Intracystic Papillary Carcinoma of The Breast: A Case Report

Abstract

Turkish Abstract

Introduction

Intracystic papillary carcinoma (IPC) is a rare, low-grade carcinoma of the breast with predilection for elderly women especially in the postmenopausal period and has an excellent prognosis for patients. IPC is a variant of papillary carcinoma and accounts for 0,5% to 1% of breast cancer ¹. IPC had been divided into three subtypes: pure IPC, IPC with ductal carsinoma in situ (DCIS), and IPC with invasion. The associated lesion is closely related with the prognosis  ².

Here, we report a postmenopausal woman who was diagnosed with IPC plus DCIS and highligt the need of a prudent approach to the cystic breast lesions in the postmenopausal period.

Case Report

A 63-years old postmenopausal woman admitted to general surgery department with a painless palpable mass on her breast. There was no abnormal nipple discharge. Family and past medical history of the patient were insignificant for breast cancer.

Physical examination revealed a palpable mass in the retroareolar area with no palpable axillary lymphadenopathy. Mammography (MMG) demonstrated an oval mass without calcification (Figure 1).

Figure 1 Mammography (MMG) demonstrated an oval subareolar mass without calcification.

There was a 27x25 mm well-defined cystic lesion in diameter including a 12x5 mm solid component with regular margins and posterior acustic shadowing on ultrasound examination (Figure 2). Fine needle aspiration biopsy of the solid component of the cyst reported as non-diagnostic material.

Figure 2 Ultrasound (USG) examination demonstrated a 27x25 mm well-defined cystic lesion in diameter including a 12x5 mm solid component with regular margins and posterior acustic shadowing.

Total excisional biopsy was performed. Post-operative histological examination of paraffin blocks revealed an intracystic papillary carcinoma with the foci of DCIS on the surgical margins (Figure 3). A wide re-excision was planned as lumpectomy performed with achieving tumor free margins.

Figure 3 Histopathological examination demonstrated papillary structures in the fibrovascular stroma and foci of DCIS in the surrounding tissue, H&E 100X

Immunohistochemical study showed complete negativity of P63 and myo-epithelial cell staining of the tumor with smooth muscle actin was negative. Estrogen and progesterone receptor profiles of the patient were both positive. There was no over-expression of C-erb-B2 oncoprotein. Patient was discharged postoperative second day of the surgery without any complication. According to medical oncology department consultation; neither adjuvant radiation nor chemotherapy therapy was administered. She was administered Tamoxifen Citrate (20mg/day) postoperatively.

Discussion

IPC is a variant of papillary carcinoma and accounts for 0,5% to 1% of breast cancer ¹. There is an excellent prognosis for patients with IPC. A review of 917 patients with IPC showed greater than 95% survival rate at ten years ³. However it has been shown to present histologically with invasion of basement membrane and even metastasis ⁴. Because of its rarity and the wide range of histopathological behavior there is still no consensus on management of IPC.

Solorzano et al stated that the diagnosis of IPC often required excisional biopsy. They showed that FNA was inconclusive or nondiagnostic 41% of cases and core needle biopsy (CNB) can not rule out invasion in 30% of cases in their study ⁵. The diagnosis of the present case was achieved with performing total excisional biopsy, because  the fine needle aspiration biopsy (FNAB) of solid component of the cyst was reported as non-diagnostic material.

 Leal et al stated that IPC is usually a low-grade carcinoma presenting with low or intermediate nuclear grade, no necrosis, high estrogen receptor positivity, and negativity for c-erbB-2. They reported that associated DCIS can be found in as many as 46% of cases, and invasive carcinoma can be found in as many as 38% ⁶. The associated lesion of the present IPC case was DCIS. Histopathological examination of the case demonstrated papillary structures in the fibrovascular stroma and foci of DCIS in the surrounding tissue. Immunohistochemical study showed complete negativity of P63 and myo-epithelial cell staining of the tumor with smooth muscle actin was negative. Estrogen and progesterone receptor profiles of the patient were both positive. There was no over-expression of C-erb-B2 oncoprotein.

 In the cases of IPC alone, IPC with DCIS, or IPC with invasion, complete local excision of the tumour with clear margins is the recommended surgical treatment ⁷. Since IPC rarely involves lymph nodes, partial mastectomy without axillary lymph node dissection is the standard treatment for patients with non-invasive IPC ^5,8. But the association with invasive carcinoma and the difficulty in evaluating the focus of invasive lesion may indicate sentinel axillary lymph node biopsy for IPC ^5,9,10. Lymph node involment in pure IPC or IPC plus DCIS has not been reported but Wasserberg et al reported that 7% of patients with IPC plus DCIS with microinvasion had axillary lymph node involment and 2% of those had distant metastasis ¹¹. In the present case there was no microinvasion focus histopathologically so we planned the surgery as partial mastectomy  procedure without SLNB for this patient.

 There is still no concensus on adjuvant radiation and endocrine therapy. A retrospective study of Fayanju et al including 45 woman with pure IPC indicates that only patients with pure IPC who are of young age (<50 years) should be considered for adjuvant radiation therapy. There has been no clear indication for adjuvant endocrine therapy either ^7,12. But this type of tumor is strongly estrogen receptor positive and hormonal therapy should be considered for its management ⁴. In the present case, neither adjuvant radiation nor chemotherapy was planned. She was administered only Tamoxifen Citrate (20mg/day) postoperatively.

 Cystic lesions of the breast in postmenopausal period deserve a prudent approach due to presence of a potential malignancy. IPC has an excellent prognosis if the management is planned according to the associated lesion. Further studies in larger series of IPC cases with long follow-up periods are needed to establish a consensus in the management of IPC.

References

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Information Presentation

12. Ulusal Meme Hastalıkları Kongresi 24-27 Ekim 2013, Antalya