Papilloma with DIN 1<br />
♦ When confined to a central<br />
papilloma, <strong>the</strong> quantity <strong>of</strong> atypia (DIN<br />
1) has no prognostic significance or<br />
impact on outcome.<br />
♦ Recurrences, when <strong>the</strong>y develop, are<br />
related to <strong>the</strong> presence <strong>of</strong> DIN in <strong>the</strong><br />
surrounding breast tissue.<br />
(MacGrogan & Tavassoli Cancer 2003)<br />
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Papilloma<br />
with florid<br />
LR DIN<br />
(hyperplasia)<br />
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CD10 CK903<br />
<strong>Papillary</strong> <strong>Lesions</strong> on Core Biopsy<br />
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At least papilloma with<br />
DIN1 ( At least an<br />
atypical papilloma)<br />
Heterogeneity in <strong>Papillary</strong> <strong>Lesions</strong><br />
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C<br />
K<br />
9<br />
0<br />
3<br />
CK903<br />
Heterogeneity in <strong>Papillary</strong><br />
<strong>Lesions</strong><br />
• Because <strong>of</strong> <strong>the</strong> common presence <strong>of</strong><br />
heterogeneity in papillary lesions,<br />
correlatiom with lesion size on<br />
mammograms is crucial when <strong>the</strong>y are<br />
noted in a core bx.<br />
• If <strong>the</strong>re is any chance <strong>of</strong> residual disease,<br />
my preference is to excise <strong>the</strong> lesion.<br />
What is your Dx?<br />
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<strong>Papillary</strong> DIN 1-3 (DCIS) with<br />
Invasion<br />
The invasive carcinoma is generally<br />
an infiltrating duct carcinoa<br />
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A Critical Question:<br />
What Constitutes Invasion in<br />
<strong>the</strong> Setting <strong>of</strong> <strong>Papillary</strong> DIN/<br />
DCIS?<br />
Solid <strong>Papillary</strong> DIN1<br />
(DCIS) with Invasion<br />
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Dislodged Cells<br />
<strong>Papillary</strong> Carcinomas<br />
(“Invasive”)<br />
a. When in association with papillary DIN 1-3<br />
(DCIS), <strong>the</strong> carcinoma is generally a classic ductal<br />
carcinoma<br />
b. With increasing use <strong>of</strong> core biopsies, dislodged<br />
tumor cell clusters are probably frequently<br />
misinterpreted as invasion<br />
c. If we can identify a papillary lesion by imaging,<br />
it would be best to proceed to excision without<br />
attempts at core biopsies or aspiration.<br />
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Recent Reviews <strong>of</strong> <strong>the</strong> Topic<br />
<strong>Papillary</strong> neoplasms <strong>of</strong> <strong>the</strong> breast: A review. Arch<br />
Pathol Lab Med 2009;133:893-907.<br />
The role <strong>of</strong> immunohistochemistry in <strong>the</strong> differential<br />
diagnsosis <strong>of</strong> papillary lesions <strong>of</strong> <strong>the</strong> breast.<br />
J Clin Pathol 2009;62:407-413.<br />
<strong>Papillary</strong> lesions <strong>of</strong> <strong>the</strong> breast: selected diagnostic<br />
and management issues. Histopathology<br />
2008;52:20-9<br />
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