Year : 2010 | Volume
: 53 | Issue : 1 | Page : 135--137
Invasive papillary carcinoma of male breast
Raman Arora, Ruchika Gupta, Alok Sharma, Amit Kumar Dinda
Department of Pathology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi-110 029, India
162, Pocket-B, Sarita Vihar, New Delhi-110 076
Breast carcinoma is uncommon in males and constitutes less than one per cent of all cancers in men. Invasive papillary carcinoma is a rare morphological type of breast cancer. Since papillary carcinoma has a favorable prognosis as compared to other histopathological subtypes, an accurate diagnosis is essential.
We report two cases of this rare histological type of male breast cancer. A 62-year-old man presented with a lump in the central quadrant of right breast and underwent simple mastectomy. Histological examination showed features of invasive papillary carcinoma. The other case was of an 81-year-old male patient with a subareolar mass in the right breast. Wide local excision of the lump showed features of an intracystic invasive papillary carcinoma. The patient subsequently underwent simple mastectomy, however, no residual tumor was found in the resection specimen. Both the patients were free of disease at one year of follow-up. Invasive papillary carcinoma is an uncommon morphological type of breast cancer in males. The intracystic variant of papillary carcinoma is extremely unusual and may be missed on cytological examination. A thorough sampling is essential for an accurate diagnosis of invasion in these cases.
|How to cite this article:|
Arora R, Gupta R, Sharma A, Dinda AK. Invasive papillary carcinoma of male breast.Indian J Pathol Microbiol 2010;53:135-137
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Arora R, Gupta R, Sharma A, Dinda AK. Invasive papillary carcinoma of male breast. Indian J Pathol Microbiol [serial online] 2010 [cited 2020 Jul 5 ];53:135-137
Available from: http://www.ijpmonline.org/text.asp?2010/53/1/135/59206
Breast cancer is uncommon in males and accounts for about one per cent of all cancers in men. One of the subtypes, papillary carcinoma, contributes a very small fraction of breast cancer in males.  Histologically, papillary carcinoma may be intraductal or intracystic and each type can be non-invasive or invasive, a distinction possible only on thorough histopathological examination.  The intracystic variant of papillary carcinoma is very uncommon with only a few cases reported in the available literature. ,,,, Unlike invasive ductal carcinoma and NOS type, the prognosis of papillary carcinoma is extremely good, even in tumors showing stromal invasion.  Hence, an accurate diagnosis of this subtype is essential.
We describe two rare cases of papillary carcinoma of the male breast, both invasive and one of them intracystic in nature.
A 62-year-old man presented with complaints of a mass in the right breast for four months. He had noticed a rapid increase in size since two months. Local examination revealed a large 6x5 cm mass in the central quadrant of right breast. There was no skin involvement or palpable axillary lymphadenopathy. Fine needle aspiration from the right breast mass yielded necrotic material, and hence was inconclusive. With a clinical suspicion of carcinoma of the right breast, the patient underwent right simple mastectomy.
On gross examination, a solid gray white tumor measuring 6.5x5x2 cm was seen in the central quadrant. There was no nipple retraction, peau d'orange or ulceration of the overlying skin. Histopathological examination of the tumor revealed features of papillary carcinoma with microscopic foci of stromal invasion [Figure 1]. On immunohistochemical analysis, the tumor cells were strongly positive for estrogen receptor and progesterone receptor while being negative for Her2/neu. Sections from nipple, peripheral resected and deep margin did not reveal involvement by the tumor. The patient is currently asymptomatic on follow-up one year after surgery.
An 81-year-old man presented with a small mass in the right breast for two months. Past history revealed that he had undergone excision of a soft tissue tumor of the right thigh 20 years ago at another institute, of which no records were available. Local examination revealed a subareolar mass measuring 2.5x2 cm in the right breast. No skin involvement or axillary lymphadenopathy was seen. A clinical diagnosis of primary breast neoplasm or a metastatic lesion was considered and the lump excised.
