Papillary lesions of the breast: A Radiopathological Pictorial Review and Diagnostic Work-up

Transcription

1 Papillary lesions of the breast: A Radiopathological Pictorial Review and Diagnostic Work-up R M Lorente-Ramos 1, MD, PhD; J Azpeitia Armán 1, MD; I Casado Fariñas 2, MD; T Rivera García 2, MD; Cueva Pérez E Unidad Central de Radiodiagnóstico de la CAM: Hospital Infanta Leonor 1 Pathology Department. Hospital Infanta Leonor 2 Unidad Central de Radiodiagnóstico de la CAM: Hospital del Henares 3 Madrid SPAIN

2 Papillary lesions of the breast Teaching Points 1.- To review clinical presentation, imaging features and pathologic findings in papillary lesions of the breast. 2.- To illustrate imaging findings (mammogram, ductography, US, MR) of cases from our series of breast papillary lesions with pathologic correlation. 3.- To analize and discuss the specific management of those lesions, including imaging and interventional procedures. 4.- To emphasize pitfalls, diagnostic difficulties and differential diagnosis.

3 Table of Contents Papillary lesions of the breast Definition. Clinical signs and symptoms. Diagnostic work-up Challenges in papillary lesions Diagnosis: imaging and pathology Management Imaging findings: Mammograms US Ductography MR-MR ductography Interventional procedures. Tips and tricks Case examples Take home points

4 Definition A papillary lesion consists of a frondforming growth pattern composed of fibrovascular stalks covered by a layer of epithelial cells with or without an intervening myoepithelial cell layer. Papillary lesions of the breast Photomicrograph. Branching papillary structures with fibrovascular cores (arrow) and lined by benign columnar cells Papillary lesions: pathologic entities Benign Intraductal papiloma Atypical Papilloma with atypia (atypical papilloma) Papilloma with DCIS Papillary DCIS Malignant Encapsulated Papillary Carcinoma Solid Papillary Carcinoma

5 Papillary lesions of the breast Clinical signs and symptoms Presentation: Palpable mass and/ or nipple discharge. Sometimes asymptomatic Nipple discharge: Suspicious: if the discharge is spontaneous, serous or bloody and is coming from a single duct. Bloody nipple discharge 22-34% of papillary lesions at presentation. Ductal carcinoma may also present with bloody nipple discharge. Cytology: Papillary groups (arrows) Bloody Discharge

6 Work-up of nipple discharge Nipple discharge Papillary lesions of the breast One duct Review/perform Mammogram,US Cytology of secretion. Several ducts Ductography Abnormal. normal Clinical review, citology of secretion+/-mr Repeated normal Abnormal. normal MR Abnormal. abnormal cytology normal normal cytology Systemic? Biopsy/surgery Surgery Follow-up Follow-up Biopsy/surgery

7 Papillary lesions of the breast CHALLENGES: Diagnosis Questions: -Is it a papillary lesion? -Benign or malignant? Difficulties: Diagnosis is difficult -Overlapping features appear clinically, imaging and even on core biopsy: Imaging: non specific findings in all techniques. Biopsy: Partial sampling: tissue fragmentation and undersampling Recommendations: Features that suggest malignancy: Size greater than 1 cm, Lesion location more than 3 cm from the nipple, Patient age greater than 50 years

8 Papillary lesions of the breast CHALLENGES: Management Questions: Should benign lesions be excised? Difficulties: Benign lesions may have an associated area of malignancy And they also have an increased risk of malignancy Recommendations: Papilloma with atypia (atypical papilloma), Papilloma with DCIS, Papillary DCIS, Encapsulated papillary carcinoma, Solid papillary carcinoma. Excision Lack of radiopathologic concordance. Excision. Benign papilloma. Discussion: surgical excision was usually recommended /recently some authors recommend follow-up

9 Imaging findings: Mammograms Papillary lesions of the breast Similar findings may appear in benign and malignant lesions Mass Usually solitary rounded or ovoid, wellcircumscribed retroareolar mass. Multiple may be peripheral masses Papilloma. Round retroareolar mass without calcifications (arrow). Calcifications Uncommon : coarse dense calcifications and microcalcifications Papilloma. Round retroareolar mass with calcifications ( arrow).

