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CASE REPORT Table of Contents   
Year : 2009  |  Volume : 52  |  Issue : 3  |  Page : 411-413
A cytological and histomorphological case study of an uncommon breast carcinoma: Invasive papillary type


Department of Pathology, Padmasree Dr. D. Y. Patil Medical College, Pimpri, Pune - 18, India

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Date of Web Publication12-Aug-2009
 

   Abstract 

Pure papillary carcinoma of the breast is a rare tumour affecting elderly postmenopausal women. We report one case in a relatively younger woman presenting with a clinically benign breast lump.The tumour showed extensive apocrine metaplasia. The ease with which abundant material with highly cellular papillary clumps is obtained on fine needle aspirate should be an important consideration favouring papillary carcinoma. The quality and quantity of stroma in papillae rather than the presence or absence of stromal support should also be a guiding criteria for excluding benign papillary lesions.

Keywords: Breast, fine needle aspiration cytology, invasive carcinoma, papillary carcinoma,

How to cite this article:
Gore CR, Panicker N K, Karve P P. A cytological and histomorphological case study of an uncommon breast carcinoma: Invasive papillary type. Indian J Pathol Microbiol 2009;52:411-3

How to cite this URL:
Gore CR, Panicker N K, Karve P P. A cytological and histomorphological case study of an uncommon breast carcinoma: Invasive papillary type. Indian J Pathol Microbiol [serial online] 2009 [cited 2019 Oct 20];52:411-3. Available from: http://www.ijpmonline.org/text.asp?2009/52/3/411/55011



   Introduction Top


Papillary configuration of epithelial cells are very common in cytological preparations from a number of unrelated breast lesions both benign and malignant. [1],[2] Many lesions apparently papillary on smears turn out to be non-papillary on subsequent histopathological examination of the excised specimen. [3] The significance of papillary proliferations for increased cancer risk, even with atypia is marginal as compared to other benign proliferative breast lesions. [4] However multiple papillomatosis has a definite risk of carcinoma developing. [5] When papillary formations are encountered in cytological material, segregation of benign from malignant lesions is a matter of debate. [6] Some have stressed the importance of absence of apocrine metaplasia in benign papillary lesions while others consider apocrine metaplasia as not a reliable criteria. [7] There is also controversy regarding the presence or absence of myoepithelial cells. [8],[9]

We report one case of papillary carcinoma of the breast which had shown apocrine metaplasia with uniform cells predominantly in papillary clumps. Features which helped diagnosis and histomorphology of the tumour are highlighted and discussed.


   Case Report Top


A 43 years old lady presented with a painless lump of four months duration. The lump was palpable in the upper outer quadrant, 3 cm in diameter, soft, mobile and well circumscribed. Clinical impression was that of a benign lesion, probably cystic.

Fine needle aspiration cytology (FNAC) was done with standard technique that yielded adequate material easily. Air dried Leishman stained smears were examined. The smears were highly cellular with many cohesive clumps of epithelial cells arranged in rounded clumps and well defined three dimentional papillary formations with finger like branching. Some fragments showed delicate fibro vascular core. Scattered discohesive epithelial cells forming small fragmented clumps were also seen. [[Figure 1], arrow].

Individual tumour cells were columnar in type and had uniform hyperchromatic nuclei, some showing prominent nucleoli. There was no remarkable pleomorphism. Background proteinous and fatty material, nibbled and nipped cytoplasmic edges and some vacuolations suggested secretory activity [Figure 1]. A few naked bare nuclei were also noted in the background [arrowhead [Figure 1]].

Though there was little clinical suspicion and fact that the smears were equivocal in certain respects, we favoured a diagnosis of carcinoma on account of the ease with which the highly cellular smears were obtained, the openness of nuclear chromatin, prominence of nucleoli in many cells and the presence of few cells in mitosis. Though suspected, the exact classification as papillary carcinoma was withheld because of the rarity of tumour and rather young age of the patient.

Modified radical mastectomy specimen received showed a soft, solid, well- circumscribed gray brown growth measuring 3 2.7 cm in the upper outer quadrant. The mass was 4.5 cm away from the nipple and well clear of the deep cut margin. Twelve lymph nodes were identified in the axillary fat, one showing grossly visible tumour deposit.

