Papillary Neoplasms of the Breast: A Review

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					                            Papillary Neoplasms of the Breast
                                                             A Review
                              Shir-Hwa Ueng, MD; Thomas Mezzetti, MD; Fattaneh A. Tavassoli, MD

● Context.—Interpretation of papillary lesions of the breast          in precise diagnosis of papillary lesions in aspirates are ad-
remains a challenging task because of the wide morpho-                dressed, and the implications of finding papillary lesions in
logic spectrum encountered in the benign, atypical, and               core biopsies are discussed. Although the focus is on intra-
malignant subtypes. Data on clinical significance and out-             ductal lesions, associated invasive carcinomas and invasive
come of papillary lesions, with superimposed atypia or ar-            micropapillary carcinoma are also presented.
eas similar to ductal carcinoma in situ partially replacing              Data Sources.—The literature on papillary lesions and
the benign elements, are sparse. Furthermore, complete                invasive micropapillary carcinoma is reviewed.
excision of even a fully developed papillary carcinoma con-              Conclusions.—It would be prudent to completely excise
fined to a dilated or cystic duct is associated with an ex-            any papillary lesion that has not been entirely removed by
cellent prognosis, whereas a complex papilloma extending              the initial core biopsy. The optimal management of local-
into multiple branches of a duct may ultimately recur as a            ized papillary lesions is complete excision with a small rim
carcinoma because of incomplete excision of microscopic               of uninvolved breast tissue without any prior needle in-
foci. This makes an outcome-based classification difficult.             strumentation if and when the papillary nature can be de-
   Objective.—An arbitrary yet practical approach to clas-            termined by imaging. Thus managed, most of these lesions
sification is outlined, with discussion of methods to cir-             behave indolently, and outcome is usually excellent.
cumvent the various diagnostic difficulties. The limitations              (Arch Pathol Lab Med. 2009;133:893–907)


T  he common feature characterizing papillary lesions is
     a papillary, arborescent epithelial proliferation sup-
ported by fibrovascular stalks with or without an inter-
                                                                      portant to note that the significance of the complete ab-
                                                                      sence of an ME cell layer for papillary lesions composed
                                                                      purely of uniform apocrine cells is not well established.
vening myoepithelial (ME) cell layer. Papillary lesions of               Furthermore, depending on their location in the mam-
the breast include intraductal papilloma, papillomatosis,             mary duct system, papillary lesions may be solitary, cen-
atypical papilloma (or papillomatosis), carcinoma arising             trally (subareolar) located or multifocal, and peripherally
in a papilloma, and intraductal papillary carcinoma (with             located within terminal duct-lobular units. These are as-
or without invasion). Distinction of these subtypes is not            sociated with different risks for associated carcinoma or
always an easy task. Adding to the difficulties, there are,            subsequent carcinoma. Whether the lesion is located sim-
currently, different terminologies and criteria used to cat-          ply in the distal portions of the duct system, but not nec-
egorize the variety of papillary lesions; some of these are           essarily in the terminal duct-lobular unit, is not always
not necessarily outcome based. When a papillary lesion is             clear cut. Therefore, the designations of papillomatosis
encountered in the breast, the most important question to             and multifocal intraductal papillary carcinoma are often
answer is whether it is benign or malignant. The complete             arbitrarily applied for multiple microscopic lesions gen-
absence of an ME cell layer in the fibrovascular fronds of             erally separated by uninvolved mammary tissue; the
a papillary lesion indicates a carcinoma; however, the                terms papilloma and papillary intraductal carcinoma have
presence of ME cells does not invariably exclude the di-              been used for the centrally located lesions. Three dimen-
agnosis of intraductal papillary carcinoma.1 Therefore, the           sional studies, however, can reliably determine the precise
role of ME markers and immunohistochemistry in the as-                location within the duct system and accurately distinguish
sessment of papillary lesions will be addressed. It is im-            the two categories.2
                                                                         This review will address the morphologic spectrum and
                                                                      the diagnostic problems associated with papillary lesions
  Accepted for publication October 15, 2008.                          as well as incorporating the concept of ductal intraepithe-
  From the Department of Pathology, Linkou Chang Gung Memorial        lial neoplasia (DIN) into the terminology.
Hospital, Chang Gung University College of Medicine, Taoyuan, Tai-
wan (Dr Ueng); and the Department of Pathology, Yale University
School of Medicine, Yale New Haven Hospital, New Haven, Connect-                       ASPIRATION CYTOLOGY
icut (Drs Ueng, Mezzetti, and Tavassoli).                                Precise classification of papillary lesions of the breast on
  The authors have no relevant financial interest in the products or
companies described in this article.
                                                                      fine-needle aspiration remains a challenging area in cy-
  Reprints: Shir-Hwa Ueng, MD, Department of Pathology, Linkou        tology.3 Of particular significance is the difficulty in dis-
Chang Gung Memorial Hospital, No. 5 Fu-Hsin St, Gwei-Shan, 
				
DOCUMENT INFO
Description: CONTEXT: Interpretation of papillary lesions of the breast remains a challenging task because of the wide morphologic spectrum encountered in the benign, atypical, and malignant subtypes. Data on clinical significance and outcome of papillary lesions, with superimposed atypia or areas similar to ductal carcinoma in situ partially replacing the benign elements, are sparse. Furthermore, complete excision of even a fully developed papillary carcinoma confined to a dilated or cystic duct is associated with an excellent prognosis, whereas a complex papilloma extending into multiple branches of a duct may ultimately recur as a carcinoma because of incomplete excision of microscopic foci. This makes an outcome-based classification difficult. OBJECTIVE: An arbitrary yet practical approach to classification is outlined, with discussion of methods to circumvent the various diagnostic difficulties. The limitations in precise diagnosis of papillary lesions in aspirates are addressed, and the implications of finding papillary lesions in core biopsies are discussed. Although the focus is on intraductal lesions, associated invasive carcinomas and invasive micropapillary carcinoma are also presented. DATA SOURCES: The literature on papillary lesions and invasive micropapillary carcinoma is reviewed. CONCLUSIONS: It would be prudent to completely excise any papillary lesion that has not been entirely removed by the initial core biopsy. The optimal management of localized papillary lesions is complete excision with a small rim of uninvolved breast tissue without any prior needle instrumentation if and when the papillary nature can be determined by imaging. Thus managed, most of these lesions behave indolently, and outcome is usually excellent.
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