Papillary neoplasms of the breast including upgrade rates and management of intraductal papilloma without atypia diagnosed at core needle biopsy.

Papillary neoplasms of the breast are a heterogeneous group of epithelial tumors nearly entirely composed of papillae. Their classification rests on the characteristics of the epithelium and the presence and distribution of the myoepithelial cells along the papillae and around the tumor. Papillary neoplasms of the breast can be diagnostically challenging, especially if only core needle biopsy (CNB) material is available. This review summarizes salient morphological and immunohistochemical features, clinical presentation, and differential diagnoses of papillary neoplasms of the breast. We include a contemporary appraisal of the upgrade rate to carcinoma (invasive carcinoma and ductal carcinoma in situ [DCIS]) and atypical hyperplasias in surgical excision specimens obtained following CNB diagnosis of papilloma without atypia, and a review of the available follow-up data in cases without immediate surgical excision.

Unusual recurrent metastasizing benign breast papilloma: a case report.

BACKGROUND: Papillary breast lesions may be benign, atypical, and malignant lesions. Pathological and clinical differentiation of breast papillomas can be a challenge. Unlike malignant lesions, benign breast papillomas are not classically associated with lymph node and distant metastasis. We report a unique case of a recurrent, benign breast papilloma presenting as an aggressive malignant tumor. CASE PRESENTATION: Our patient was a 56-year-old postmenopausal African American woman who was followed in the breast clinic with a long history of multiple breast papillomas. She underwent multiple resections over the course of 7-9 years. After being lost to follow-up for 2 years, she once again presented with a slowly enlarging left breast mass. Subsequent imaging revealed a predominantly cystic mass in the left breast, as well as a suspicious hypermetabolic internal mammary node and a hypermetabolic nodule in the pretracheal space. Biopsy of the internal mammary node demonstrated papillary neoplasm with benign morphology and immunostains positive for estrogen receptor, progesterone receptor, and human epidermal growth factor receptor 2/Neu. Due to the clinical picture concerning for malignancy, the patient was then started on endocrine therapy with palbociclib and letrozole before surgery. She then underwent simple mastectomy and sentinel lymph node dissection with negative nodes and pathology once again revealing benign papillary neoplasm. She underwent adjuvant chest wall radiation for 6 weeks and received letrozole following completion of her radiation therapy. She was without evidence of disease 30 months after surgery. CONCLUSIONS: We present an unusual case of multiple recurrent peripheral papillomas with entirely benign histologic features exhibiting malignant behavior over a protracted period of many years, with an invasion of pectoralis musculature and possibly internal mammary and mediastinal nodes. Her treatment course included multiple surgeries (ultimately mastectomy), radiation therapy, and endocrine therapy.

Intraductal oncocytic papillary neoplasm of the pancreas: A systematic review.

BACKGROUND: Intraductal oncocytic papillary neoplasm of the pancreas (IOPN-P) is a rare subtype of intraductal papillary mucinous neoplasm (IPMN). This study was performed to summarize the clinicopathological features and management of IOPN-P. METHODS: English-language articles were searched from MEDLINE and EMBASE from the first report of IOPN-P in 1996 until 1 May 2019 following the methodology in the PRISMA guidelines. RESULTS: In total, 66 patients from 24 full articles were included in the final data analysis. The patients' average age was 61 years, and the male/female ratio was 1. Most lesions were large (average size, 5.50 cm), located in the pancreatic head, and found either incidentally or by uncharacteristic abdominal symptoms. IOPN-P was usually a cystic and solid lesion with or without mural nodules on radiological examination. A definitive diagnosis was often acquired from fine needle aspiration biopsy or postoperative pathology. All tumors were diagnosed as carcinoma in situ or minimally invasive carcinoma, necessitating surgical resection. The prognosis of IOPN-P was better than that of other IPMN subtypes, even when metastasis occurred. Recurrence after surgical resection of IOPN-P was rare. CONCLUSIONS: IOPN-P is rare among IPMN subtypes with unique pathological characteristics. Because of the nontypical symptoms and radiological findings, a definitive preoperative diagnosis usually depends on multimodal examinations. Management and surveillance of IOPN-P after surgical resection should be differentiated from those of other pancreatic benign cystic lesions because of its relative malignancy, but IOPN-P should also be differentiated from other IPMN subtypes and malignant cystic tumors because of its favorable prognosis.

[A Case Report of Breast Cancer Followed Up as Intraductal Papilloma].