10 Imaging findings: US and Doppler Papillary lesions of the breast Benign and malignant lesions represent a solid growth within the duct with variable solid and cystic component. * * Solid mural nodule (*) within a dilated duct (arrows) An intracystic mass (*) Wellcircumscribed hypoechoic solid mass (arrow) A complex cyst Highly vascular, sometimes a vascular pedicle within a nodule

11 Imaging findings: Ductography Papillary lesions of the breast Indications: Spontaneous unilateral single-pore nipple discharge of any kind. More suspicious bloody or serous. Findings Intralumin al filling defect Ductal wall irregularit y, and distortion Ductal dilatation

12 Imaging findings: MR Papillary lesions of the breast MR + Gd Round, ovoid, or lobulated well-circumscribed masses With or without ductal dilatation Usually contrast enhancement with variable enhancement patterns T1 T1 Gad MR ductography Direct: cannulation and Gad injection within the duct. Indirect. Heavily T2- weighted sequences and high spatial resolution T2 DW

13 Interventional procedures Papillary lesions of the breast Guidance: Mammography, US, or MR imaging. US preferred Nipple or retroareolar lesions: Difficulties: Painful Tricks: Additional anesthesia. US approach from a distant point sometimes changing patient positioning Lesions within a duct or complex cysts Difficulties: If the cystic area disrupts and disappears with the first pass the mass may be difficult to identify Tricks: Accurate targeting of the solid area, trying to avoid the cystic component Use of a vacuumassisted directional device may help MR guided biopsies Difficulties: Lack of adequate compression of the anterior breast. Trick: second-look US

14 Pathology Papillary lesions of the breast Keys Presence of fibrovascular stalks Diagnostic criteria for papillary lesions Cell types: epithelial and myoepithelial. Absence of myoepithelial cells indicates carcinoma Stroma of papillae: prominent fibrosis with epithelial entrapment Upgrading on surgery 4%. Difficulties in biopsy Lesion heterogenicity: wide morphologic spectrum in benign, atypical and malignant lesions, within a single lesion Partial sampling: tissue fragmentation and undersampling. On H-E stains fragmentation

15 Case 1 32-year old woman. Right breast single-pore bloody discharge Mammogram US Ductography What is your BIRADS? Which is the next step?

16 Case 1 FINDINGS Mammogram depicts a partially circumscribed nodule US Well-circumscribed nodule within a duct. Ductography. Filling defect within a duct BIRADS 4A US US Nodule (yellow arrow) within a duct (green arrows) Ductography. Filling defect within a dilated duct (arrow) HE: Papilloma Ductography NEXT STEP: FNAB/Core biopsy DIAGNOSIS TIP. Papillomas are located central, within a few centimeters of the nipple and grow within the duct Papilloma

17 Case 2 44-year old. Left breast one-pore bloody discharge Ductography US What is your BIRADS? Which is the next step?

18 Case 2 FINDINGS US. Multiple small hypoechoic nodules, two in the central area, one peripheral (Upper outer quadrant) Ductography. Multiple filling defects on ductography, both central and peripheral. HE.- Papillomas (arrows) HE BIRADS 4A NEXT STEP: FNAB/Core biopsy DIAGNOSIS Papillomatosis TIP. Multiple papillomas are usually located on distal ducts. Presentation is usually asymptomatic but also serous or bloody nipple discharge. Increased risk of malignancy.

19 Case 3 61-year old woman. Single-duct bloody nipple discharge for two weeks Mammogram US Ductography What is your BIRADS? Which is the next step?

20 Case 3 FINDINGS Mammogram. Normal US. Well-circumscribed 5 mm nodule immediately beneath the nipple Ductography. Central filling defect HE.- Papilloma with atypia. Mioepthelial cells on P63 Nipple HE BIRADS 4A NEXT STEP: FNAB/Core biopsy p63 DIAGNOSIS Papilloma with atypia (atypical papilloma) TIP. Variable criteria have been used for diagnosis of atypical papilloma. No specific findings appear on imaging

21 Case 4 Mammogram 40-year old woman. Single duct bloody discharge US Ductography What is your BIRADS? Which is the next step?

22 Case 4 FINDINGS Mammogram depicts a circumscribed nodule Cyst with solid area on US. Ductography. Filling defect within a dilated duct HE BIRADS 4B NEXT STEP FNAB/Core biopsy of solid component of the lesion. Papilloma with atypia. EXCISION DIAGNOSIS HE TIP. Complex cysts should prompt biopsy of the solid area Papilloma with DCIS

23 Case 5 82-year old woman. Palpable mass Mammogram US Gad T1 T2 What is your BIRADS? Which is the next step? MR

24 Case 5 FINDINGS Mammogram. Well- Circumscribed lobulated mass US.Solid highly vascular circumscribed mass with small cystic areas MR. Lobulated mass predominantly hyperintense on T1 and T2 sequences with hypo T1, hyper T2 cystic areas. Contrast enhancing curve type 2 HE Neoplastic cells Papilla BIRADS 4C NEXT STEP Core biopsy. DIAGNOSIS Solid papillary carcinoma TIP. Variant of DCIS. Single or multiple circumscribed nodules of neoplastic cells, with solid pattern and grossly well circumscribed. Frequent mucin production. It appears usually in older women (70 yo)

25 Case 6 81-year old woman. Palpable mass Mammogram US MR STIR MR Gad Doppler What is your BIRADS? Which is the next step?