Pathological examination revealed an intracystic papillary carcinoma with focal invasion into the adjacent stroma. The tumor cells were polyhedral with mild nuclear atypia and occasional mitoses [Figure 2]. Immunohistochemically, the tumor cells were positive for estrogen and progesterone receptor [Figure 3] and negative for Her2/neu (c-erb-B2). The peripheral resected margins of the lumpectomy specimen were free of tumor. With a pathological diagnosis of papillary carcinoma, a right simple mastectomy was then performed. No tumor was identified grossly and multiple histological sections also failed to reveal any residual tumor. The patient has been asymptomatic with no evidence of recurrence in one year of follow up.
Male breast cancer is infrequent and represents less than one per cent of cancers in men.  Papillary carcinomas, both noninvasive and invasive, constitute one to two per cent of breast carcinoma in females. However, papillary carcinomas account for a slightly greater proportion of male breast cancers.  The clinical presentation of breast cancer in males is similar to that in females, except for higher median age at presentation in males (60 vs. 53 years). 
Histologically, papillary carcinoma is divided into intraductal and intracystic; further subdivided into invasive and noninvasive. In majority of the cases, the tumor cell nuclei are intermediate-grade and the histologic grade of the tumor is 2 (modified Scarff-Bloom-Richardson grading system). Radiologic investigations show that calcifications are common, especially when ductal carcinoma-in situ (DCIS) is present. DCIS in such cases is usually, though not exclusively, of papillary pattern. Other patterns of DCIS may also be seen. ,, Extension of tumor into breast parenchyma and fat beyond the zone of reactive changes is the most reliable histological criterion for invasion. In cases with a doubt of tumor displacement due to prior needling, features favoring true invasion include absence of hemorrhage, fat necrosis of needle track or tissue disruption at this site.  In both our cases, true microscopic invasion was noted in the adjacent parenchyma.
Intracystic papillary carcinoma (ICPC) is extremely rare in males with very few case reports in the available literature. ,,,, ICPC is a localized breast cancer with presence of papillary structures within or on the wall of a cyst.  Fine needle aspiration, in such cases, is rarely diagnostic due to the low cellularity and an excision biopsy is required to make the diagnosis. Thorough histopathological examination is mandatory to detect invasion in an intracystic papillary carcinoma. ICPC has been divided into three types: (i) pure (with/ without invasion), (ii) with associated intraductal carcinoma, and (iii) with associated usual type of invasive ductal carcinoma.  The nature of associated lesion is essential for prognostication and an accurate assessment of margins of excision. In our patient, the tumor was a pure invasive ICPC with no associated intraductal or invasive breast carcinoma of the usual type.
The intraductal type of papillary carcinoma is more common than intracystic. The clinical presentation is similar for both types of papillary carcinomas. Intraductal papillary carcinoma is usually well circumscribed, solid, and soft to moderately firm mass. Histologically, the tumor exhibits florid delicate finger-like papillae along with few tubular or adenomatoid areas.  The fundamental question is to differentiate between intraductal papilloma and papillary carcinoma, especially when invasion is focal in nature. In papillary carcinomas, the fibrovascular stroma is less conspicuous due to the pronounced epithelial component; epithelial cells proliferate in a disorderly fashion and have hyperchromatic nuclei, high nucleo-cytoplasmic ratio and variable number of mitotic figures.  Though the presence of myoepithelial cells suggests a benign neoplasm, occasional myoepithelial cells may be seen in papillary carcinoma and do not negate the diagnosis.  The detection of invasion in papillary carcinoma may be difficult due to zones of fibrosis, recent or old hemorrhage and chronic inflammation around the tumor. Hence, thorough sampling and careful assessment of suspicious foci is essential for diagnosis of invasion.
The prognosis of papillary carcinoma depends on the presence or absence of invasion. Non-invasive papillary carcinoma can be regarded as a form of intraductal carcinoma and complete resection cures such patients. In invasive tumors, the frequency of axillary lymph node metastasis depends on the size of the invasive component and histological grade. Even in patients with nodal metastasis, the prognosis of invasive papillary carcinoma has been reported to be favorable. 
Invasive papillary carcinoma is a rare tumor of male breast and carries a favorable prognosis. Intracystic variant of papillary carcinoma is extremely infrequent and carries the risk of under diagnosis on aspiration cytology. Hence, accurate histopathological diagnosis is mandatory and invasion needs to be searched carefully.
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