The patient was a 50-year-old woman. She had been diagnosed with bilateral breast tumors at another hospital 5 years previously and was followed up every 2 months. Ultrasonography showed hypoechoic masses in her breasts. The largest tumor in the right breast was 15mm in diameter and located in region A, while that in the left breast was 8mm in diameter and located in region B. Magnetic resonance imaging(MRI)showed multiple bilateral breast tumors. The largest tumor was 12mm in diameter and was suggestive of breast cancer. Core needle biopsies(CNB)of the largest tumors in both breasts were performed. Intraductal papilloma(IDP)and low-grade intraductal papillary carcinoma were diagnosed in the right and left breasts, respectively, on immunohistochemical staining. We performed left nipple-sparing mastectomy with sentinel lymph node biopsy and right tumor excision for diagnoses of carcinoma of the left breast(cTisN0M0)and IDP of the right breast. The histopathological diagnosis of the left breast tumor was pT1aN0M0, triple negative breast cancer with extensive intraductal components, and that of the right breast tumor was IDP with atypical ductal hyperplasia. Chemotherapy was administered postoperatively. Several studies have reported that peripheral IDP often coexists with or follows the development of carcinoma. Therefore, we should also closely follow-upthe patient's right breast.

Mammotome biopsy in diagnosing and treatment of intraductal papilloma of the breast.

UNLABELLED: Intraductal papilloma is a benign breast tumor which needs histopathological verification because of the risk of cancer coincidence. THE AIM OF THE STUDY: To assess the value of the mammography-guided and ultrasound-guided vacuum-assisted core biopsy in the diagnosis and treatment of intraductal papillomas of breast and to answer the question if mammotome biopsy allows to avoid surgery in these patients. MATERIAL AND METHODS: In the period 2000-2011, a total of 2246 vacuum-assisted core biopsies were performed, of which 1495 were ultrasound-guided and 751 were mammography-guided (stereotaxic). In 76/2246 patients (3.4%), aged 19-88 years (mean age was 51,5) histopathological examination confirmed intraductal papilloma. RESULTS: Atypical lesions were accompanying intraductal papilloma in 16/76 cases (21%). Open surgical biopsy performed in these group revealed invasive cancer in 3 women. In all 60 cases (79%) with benign papilloma in biopsy specimens, further clinical observation did not show recurrence or malignant transformation of lesions. CONCLUSIONS: Vacuum-assisted core biopsy is a minimally invasive and efficient method used for diagnosing intraductal papilloma of the breast. If histopathological examination confirms a benign character of the lesion, surgery may be avoided but regular follow-up is recommended. However, in all cases histopathological diagnosis of papilloma with atypical hyperplasia, should always be indication for surgical excision.

Management of benign intraductal solitary papilloma diagnosed on core needle biopsy.

BACKGROUND: The purpose of this study was to determine whether surgical excision of benign solitary intraductal papillomas (BSIP) diagnosed by core needle biopsy (CNBx) without an associated high-risk lesion and concordant with imaging is justified. METHODS: A review of all papillary lesions diagnosed by CNBx from January 2003 to June 2010 was performed. Available histologic and radiologic materials were evaluated in a blinded fashion by three pathologists and three dedicated breast radiologists, respectively, to assess for concordance. The papillary lesions were designated as benign, atypical, or malignant. There were 16 BSIPs excluded because of an adjacent high-risk lesion or same-quadrant ipsilateral cancer. All immediate and delayed excisional specimens were reviewed. Clinical and radiologic data were recorded. RESULTS: A total of 299 papillary lesions diagnosed on CNBx and concordant with imaging were identified. Of these, 240 (80 %) were classified as benign, 49 (16 %) atypical, and 10 (3 %) malignant. After exclusions, 77 of 224 women in our study cohort (34 %) underwent surgical excision with no atypical or malignant upgrades. Of the remaining 147 women diagnosed with a BSIP on CNBx, 47 (32 %) were lost to follow-up and 100 (68 %) were observed. All 100 observed patients had stable imaging findings at follow-up (4.8-93.8 months, mean 36.0 months). CONCLUSIONS: The likelihood of diagnosing atypia or malignancy after surgical excision of a BSIP diagnosed on CNBx without associated high-risk lesion or ipsilateral quadrant malignancy is extremely low. For this distinct subset of patients with a BSIP, these data justify close imaging follow-up, rather than surgical excision.

International consensus guidelines 2012 for the management of IPMN and MCN of the pancreas.

The international consensus guidelines for management of intraductal papillary mucinous neoplasm and mucinous cystic neoplasm of the pancreas established in 2006 have increased awareness and improved the management of these entities. During the subsequent 5 years, a considerable amount of information has been added to the literature. Based on a consensus symposium held during the 14th meeting of the International Association of Pancreatology in Fukuoka, Japan, in 2010, the working group has generated new guidelines. Since the levels of evidence for all items addressed in these guidelines are low, being 4 or 5, we still have to designate them "consensus", rather than "evidence-based", guidelines. To simplify the entire guidelines, we have adopted a statement format that differs from the 2006 guidelines, although the headings are similar to the previous guidelines, i.e., classification, investigation, indications for and methods of resection and other treatments, histological aspects, and methods of follow-up. The present guidelines include recent information and recommendations based on our current understanding, and highlight issues that remain controversial and areas where further research is required.