26 Case 6 FINDINGS Mammogram. Wellcircumscribed mass US. Mixed solid and cystic lesion. Low-level echoes are depicted within the cystic areas, consistent with hemorrhage US Doppler.Vessels are depicted on solid area MR Hyperintense lesion on T2 w image. Contrast enhancement. BIRADS 4C NEXT STEP Core biopsy. DIAGNOSIS Encapsulated papillary carcinoma HE Absence of myoepithelial cells TIP. Invasive tumor with excellent prognosis. Terminology. INCORRECT: Intracystic or encysted papillary carcinoma. CORRECT: Encapsulated papillary carcinoma p63

27 Case 7 14-year old girl. Refers palpable mass for two weeks US Doppler US What is your BIRADS? Which is the next step?

28 Case 7 FINDINGS HE US. Vascular solid mass (M) within a dilated duct (arrows) H-E. Focal areas of sclerosis appear M BIRADS 4A NEXT STEP Core biopsy DIAGNOSIS HE: Areas of sclerosis with entrapped cells TIP. A variant of papilloma with sclerosis in the papillary structures, either focal or diffuse. Sclerosing papilloma

29 Case 8 63-year old woman. Serous single- duct discharge US Doppler US Mammogram What is your BIRADS? Which is the next step?

30 Case 8 FINDINGS Mammogram. Circumscribed central mass US. Vasular mass within a cyst BIRADS 4B NEXT STEP Core biopsy DIAGNOSIS Ductal Adenoma HE HE TIP. It is a highly sclerotic variant of papillary benign lesions in which the papillary architecture is obliterated. On imaging, findings are similar to papilloma

31 Case 9 78-year old woman. Palpable mass Mammogram US What is your BIRADS? Which is the next step?

32 Case 9 FINDINGS Mammogram. Tubular lesion with heterogenous, coarse calcifications. US. Lobulated mass. Margins difficult to evaluate due to acoustic shadowing from calcifications. BIRADS 4C DIAGNOSIS Encapsulated papillary carcinoma NEXT STEP Core biopsy. HE Calcifications HE TIP. Remember features that suggest malignancy: size greater than 1 cm, lesion location more than 3 cm from the nipple, patient age greater than 50 years HE: Atypical cells and calcifications TIP. Calcifications are infrequent in papillary lesions but may appear

33 Take home points Papillary lesions of the breast Spontaneous bloody or serous nipple discharge One duct Several ducts Findings mammogram: Well-circumscribed mass Calcificactions may appear excision Mammogram US Ductography MR If normal Mammogram US Systemic? Sometimes MR Papilloma with atypia (atypical papilloma) Pailloma with DCIS Papillary DCIS Encapsulated papillary carcinoma Solid papillary carcinoma Histopathology Findings US : Solid area within a cyst Hemorrhage component within a cyst Solid lesión within a duct Solid mass Findings Ductography: Filling Defect Duct dilatation Distorsion Findings MR Well-circumscribed mass Mixed mass Different enhancement patterns Followup/excision Lack of radiopathologic concordance Benign papilloma Fine needle aspiration biopsy Core biopsy Vacuum assisted biopsy

34 References: Papillary lesions of the breast Yamaguchi R, Tanaka M, Tse G M, Yamaguchi M, Terasaki H, Hirai Y, Nonaka Y, Morita M, Yokoyama T, Kanomata N, Naito Y, Akiba J, Yano H. Management of breast papillary lesions diagnosed in ultrasound-guided vacuum-assisted and core needle biopsies. Histopathology 2015:66; Sheiman LS, Levesque PH. The In's and Out's of Ductography: A Comprehensive Review. Curr Probl Diagn Radiol Jun 5. pii: S (15) doi: /j.cpradiol [Epub ahead of print]. Nicholson BT, Harvey JA, Patrie JT, Mugler JP. 3D-MR Ductography and Contrast- Enhanced MR Mammography in Patients with Suspicious Nipple Discharge; a Feasibility Study. Breast J. 2015;21(4): Pulgar Boin D, Jans Baez J, Petric Guajardo M, Oddo Benavides D, Navarro Ortega ME, Razmilic Valde s D,Camus Apphun M. Breast papillary lesions: an analysis of 70 cases. ecancer 2014, 8:461 DOI: /ecancer Accesed 2 spt Jagmohan P, Pool FJ, Putti TC Wong J. Papillary lesions of the breast: imaging findings and diagnostic challenges. Diagn Interv Radiol 2013; 19: Ueng SH1, Mezzetti T, Tavassoli FA. Papillary neoplasms of the breast: a review.arch Pathol Lab Med Jun;133(6): Soo MS, Williford ME, Walsh R, Bentley RC, Kornguth PJ. Papillary carcinoma of the breast. Imaging findings. Am J Roengenol 1995;164: