The patient was a 54-year-old Brazilian woman presenting a progressive mass in the right breast. The clinical exam showed a 9 x 8 cm tumor and a hardened axillary lymph node. It was clinically considered a T3N1M0 breast tumor (Figure 1A). Mammography showed multiple oval formations, occupying the whole breast (Figure 2A). Ultrasonography showed the presence of multiple cysts, many of which containing vegetating lesions with intense vascular flow (Figure 2B) and absence of axillary lesion. Magnetic resonance imaging showed multiple oval cysts associated with vegetative lesions, a 4.7cm infiltrative area near the pectoral muscle (Figure 2C), and normal enlarged lymph node. As findings highly suspicious of malignancy were noted, radiological staging was performed. Abdominal ultrasound, bones scan and thoracic radiography showed absence of metastatic disease.
Clinical exam. (A) lump in right breast; (B) marked area showing clinical localization; (C) open biopsy.
Radiologic findings. (A) Mammography: multiple round image in the whole right breast; (B) breast ultrasound: cystic mass with intense vascular flow; (C) MRI findings: infiltrative solid mass with intense early enhancement and washout kinetic curve associated with multiple cysts occupying the right breast.
The core biopsy showed a benign complex papillary lesion. Since the radiologic and
pathologic divergence did not allow a definitive diagnosis of malignancy, an
ultrasound-guided stereotactic needle biopsy was scheduled. The open biopsy was performed
in a vegetative intracystic lesion (Figures 1B and
1C) and pathologic findings showed a papillary
neoplasia with atypical cells. Due to atypical findings and the necessity to evaluate the
whole lesion,11 Sydor MK, Wilson JD, Hijaz TA, Massey HD, Paredes ESS. Underestimation
of the presence of breast carcinoma in papillary lesions initially diagnosed at
core-needle biopsy. Radiology 242(1):58-62.
2 Liberman L, Tornos C, Huzjan R, Bartella L, Morris EA, Dershaw DD. AJRIs
surgical excision warranted after benign, concordant diagnosis of papilloma at
percutaneous breast biopsy? ARJ. 2006;186(5):1328-1334.
3 Ueng SH, Mezzeti T, Tavassoli FA. Papillary neoplasms of the breast.
Arch Pathol Lab Med. 2009;133(6):893-907.-44 Youk JH, Kin EK, Kwak JY, Son EJ. Atypical papilloma diagnosed by
sonographically guided 14-gauge core needle biopsy of breast mass. AJR.
2010;194(5):1397-492. the patient underwent a simple mastectomy with sentinel lymph node
dissection. No reconstructive surgery was considered because of the lesion size and tumor
characteristics. The macroscopic assessment showed a 7.5 x 6.0 cm solid-cyst lesion, with a
3.8 cm solid component (Figure 3A). The microscopy
revealed a sclerosing papilloma harboring ductal carcinoma in situ in
about 30% of the lesion (Figures 3B and 3C), with free margins and absence of lymph node
metastasis. Immunohistochemistry for myoepithelial cells was performed in order to exclude
foci of invasion in the periphery of the lesion (Figure 3D).
Pathologic findings. Macroscopic finding: (A) Gross examination showed a large solid-cystic tumor. Microscopic findings: (B) papillary neoplasia with sclerotic stroma (HE, 40x); (C) areas containing carcinoma in situ (HE, 200x); (D) Immunohistochemistry positive for myoepithelial cells (Calponin, 200x).
Mammary extensive papillomatous lesions represent a clinical challenge, especially when
observing a highly suspicious malignant tumor based on clinical and radiological
findings.55 Lam WWM, Chu MCW, Tang APY, Tse G, Ma TKF. Role of radiologic features
in the management of papillary lesions of the breast. AJR 2006;186(5):1322-
1327. As core biopsy showed a benign lesion,
an open biopsy in the vegetative intracystic lesion was performed to improve material
sampling. So, when a definitive diagnosis of malignancy cannot be done because of
discordant findings, sampling limitations of a core biopsy55 Lam WWM, Chu MCW, Tang APY, Tse G, Ma TKF. Role of radiologic features
in the management of papillary lesions of the breast. AJR 2006;186(5):1322-
1327. or open biopsy, or limited sensibility of breast images,55 Lam WWM, Chu MCW, Tang APY, Tse G, Ma TKF. Role of radiologic features
in the management of papillary lesions of the breast. AJR 2006;186(5):1322-
1327.,66 Eliada R, Chong H, Lylmarni S, Goldberg F,Muradai S. Papilllary lesions
of the breast: MRI, ultrasound, and mammographic appearances. AMJ J Roentgenol.2012;
183(2): 264-71. resection of the
entire lesion is mandatory11 Sydor MK, Wilson JD, Hijaz TA, Massey HD, Paredes ESS. Underestimation
of the presence of breast carcinoma in papillary lesions initially diagnosed at
core-needle biopsy. Radiology 242(1):58-62.