[Intraductal papillomas of the breast--clinico-morphological review and analysis [corrected] of 23 cases].

After a review of recent publications on the topic, the frequency, the classification and the typical clinical findings of the intraductal papillomas has been examined. The main attention have been paid on diagnosis of the disease, the risk of turning the papilloma in carcinoma of the breast and up to date treatment tactics. In a retrospective analysis of 23 cases with intraductal papillomas, histologically verified for the period 2004-2007 the clinical and morphological characteristics have been examined.

Papillary lesions of the breast: a review.

Papillary lesions comprise a wide spectrum of lesions in terms of their clinical presentation, morphologic appearance, malignant potential, and clinical behavior. Their defining feature is that of a fibrovascular stromal core lined by epithelial and myoepithelial cells, attached to the wall of the duct and extending into the duct lumen. Papillary lesions are often diagnostically challenging both on core biopsy and in excision specimens. Much of the difficulty arises from the many different terminologies that are used to describe the various entities that are included under the umbrella term of papillary lesions. Separation of papillary lesions into categories with a meaningful clinical outcome is most appropriate; however, there is a relative paucity of well-designed outcome studies with substantial cohort numbers to provide information in this regard. We use a pragmatic approach to the classification of papillary lesions in our practice, as we will outline in this review. We will also discuss controversies surrounding papillary lesions and focus on management of these lesions on core biopsy and in excision specimens.

International consensus guidelines for management of intraductal papillary mucinous neoplasms and mucinous cystic neoplasms of the pancreas.

Non-inflammatory cystic lesions of the pancreas are increasingly recognized. Two distinct entities have been defined, i.e., intraductal papillary mucinous neoplasm (IPMN) and mucinous cystic neoplasm (MCN). Ovarian-type stroma has been proposed as a requisite to distinguish MCN from IPMN. Some other distinct features to characterize IPMN and MCN have been identified, but there remain ambiguities between the two diseases. In view of the increasing frequency with which these neoplasms are being diagnosed worldwide, it would be helpful for physicians managing patients with cystic neoplasms of the pancreas to have guidelines for the diagnosis and treatment of IPMN and MCN. The proposed guidelines represent a consensus of the working group of the International Association of Pancreatology.

Breast disease: a primer on diagnosis and management.

Currently, mammography is the only method of detecting nonpalpable, early breast cancer. At this stage, 90% of the cancers are curable. Clearly, this fundamental tenet accentuates the importance of compliance and knowledge of guidelines. Although risks of mammography are minimal to nil, interpretation occasionally can be challenging, with equivocal results. New technologies are being evaluated and advances in measurement of cellular electrical potential differentials in breast tissue have produced exciting results, when compared with mammography and ultrasound. These screening efforts have increased the diagnosis of both invasive and noninvasive ductal and lobular carcinoma of the breast. For DCIS in particular, conservative, contemporary treatment options exist. These include lumpectomy with breast irradiation excluding axillary dissection. Selected patients may be treated with only lumpectomy. Although breast carcinoma is a major focus due to incidence, morbidity and mortality, the varieties of benign conditions cause many women genuine concern. Treatment options for fibrocystic change run a gamut, including cost-effective basic dietary changes, vitamin use, "health"/natural type treatments, analgesic, as well as hormonal manipulations and, on occasion, surgical intervention. Fortunately, with most patients, common sense and conservatism prevail. The presence of fibroadenomas diagnosed clinically, by ultrasound or mammography, in women aged 18-25 and beyond can create perplexing diagnostic dilemmas. Should the lesion be removed or observed? Differences of opinion exist and must be tempered by recent observations that women with complex fibroadenomas, sclerosing adenosis, epithelial calcification or papillary appocrine changes have a two- to threefold increased risk of breast cancer. The key to management in all these clinical situations is individualization. Conservatism is particularly acceptable in women under the age of 25 if a fibroadenoma is not increasing in size or not psychologically disturbing. Provoked or unprovoked nipple discharge is a clinical conundrum for patients. It is unsuspected and unwanted. While some whitish discharges result from stimulation or medication, others may have a more subtle etiology. Serous, serosanguineous, or bloody discharges mandate evaluation. Duct injection mammography and frequent excision of ductal systems are necessary. The clinician cannot forget other less common conditions, such as thrombophlebitis, fat necrosis, or infection. All clinical conditions of the breast provide a constellation of diagnostic and management problems. They are of real concern for every woman and must be resolved in an appropriate, prompt, and conscientious fashion.