Papillary Breast Cancer: Section 5.c.

CONTENTS:

5.10 Papillary Breast Carcinoma
5.10.1 Micro-papillary Carcinoma
5.10.2 Intra-ductal Papillary Breast Cancer
5.10.3 Encapsulated Papillary Carcinoma
5.10.4 Solid Papillary Carcinoma
5.10.5 Invasive Papillary Carcinoma

Inflammatory breast cancer, on this page, is the problematic one for diagnosis.

5.11 Inflammatory Carcinoma
5.12 Metaplastic Carcinoma
5.13 Adenoid Cystic Carcinoma
5.14 Paget’s Disease of the Nipple
5.15 Malignant Phyllodes Tumor (Cystosarcoma Phyllodes)

Forward to 5D on rare types. Back to 5B on lobular types.

5.10 Papillary Breast Carcinoma

Papillary breast carcinoma poses a difficult diagnostic challenge for the Pathologist. This is because an adequate histological assessment requires adequate sampling of the entire lesion for microscopic review.

There are several types of malignant papillary lesions including:

micro-papillary carcinoma;
intra-ductal papillary breast cancer;
encapsulated papillary carcinoma and
solid papillary breast carcinoma.

A regular cancer biopsy is like a slice of cheese in a cup of water. But papillary cancer falls apart like a scoop of cottage cheese in a cup of water. That’s why these papillary lesions need re-biopsying with bigger pieces.

5.10.1 Micro-papillary Carcinoma

Invasive micro-papillary carcinoma is a luminal-type breast cancer and has a tendency for lympho-vascular invasion and metastasis to regional lymph node. However, as yet clinical data suggests no worse prognosis for this type of cancer.

In the 2012 The World Health Organization (WHO) guidelines, invasive papillary carcinoma is now regarded as an adenocarcinoma of the breast with a micro-papillary morphology, and there is no prognostic meaning.

Radiologists are taught that micro-papillary carcinoma with tram-track micro-calcifications has a worse prognosis.

I also have an older page about invasive micropapillary breast cancer, which is still reasonably decent.

Figure 5.22 Micro-papillary Carcinoma

Photomicrograph of the histology of this tumor shows small
groups of adenocarcinoma cells with large, ‘open,’
vesicular nuclei and prominent nucleoli. (H&E x 20)

papillary breast carcinoma

5.10.2 Intra-duct Papillary Breast Carcinoma

Intra-duct papillary breast carcinoma is a form of ductal carcinoma in-situ (DCIS) but is distinct from benign or atypical true papillomas.

Intra-duct papillary breast carcinoma is usually unrelated to intra-duct papilloma, and it is not thought to arise from an intra-duct papilloma.

So a papilloma in a duct, won’t turn into a cancer?

True. But I bet everyone is so anxious that they remove it anyway.

5.10.3 Encapsulated Papillary Breast Carcinoma

From the 2012 WHO guidelines, ‘encapsulated papillary carcinoma’ is a new term for ‘intra-cystic papillary carcinoma.’ The capsule surrounding the tumor lacks myoepithelial cells and so it is a true fibrous capsule.

Encapsulated papillary carcinoma is considered by some to be an in-situ lesion and by others to be a slow-growing form of invasive papillary carcinoma.

So, if the cancer invasion passes beyond the capsule, this warrants a diagnosis of invasive carcinoma. This type of tumor has a good prognosis.

5.10.4 Solid Papillary Breast Carcinoma

Solid papillary breast carcinoma is a localized, multi-nodular, usually non-invasive tumor. It may be difficult to discern the papillary nature of this tumor because of the solid growth pattern. The prognosis is good.

How do you get a mouse to smile? Say cheese.

5.10.5 Invasive Papillary Breast Carcinoma

Invasive papillary carcinoma of the breast is rare and accounts for less than 1 % of invasive breast cancers. In most cases, this type of tumor occurs in older, post-menopausal women.

The 2012 WHO guidelines, classify invasive papillary carcinoma as an adenocarcinoma of the breast with a papillary morphology. However, there is no prognostic meaning

Invasive papillary carcinoma has a well-defined border, although the tumor invades with small, finger-like projections; it is usually a Grade 2 or moderate-grade tumor. In many cases of invasive papillary carcinoma, in-situ ductal carcinoma (DCIS) is also present.

