44 Questions
What is the age range when intraductal papilloma of the breast most commonly occurs?
30-50 years
What is the typical diameter of an intraductal papilloma?
Less than 3 cm
What is the characteristic of the duct that contains the papilloma?
It may be dilated
What is the percentage of cases where intraductal papilloma is solitary?
90%
What is the characteristic of the stroma in broad papillary fibrovascular cores of a papilloma?
It is always hyalinized
What is the purpose of immunostains such as p63, calponin, and smooth muscle myosin heavy chain?
To highlight the presence of a myoepithelial cell component
What is the characteristic of necrosis in intraductal papilloma?
It is nearly always absent
What is the nature of intraductal papilloma according to clonal analysis?
It is a clonal lesion
Encapsulated papillary carcinomas are typically
ER positive and HER2 negative
What percentage of encapsulated papillary carcinomas have high-grade nuclei and a brisk mitotic rate?
3%
Solid papillary carcinoma often presents in
older women
What is commonly seen in solid papillary carcinoma?
Mucin production
According to the WHO Working Group, how should tumors with rounded nests and a complete or partial myoepithelial cell layer be classified?
In situ carcinoma, solid papillary pattern
What is the major differential diagnostic consideration for solid papillary carcinoma?
Usual ductal hyperplasia
What is characteristic of solid papillary carcinoma with reverse polarity?
Apically located nuclei
What is often present in the papillary cores of solid papillary carcinoma with reverse polarity?
Foamy histocytes
Solid papillary carcinoma with reverse polarity typically infiltrates through the breast parenchyma and adipose tissue in a
Haphazard pattern
What is the subsequent breast cancer risk similar to for proliferative lesions without atypia?
1.5-2 fold
What is characteristic of papillary DCIS?
Single population of atypical epithelial cells
What is a key feature that aids in the diagnosis of solid papillary carcinoma?
ER positivity and CK5/6 negativity
What is a potential diagnostic trap in papillary DCIS?
Scattered large pale eosinophilic cells along the basal layer
What is encapsulated papillary carcinoma often associated with?
Bloody nipple discharge
What is a concern in the diagnosis of encapsulated papillary carcinoma?
Absence of myoepithelial cells at the periphery of the tumor
What is important to evaluate for in encapsulated papillary carcinoma?
Areas of unequivocal conventional invasive carcinoma
Why is it challenging to diagnose associated invasive carcinoma in encapsulated papillary carcinoma?
The majority of patients have undergone a core needle biopsy procedure
What is a characteristic of papillomas with foci of atypical hyperplasia?
Associated with a substantially increased risk for carcinoma
What is a characteristic of multiple papillomas?
Associated with a substantially increased risk for carcinoma
What is a characteristic of papillary DCIS in contrast to DCIS involving a papilloma?
Absence of a myoepithelial cell layer along the fibrovascular cores
What is a common feature of necrosis in papillomas involved by florid UDH?
It is most often focal in nature
What is the result of sclerosis in papillomas?
Both A and B
What is the diagnostic feature that supports the diagnosis of a sclerosed papilloma?
Presence of a two-cell layer
What is the purpose of using ER and HMW cytokeratin stains in cases of florid UDH?
To distinguish between usual ductal hyperplasia and carcinoma in situ
What is the characteristic feature of ductal adenoma?
Intraductal location with a dense fibrotic capsule
What is the diagnostic feature that supports the diagnosis of ADH in an intraductal papilloma?
Combined use of ER and CK5/6
What is the recommendation of the WHO Classification of Tumors of the Breast Working Group for foci of low nuclear grade atypia?
Classify as intraductal papilloma with ADH
What is a common feature of excision specimens of benign intraductal papilloma that have had a prior needling procedure?
Presence of small irregular nests and single epithelial cells with degenerative features
What is the management approach for solitary intraductal papilloma?
Local excision
What is the significance of squamous metaplasia in intraductal papilloma?
It is probably secondary to focal necrosis
What is a characteristic feature of the epithelial cells in SPCRP?