Micro sections showed an epithelial tumour having a complex papillary pattern with small areas having solid growth pattern. The papillae in most areas had easily discernable but delicate fibrovascular core [arrow, [Figure 2]] with columnar type tumour cells arranged perpendicularly. The cells were fairly uniform but showed overlapping and heaping up with loss of polarity. Nuclei were hyperchromatic, oval, vesicular with prominent nucleoli. Increased mitoses were obvious. Cytoplasm was moderate and showed apical apocrine snouts in most areas [arrowhead [Figure 2]]. A small area of stromal invasion with desmoplasia was also seen. The one lymph node with grossly visible metastasis showed exclusively papillary pattern of growth in the tumour deposit [Figure 3].


   Discussion Top


Pure papillary carcinoma of the breast is a rare type of carcinoma affecting predominantly elderly postmenopausal women with an incidence rate of 0.3-2% with a favourable prognosis. [7],[10] Our patient was relatively younger and the mass was clinically thought to be benign. Cytological diagnosis of papillary carcinoma can pose a problem because of the cohesiveness of the cell clumps and uniformity of the rather bland nuclei. Bare oval nuclei of scattered cells also add to the dilemma. The fact that a variety of breast lesions like intraduct papilloma, fibrocystic disease, fibroadenoma, mucinous carcinoma, cribriform intraductal carcinoma and low grade intraductal or invasive carcinoma not otherwise specified (NOS) and many other miscellaneous lesions can yield papillary appearing formations in smears is another important consideration. [1],[2]

Nuclear atypia in smears from papillary carcinoma can be higly variable from none to that of moderate or severe degree. [1] Though the popular impression is that the neoplastic papillae lack well developed stroma, well developed fibrovascular stroma is invariably present in most papillary carcinomas as in our case. However the connective tissue core of malignant papillae tend to be thinner, delicate with less collagen and ground substance compared to that of benign papillae. [4],[8] Similarly myoepithelial cell proliferations is not uncommon in papillary carcinomas. [8],[9] With regard to aprocrine metaplasia opinions vary. Some are emphatic about its absence in papillary carcinoma while others maintain that it is not a reliable criteria to exclude carcinoma. [7] Our case had extensive apocrine type secretory activity.

It is felt that the ease with which abundant material is obtained and aspirate showing numerous cellular papillary clumps in the smears should be an important consideration in favour of papillary carcinoma in the elderly with apparently well defined softer lumps. The quality and quantity of stroma in the papillae rather than just the presence or absence of stromal support should also be a guiding criteria.

 
   References Top

1.Clair W. Michael, Bruce Buschmann. Can true papillary neoplasms of breast and their mimickers be accurately classified by cytology? Cancer Cytopathol 2002;96:92-100.  Back to cited text no. 1    
2.Kline TS, Kanna V. Papillary carcinoma of the breast: A cytomorphologic analysis. Arch Pathol Lab Med 1986;110:189-91.  Back to cited text no. 2    
3.Aylin simsir, Jerry Waisman, Kim Thorna, Joan Cangiarella. Mammary lesions diagnosed as "papillary" by aspiration biopsy. Cancer Cytopathol 2003;99:156-65.  Back to cited text no. 3    
4.Jason T Lewis, Lynn C Hartmann, Robert A, et al . An analysis of breast cancer risk in women with single, multiple and atypical papilloma. Am J Surg Pathol 2006;30:665-72.  Back to cited text no. 4    
5.Haagensen CD. Multiple intraductal papilana. In : Haagense CD, ed Disease Of The Breast 3 rd ed. Philadelphia, PA : WB Saunders Co; 1986: 176-91.  Back to cited text no. 5    
6.Jeffrey P B, Ljung B M. Benign and malignant papillary lesions of the breast. Am J Clin Pathol 1994;101:500-7.   Back to cited text no. 6    
7.Fisher ER, Palekar As, Redmond C, Barton B, Fisher B. Pathologic findings from the National Surgical Adjuvant Breast project ( protocol no. 4 ) VI. Invasive papillary cancer. Am J Clin Pathol 1980;73;313-22.   Back to cited text no. 7    
8.Tariq Murad, Swaid Swaid, Paulette Prichett. Malignant and benign papillary lesions of the breast. Human Pathology 1977;8:379-90.  Back to cited text no. 8    
9.Murad TM: Evaluation of different techniques utilized in diagnosing breast lesions. Acta Cytol 1975;19:499.  Back to cited text no. 9    
10.Tavassoli FA, Devilee P (Eds) World Health Organisation Classification of Tumours. Pathology and Geneticsl of Tumours of the Breast and Female Genital Organs IARC press : Lyon 2003.  Back to cited text no. 10    

Top
Correspondence Address:
Charusheela R Gore
G/P 158, Near D. Y. Patil School, Shahunagar, Chinchwad, Pune - 19
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0377-4929.55011

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    Figures

  [Figure 1], [Figure 2], [Figure 3]

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