Figure 5.23 Invasive Papillary
Breast Cancer

Photomicrograph of the histology of this tumor a well-differentiated
adenocarcinoma with invasion by groups of cells with large,
vesicular nuclei and prominent nucleoli. (H&E x 20)

5.11 Inflammatory Carcinoma

Inflammatory breast carcinoma (IBC) is acknowledged to be a highly aggressive form of breast cancer, with characteristic symptoms and signs and diffuse infiltration of the breast. So, IBC’s are invasive and of no special type (NST), Grade 3 tumors.

Inflammatory breast cancer is more likely to present clinically with diffuse swelling of the breast, rather than with a breast lump. Another clinical symptom is redness of the skin on the breast. Imaging studies detect inflammatory breast cancer.

Why is this hard to diagnose, Doc?

Because an infection called mastitis can cause skin redness and swelling. Misdiagnosis is common and physicians often prescribe antibiotics.

Do they get mammography and ultrasound and an eventual cancer diagnosed? Won’t that tell the answer?

Not always. The skin thickening from cancer and infection looks the same on ultrasound and mammogram. The abnormalities below the skin can be missed.

Why is Inflammatory Breast Cancer hard to Diagnose

Inflammatory carcinoma can mimic an infection, and the entire breast can become warm and swollen with thickening of the skin. These symptoms and signs are due to blockage of the skin lymphatics by the tumor.

Inflammatory breast cancer carries a poor prognosis. Breast cancer specialists recommend initial staging evaluation for this type of breast cancer.

Imagine this tragedy: The family doctor is treating with antibiotics, the radiologist report didn’t find a cancer. Time passes and the cancer gets worse. Months later, the breast is rock hard, very red and extremely tender. So new antibiotics, more mammograms and ultrasounds, and still the cancer is not diagonosed.

Sounds horrible.

Then the cancer might cause a lymph node enlargement and finally the true diagnosis is made. The patient is furious and the doctors blame each other. I’ve seen this happen many times in my career.

Well, somebody must have screwed up, right?

I don’t think so. It’s the nature of this nasty cancer to seem like an infection.

Figure 5.24 Inflammatory Carcinoma

A. Thermal imaging (thermography) of the left breast (red) in
extensively infiltrating inflammatory carcinoma may suggest a
breast infection. B. Mammographic X-ray of the breast shows
extensive, sub-areolar tissue density, involving much of the breast.

papillary breast cancer

Figure 5.25 Inflammatory Carcinoma

Photomicrographs of the histology of inflammatory carcinoma.
A. Poorly differentiated carcinoma cells are associated with tissue
fibrosis, inflammation and plugging of vessels and lymphatics
with malignant cells. (H&E x10) B. High power image of a lymphatic
vessel plugged with tumor cells. (H&E x 40) C. High power image
of a blood vessel plugged with tumor cells. (H&E x 40)

Fig 5-25 Inflammatory carcinoma

5.12 Metaplastic Carcinoma

Metaplastic carcinoma now includes a group of unrelated tumors that show squamous or mesenchymal elements, including spindle, chondroid, osseous, and rhabdomyoid cells that may be mixed with carcinoma of ‘usual’ type. In addition, metaplastic carcinomas may be low-grade or high-grade tumors, but as a group, they have a worse prognosis than other breast cancers.

Metaplastic carcinoma is a well-circumscribed tumor that contains a mixture of poorly-differentiated ductal carcinoma, mesenchymal (sarcomatous), and other epithelial (e.g., squamous cell) elements.

Metaplastic breast cancer was not recognized as a distinct diagnosis until 2000, so knowledge about treatment patterns and outcomes is limited for this malignancy.

Figure 5.26 Examples of Metaplastic Change in Breast Cancer.

A. Invasive ductal carcinoma (IDC) with squamous metaplasia.
B. and with chondroid metaplasia C. and with osseous metaplasia.
(H&E x 40, x 20, x10)

Fig 5-26 Metaplastic Carcinoma

5.13 Adenoid Cystic Carcinoma

Adenoid cystic carcinoma is the most common ‘salivary-type’ tumor of the breast and is usually a low-grade malignant tumor.