They express both low and high molecular weight cytokeratins
What is a key difference between SPCRP and 'breast tumor resembling tall cell variant of papillary thyroid carcinoma'?
SPCRP expresses breast markers and lacks expression of thyroid markers
What type of mutations have been identified in SPCRP?
IDH2, PIK3CA, and PIK3R1
What is the clinical behavior of SPCRP?
Indolent and low-grade
What should be excluded before diagnosing invasive papillary carcinoma?
All of the above
Why is invasive papillary carcinoma a very rare entity?
Because it is often misclassified as papillary DCIS or encapsulated papillary carcinoma
Study Notes
Intraductal Papilloma
- Age range: 30-50 years
- Can arise in large or small ducts
- Can be identified grossly as a polypoid intraductal mass or found only on microscopic examination
- Features:
- Soft and friable
- May have areas of hemorrhage
- Duct containing the papilloma may be dilated
- Diameter rarely exceeds 3 cm
- Approximately 90% of cases are solitary
- Multiple papillomas are seen in slightly younger patients, arise in smaller, more peripherally located ducts, and are bilateral in one-quarter of cases
Morphologic Variations of Intraductal Papilloma
- Partial or total hemorrhagic infarct
- Necrosis (focal and rare)
- Squamous metaplasia (uncommon)
- Entrapped glands within or adjacent to the papilloma
- Superimposed florid UDH (ductal hyperplasia)
- Ductal adenoma (lacks arborescent papillary quality, but has intraductal location with a dense fibrotic capsule and distorted epithelial proliferation)
- Sebaceous metaplasia (exceptionally rare)
- ADH (atypical ductal hyperplasia) and DCIS (ductal carcinoma in situ) arising in an intraductal papilloma
Papillary Ductal Carcinoma In Situ
- Distinct from papilloma with DCIS
- Characterized by a single, uniform population of atypical epithelial cells
- Cells are arranged perpendicular to the delicate fibrovascular cores
- No myoepithelial cells lining the fibrovascular cores
- Diagnostic clues:
- Presence of other patterns of DCIS in adjacent ducts
- Absence of apocrine metaplasia within the papillary proliferation
Encapsulated Papillary Carcinoma
- Well-circumscribed papillary tumor surrounded by a thick fibrous capsule
- Arises in older women, centrally located, and often presents as a breast mass with or without bloody nipple discharge
- Microscopic features:
- Delicate fibrovascular cores
- Monotonous proliferation of atypical epithelial cells
- Solid or cribriform architecture
- Absence of myoepithelial cells along the fibrovascular cores and at the periphery
- Potential for low-grade invasive carcinoma
Solid Papillary Carcinoma
- Presents in older women, often as an image-detected breast mass
- Microscopic features:
- Multiple, solid nests of neoplastic epithelial cells
- Fine fibrovascular network conferring papillary architecture
- Spindled epithelial cells with a streaming appearance
- Granular eosinophilic cytoplasm and fine nuclear chromatin consistent with endocrine differentiation
- Mucin production
- Absence of myoepithelial cells within the neoplastic nodules
- Potential for invasive carcinoma
Solid Papillary Carcinoma With Reverse Polarity
- Characterized by solid papillary nests of bland columnar epithelial cells with nuclei of low or intermediate grade located apically (reverse polarity)
- Foamy histocytes are often present in the papillary cores
- Tumor cells infiltrate through the breast parenchyma and adipose tissue in a haphazard pattern
- Absence of a surrounding myoepithelial cell layer
- Typically ER, PR, and HER2 negative
- Express low and high molecular weight cytokeratins
Invasive Papillary Carcinoma
- Very rare entity
- Should be distinguished from papillary DCIS, encapsulated papillary carcinoma, and/or solid papillary carcinoma with associated invasive ductal or mucinous carcinoma
Learn about intraductal papilloma of the breast, its occurrence, symptoms, and characteristics. This quiz covers the pathology of intraductal papilloma, including its diagnosis and features.
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