Year : 2010 | Volume
: 53 | Issue : 1 | Page : 112--114
Multiple intraductal papillomas of breast clinically masquerading as malignancy
Pallavi Singh, Vatsala Misra, Premala A Singh, Ravi Mehrotra
Department of Pathology, Moti Lal Nehru Medical College, Allahabad, India
Department of Pathology, M.L.N. Medical College, Allahabad - 211001
Background: Intraductal papilloma is characterized by proliferation of epithelial and myoepithelial cells overlying fibro-vascular stalks creating an arborescent structure within the lumen of duct. Some times multiple papillomas with florid proliferation of epithelium may be confused with malignancy. A case of multiple intraductal papillomas of breast with ulceration of overlying skin and large lump leading to clinical diagnosis of malignancy is documented here. Case Report: A 45-year-old female presented with ulcerated mass of six months duration in the left breast. On examination, a firm, immobile lump of 8× 10 cm in size involving nipple with excoriation of surrounding skin and serosanguinous discharge from nipple was present. There was no axillary lymphadenopathy. No family history of carcinoma breast was present. Fine needle aspiration smears showed benign cellular changes with apocrine metaplasia. Biopsy from an area adjacent to nipple showed intraductal papilloma. Simple mastectomy showed lobulated dirty white mass with well circumscribed nodules below the nipple and areola. On histology with immunohistochemistry a diagnosis of multiple intraductal papillomas was made. Patient is on regular follow-up and doing well. Conclusion: The case highlights the problem in differentiating marked papillomatosis from a malignant lesion of breast and importance of biopsy with immunohistochemistry in such cases for proper management.
|How to cite this article:|
Singh P, Misra V, Singh PA, Mehrotra R. Multiple intraductal papillomas of breast clinically masquerading as malignancy.Indian J Pathol Microbiol 2010;53:112-114
|How to cite this URL:|
Singh P, Misra V, Singh PA, Mehrotra R. Multiple intraductal papillomas of breast clinically masquerading as malignancy. Indian J Pathol Microbiol [serial online] 2010 [cited 2020 Sep 25 ];53:112-114
Available from: http://www.ijpmonline.org/text.asp?2010/53/1/112/59197
Intraductal papilloma is characterized by proliferation of epithelial and myoepithelial cells overlying fibrovascular stalks creating an arborescent structure within the lumen of duct. Majority of the cases present during the fourth and fifth decade of life.  They are broadly divided into central (large duct) papilloma, usually located in the sub areolar region and peripheral papilloma arising in the terminal duct lobular unit (TDLU). Their sizes vary from a few millimeters to 3-4 cm or larger. They can be single (central) or multiple (peripheral).  Ulceration of skin is rare. A case of multiple intraductal papillomas of breast with marked epithelial proliferation that clinically masqueraded as malignancy is documented here.
A 45-year-old female presented with an ulcerated mass in the left breast of six months duration. On examination, a firm, immobile lump of 8x10 cm in size involving nipple with excoriation of surrounding skin and serosanguinous discharge from nipple was present. There was no axillary lymphadenopathy. No family history of carcinoma breast was present.
Fine needle aspiration (FNA) smears were highly cellular with cells lying in groups and sheets. These cells were mostly uniform with abundant cytoplasm, eccentric nuclei and inconspicuous nucleoli. However, some cells had high nuclear: cytoplasmic ratio with prominent nucleoli. Apocrine metaplasia was also seen in some areas. The background mainly consisted of lipid laden macrophages [Figure 1].  A differential diagnosis of ductal papilloma and papillary intraductal carcinoma was made. An incisional biopsy from an area adjacent to nipple was done. Biopsy showed lactiferous ducts with papillomatous proliferation lined by epithelial and myoepithelial cells [Figure 2] and [Figure 3]. A diagnosis of intraductal papilloma was made. However, mastectomy was advised to further rule out a possibility of malignancy. The patient underwent mastectomy.
Simple mastectomy specimen measuring 10x8x4 cm in size with discolored and excoriated skin of areola and retraction of nipple was received [Figure 4]. Cut section showed lobulated dirty white mass with well circumscribed nodules ranging in size from 0.5 cm-2.0cm. Margins were well defined without evidence of infiltration. Multiple (15 sections from different areas and levels) sections were processed.
Microscopically, sections from the lesion showed stratified squamous epithelium underneath which were numerous closely packed arborescent structures composed of fibrovascular stalks [Figure 5]A covered by a layer of myoepithelial cells and overlying epithelial cells [Figure 5]B. There were areas of apocrine metaplasia, inflammation and ductal pseudo infiltrative pattern at places [Figure 5]C. Focal atypical epithelial changes were also seen [Figure 5]D. Smooth muscle actin and P63 positive myoepithelial cells in pseudo infiltrative areas helped make a diagnosis of multiple ductal papillomas with marked epithelial proliferation and rule out malignancy [Figure 5]E and F. Patient is on regular follow-up and is doing well.
Intraductal papilloma is a papillary clonal proliferation of ductal epithelial cells and thus classified as true neoplasm. More than 80% patients present with spontaneous, unilateral, serous, serosanguinous and bloody discharge from nipple. It is associated with risk of carcinoma in 7% of women less than 60 years of age and 30% in more than 60 years of age.  Hence, clinically they may mimic a malignant neoplasm. In the present case, the patient presented with breast mass that was large firm, immobile and ulcerated involving nipple and areola and was highly suggestive of a malignant lesion clinically. But the presence of two types of cell population, cells lying in sheets and groups and forming ill-defined papillae indicated an intraduct papilloma on FNA smears. Most of the cells were uniform with abundant cytoplasm and eccentric nuclei with inconspicuous nucleoli in a background of macrophages. However, some groups of cells with high nuclear: cytoplasmic ratio with prominent nucleoli still led to a suspicion of malignancy and mastectomy was advised for definite diagnosis.
Sections from most of the areas showed features in favor of papilloma. However, pseudo proliferative areas with anisokaryosis continued to raise a suspicion of invasive micropapillary carcinoma that was ruled out by immunohistochemical demonstration of myoepithelial cells in these areas, lack of peritumoural lymphovascular invasion and axillary lymph node metastasis.  Other differential diagnosis considered was papillary intraductal carcinoma which was ruled out by the presence of both epithelial and myoepithelial cells, apocrine metaplasia and prescence of definite fibro vascular stalks.
Risk of malignancy arising from the papilloma depends on the extent of epithelial atypia. If epithelial atypia is confined to the papilloma, without surrounding atypia, the risk of subsequent invasive breast carcinoma is similar to that of non atypical papilloma. As expected, epithelial atypia when present simultaneously both within and outside a papilloma is associated with moderate to highly increased relative risk. Progression to malignancy is more common in peripheral papilloma than the central one. In the present case, both central as well as peripheral papilloma were present. Therefore it had become mandatory to rule out any possibility of malignancy. 
Thus, the present case highlights the problem in differentiating marked papillomatosis from a malignant lesion of breast and the importance of biopsy with immunohistochemistry in such cases for proper management.
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