Variants of adenoid cystic carcinoma can be recognized, but use of a grading system for adenoid cystic carcinoma is now thought to have no practical value.

Adenoid cystic carcinoma of the breast has a distinctive histologic pattern that is morphologically identical to adenoid cystic carcinoma found in the salivary glands (and other sites).

This tumor tends to be associated with a favorable prognosis, even when tumor size is large; the reported incidence of axillary metastases is less than 5%.

Figure 5.27 Adenoid Cystic Carcinoma

Photomicrograph of the distinctive pattern of infiltration, with
a trabecular ‘web’ of cells associated with myxoid secretions.
(H&E x 10)

Fig 5-27 adenoid cystic

5.14 Paget’s Disease of the Nipple

Paget’s disease of the nipple presents clinically with nipple inflammation, retraction, fissuring, pain, itching, bleeding, and/or eczematous-like change.

Nearly all cases of mammary Paget’s disease have an underlying in-situ or infiltrating breast carcinoma. It is important to examine the breast for evidence of underlying invasive breast cancer when Paget’s disease is diagnosed.

Figure 5.28 Paget’s Disease of the Nipple with Underlying
Invasive Ductal Carcinoma

Photomicrograph of a section through the nipple shows surface epithelium
(top) containing nests of ductal carcinoma cells or Paget’s cells. (H&E x 20)

papillary breast cancer

5.15 Malignant Phyllodes Tumor (Cystosarcoma Phyllodes)

Although most phyllodes tumors are benign, some are malignant, and some are borderline (in between non-cancerous and cancerous). Malignant phyllodes tumors or ‘cystosarcoma phyllodes’ make up 10% of all phyllodes tumors.

Malignant phyllodes tumors are a form of sarcoma as they grow in the connective tissue of the breast, not in the ducts. They present as a smooth lump beneath the skin. These tumors can grow very rapidly. Symptoms can also mimic those of other types of breast cancer.

Mammography will show a radio-dense, possibly lobulated breast mass without micro-calcification. The histology shows hyper-cellular stroma with mitotically active cells and epithelial cells.

Because this is a rare breast tumor, there are no evidence-based treatment guidelines. But in 2007, Grabowski and colleagues studied 752 malignant phyllodes tumors of the breast (Grabowski et al., 2007). For patients with malignant phyllodes tumor, the relative annual survival at one year was 94 % and at 10 years was 99.6 %. Thus, after ten years, women treated for malignant phyllodes tumor of the breast are no more likely to die than the general population.

Treatment is by complete surgical excision of the tumor.

Figure 5.29 Malignant Phyllodes Tumor

A. Mammographic X-Ray appearance shows radio-dense lobules
but without a well-defined border. B. Photomicrograph of the
histology of malignant phyllodes tumor shows hyper-cellular, spindle-cell
areas; C. the spindle-cell areas may show cell atypia and mitoses.
(H&E x 10 and x 20)

Fig 5-29 Malignant phyllodes tumor

References

Grabowski, J., Salzstein, S.L., Sadler, G.R., Blair, S.L. (2007). Malignant phyllodes tumors: a review of 752 cases. 73(10), 967-9. (Retrieved November 14^th 2014): https://www.ncbi.nlm.nih.gov/pubmed/17983058

Page, D.L., Salhany, K.E., Jensen, R.A., et al. (1996). Subsequent breast carcinoma risk after biopsy with atypia in a breast papilloma. Cancer 78:258-266. (Retrieved November 13^th 2014): https://www.ncbi.nlm.nih.gov/pubmed/8674001

More references for this section are on this page

Patient Information

National Cancer Institute Inflammatory Breast Cancer (Retrieved January 9^th2014):http://www.cancer.gov/cancertopics/factsheet/Sites-Types/IBC

Breast Cancer Org. IDC Type:Papillary Carcinoma of the Breast. (Retrieved January 9^th2014):https://www.breastcancer.org/symptoms/types/papillary

More patient information for this section is on this page

Forward to 5D on rare types. Back to 5B on lobular types.