| Abstract|| |
Invasive papillary carcinoma is a rare variant of breast cancer. We report an unusual case of invasive papillary carcinoma of the breast with high nuclear grade, brisk mitosis, necrosis, extensive apocrine differentiation, and intense lymphoplasmacytic infiltrate; additionally triple-negativity for estrogen and progesterone receptors and Her2 neu. The patient underwent modified radical mastectomy and adjuvant chemotherapy. But, it was a node negative breast carcinoma. Increasing the awareness of this clinicopathologic entity would be helpful in avoiding overtreatment of patients with this cancer even if the tumor has negative morphological and immunohistochemical prognosticators.
Keywords: High nuclear grade, invasive papillary carcinoma-breast, node negative, triple negative-breast cancer
|How to cite this article:|
Terzi A, Uner AH. An unusual case of invasive papillary carcinoma of the breast. Indian J Pathol Microbiol 2012;55:543-5
| Introduction|| |
Papillary carcinoma (PC) of breast, which comprise less than 2% of breast cancer, is diagnosed predominantly in postmenopausal patients. , PC, a special histologic variant of breast carcinoma, is characterized by an expansile papillary lesion which generally consists of one large tumor nodule surrounded by a thick fibrotic wall. Myoepithelial cell layer (MCL) is absent within the papillae or at the periphery of tumor. This type cancers with or without stromal invasion are termed as "encapsulated or intracystic PC". Furthermore, regardless of whether these lesions are in situ or invasive in nature, current studies have shown that they have an excellent prognosis with only sufficient local therapy. ,,,,, They tend to have low-grade nuclei and low mitotic activity, and to be estrogen (ER) and progesterone (PR) receptors positive and Her2 neu negative. , There is only one case of invasive PC which is reported as triple-negative in the literature.  We report a node negative invasive PC-breast, which is triple negative and has some adverse histomorphological features.
| Case Report|| |
A 61-year-old female noticed a painless mass in her left breast 1 year ago, which has grown relatively fast for the past 2 months. In the physical examination a 3 × 2 cm relatively hard semifixed nodule was palpated in the upper-outer quadran. Ultrasonography showed a lobulated, well delineated heterogeneously hypoechoic solid lesion with millimetric calcifications. Mammographically a lobulated nodular density with uniform punctate calcifications was noted. Axillary lymphadenopathy was not detected. First an excisional biopsy was performed and then a radical mastectomy and lymph node dissection was performed at another center.
The gross examination of the excised specimen showed a relatively well circumscribed 3.5 × 2.5 × 2 cm cream-colored mass with areas of necrosis. The neoplasm was very close to the surgical margins. In the microscopic evaluation, majority of the neoplasm was composed of blunt or delicate papillary structures with central cores. It was noted that the neoplasm showed expansile growth pattern, which was mostly circumscribed by a thick fibrous pseudocapsule [Figure 1] with several invasion foci into and beyond it. The invasive areas were composed of solid epithelial islands or duct-like structures possessing papillary projections [Figure 2]. There was remarkable lymphoplasmacytic stromal infiltrate. Neoplastic cells had high grade nuclei, but apocrine cytoplasmic features [Figure 3]. The cytoplasmic granules of neoplastic cells were periodic acid-Schiff positive after diastase digestion. There was widespread cytoplasmic GCDFP-15 immunostaining. Abundant necrosis and high mitotic activity (over 20 mitosis/10 high-power microscopic field) and microcalcifications were noteworthy.
|Figure 1: Delicate papillary structures with central cores and circumscribed by a thick fibrous pseudocapsule. Microcalcifications is noteworthy (hematoxylin and eosin, ×40)|
Click here to view
|Figure 2: The area of invasion beyond the fibrous wall with remarkable lymphoplasmacytic infiltrate (hematoxylin and eosin, ×100)|
Click here to view
|Figure 3: Apocrine cytoplasmic features associated with high nuclear grade. Note high mitotic activity (hematoxylin and eosin, ×200)|
Click here to view
MCL were not observed within the papillary processes or at the periphery of the tumor with smooth muscle actin, p63 and CD10; residual basement membrane could not be demonstrated with collagen-IV immunostaining. Tumor cells were negative for ER, PR, and Her2 neu [Figure 4], in the immunostudies, wich performed with positive controls. They were also negative with high molecular weight cytokeratins.
|Figure 4: Nonspecified cytoplasmic staining with ER, PR, and Her2 neu in the tumor cells (immunohistochemistry; ER and PR, ×200, Her2 neu, ×200 and ×400)|
Click here to view
There was no evidence of malignancy in the breast tissue outside of the lesion. There was an intramammarian lymph node with reactive changes in the vicinity of the neoplasm. Although the invasion area was very close to its capsule, no evidence of metastasis or direct invasion was seen within the lymph node [Figure 5].
|Figure 5: An invasion area beyond the wall of the neoplasm, close to the intramammarian lymph node (hematoxylin and eosin, ×100)|
Click here to view
Residual tumor was not identified in the mastectomy specimen and none of the 18 axillary lymph nodes had any metastatic foci as far as we learnt from the mastectomy report.
| Discussion|| |
There are some difficulties in differentiating and naming of papillary lesions of breast. The complete absence of MCL in the fibrovascular fronds of a papillary tumor that appears intracystic or encapsulated indicates a carcinoma. In contrast to papillary in-situ ductal carcinomas, in encapsulated PC there is no identifiable MCL. ,,, Some authors tend to accept the PC as a variant of intraductal carcinoma even if it lacks demonstrable MCL around the cystically dilated duct, because the tumor is well delineated and behaves like noninvasive carcinoma. They are best regarded as intraductal PC for management purposes, particularly if persistence of a basement membrane around the duct can be ascertained with collagen-IV or laminin immunostains.  If there is demonstrable invasion into or beyond the wall of the tumor nodule, it can be named as invasive PC. However, some authors still prefer naming this type of tumors as encapsulated or intracystic PC since it behaves as low-grade invasive carcinomas. ,,,,,
In our case, neither MCL nor residual basement membrane could be demonstrated by immunostudies. There were several infiltrative neoplastic foci beyond the wall of the tumor. Schnitt et al. recommended to avoid categorization of encapsulated PC as clear invasive PC and further, the size should be reported based on the frankly invasive component, in order to avoid overtreatment.  We reported the case as invasive PC and the tumor size as 3.5 cm based on its entire size since we did not observe any MCL around the tumor nodule. Despite the fact that we pointed out to the excellent prognosis of this type breast carcinoma in our report, the patient underwent radical mastectomy, which was followed by adjuvant chemotherapy at another center.
Our case supports the view that invasive PC is special form of low-grade invasive breast carcinomas with good prognosis, even if it has negative prognosticators. Hence, the awareness of this clinicopathologic entity is important.
| References|| |
|1.||Ibarra JA. Papillary lesions of the breast. Breast J 2006;12:237-51. |
|2.||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. |
|3.||Wynveen CA, Nehhozina T, Akram M, Hassan M, Norton L, Van Zee KJ, et al. Intracystic papillary carcinoma of the breast: An in situ or invasive tumor? Results of immunohistochemical analysis and clinical follow-up. Am J Surg Pathol 2011;35:1-14. |
|4.||Hill CB, Yeh IT. Myoepithelial cell staining patterns of papillary breast lesions: From intraductal papillomas to invasive papillary carcinomas. Am J Clin Pathol 2005;123:36-44. |
|5.||Rakha EA, Gandhi N, Climent F, van Deurzen CH, Haider SA, Dunk L, et al. Encapsulated papillary carcinoma of the breast: an invasive tumor with excellent prognosis. Am J Surg Pathol 2011;35:1093-103. |
|6.||Grabowski J, Salzstein SL, Sadler GR, Blair S. Intracystic papillary carcinoma: A review of 917 cases. Cancer 2008;113:916-20. |
|7.||Kuroda N, Ohara M, Inoue K, Mizuno K, Fujishima N, Hamaguchi N, et al. The majority of triple-negative breast cancer may correspond to basal-like carcinoma, but triple-negative breast cancer is not identical to basal-like carcinoma. Med Mol Morphol 2009;42:128-31. |
|8.||Ueng SH, Mezzetti T, Tavassoli FA. Papillary neoplasms of the breast: a review. Arch Pathol Lab Med 2009;133:893-907. |
|9.||Collins LC, Schnitt SJ. Papillary lesions of the breast: selected diagnostic and management issues. Histopathology 2008;52:20-9. |
Department of Pathology, Baskent University, School of Medicine, Bahçelievler, Ankara, 06490
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]