2 Liberman L, Tornos C, Huzjan R, Bartella L, Morris EA, Dershaw DD. AJRIs
surgical excision warranted after benign, concordant diagnosis of papilloma at
percutaneous breast biopsy? ARJ. 2006;186(5):1328-1334.
3 Ueng SH, Mezzeti T, Tavassoli FA. Papillary neoplasms of the breast.
Arch Pathol Lab Med. 2009;133(6):893-907.-44 Youk JH, Kin EK, Kwak JY, Son EJ. Atypical papilloma diagnosed by
sonographically guided 14-gauge core needle biopsy of breast mass. AJR.
2010;194(5):1397-492.,66 Eliada R, Chong H, Lylmarni S, Goldberg F,Muradai S. Papilllary lesions
of the breast: MRI, ultrasound, and mammographic appearances. AMJ J Roentgenol.2012;
183(2): 264-71.
due to high association with malignancy.11 Sydor MK, Wilson JD, Hijaz TA, Massey HD, Paredes ESS. Underestimation
of the presence of breast carcinoma in papillary lesions initially diagnosed at
core-needle biopsy. Radiology 242(1):58-62.,22 Liberman L, Tornos C, Huzjan R, Bartella L, Morris EA, Dershaw DD. AJRIs
surgical excision warranted after benign, concordant diagnosis of papilloma at
percutaneous breast biopsy? ARJ. 2006;186(5):1328-1334.,44 Youk JH, Kin EK, Kwak JY, Son EJ. Atypical papilloma diagnosed by
sonographically guided 14-gauge core needle biopsy of breast mass. AJR.
2010;194(5):1397-492. The open biopsy was an attempt to improve the
pathological results that were hindered by limitation of diagnostic procedures and
discordant findings. Also, the indication for diagnostic mastectomy,77 Fenoglio C, Raffaele L. Sclerosing papillary proliferations in the
female breast. A benign lesion often mistaken for carcinoma. Cancer 1974; 33(3):
691-700. as seen in this case, is a fact that must be thoroughly discussed
with the patient.
References
-
1Sydor MK, Wilson JD, Hijaz TA, Massey HD, Paredes ESS. Underestimation of the presence of breast carcinoma in papillary lesions initially diagnosed at core-needle biopsy. Radiology 242(1):58-62.
-
2Liberman L, Tornos C, Huzjan R, Bartella L, Morris EA, Dershaw DD. AJRIs surgical excision warranted after benign, concordant diagnosis of papilloma at percutaneous breast biopsy? ARJ. 2006;186(5):1328-1334.
-
3Ueng SH, Mezzeti T, Tavassoli FA. Papillary neoplasms of the breast. Arch Pathol Lab Med. 2009;133(6):893-907.
-
4Youk JH, Kin EK, Kwak JY, Son EJ. Atypical papilloma diagnosed by sonographically guided 14-gauge core needle biopsy of breast mass. AJR. 2010;194(5):1397-492.
-
5Lam WWM, Chu MCW, Tang APY, Tse G, Ma TKF. Role of radiologic features in the management of papillary lesions of the breast. AJR 2006;186(5):1322- 1327.
-
6Eliada R, Chong H, Lylmarni S, Goldberg F,Muradai S. Papilllary lesions of the breast: MRI, ultrasound, and mammographic appearances. AMJ J Roentgenol.2012; 183(2): 264-71.
-
7Fenoglio C, Raffaele L. Sclerosing papillary proliferations in the female breast. A benign lesion often mistaken for carcinoma. Cancer 1974; 33(3): 691-700.
Publication Dates
-
Publication in this collection
Nov-Dec 2014