M Muttarak MD,
A Somwangprasert MD, B Chaiwun MD Departments of Radiology, Surgery,
Pathology, Chiang Mai University, Chiang Mai, Thailand
A 44-year-old-woman presented with a painless lump in the
right breast for 10 months. She had no nipple discharge and
no familial history of breast carcinoma. She was treated at
a provincial hospital by aspiration of the mass which revealed
bloody fluid. She was informed that there was no abnormality.
A few weeks later, she felt a lump again in her right breast,
so she came to our hospital. Physical examination revealed
a 3.5 cm, mobile mass in the upper outer quadrant of the right
breast. There was no evidence of axillary lymphadenopathy.
The patient was admitted for excisional biopsy of the breast
Mammography showed scattered fibroglandular breasts with
a 3.5 cm partially circumscribed, dense mass in the right
upper outer quadrant (Fig 1). The mass contained no calcification.
The axillary lymph nodes appeared normal. Ultrasonography
(US) of the mass showed a complex mass with cystic and solid
components (Fig 2). The mass also showed some posterior acoustic
enhancement. Colour Doppler US demonstrated vascular flow
within the solid component of the mass (Fig 3).
Figure 3 Transverse color Doppler
US image shows vascular flow within the solid components.
At gross examination, the specimen contained a circumscribed
mass measuring 3.5 cm with bloody content and solid nodular
masses protruding into cystic space (Fig 4). At microscopy,
there were multiple papillary fronds with thin fibrovascular
cores. The columnar epithelial cells revealed a pleomorphic
appearance (Fig 5-6). Invasive malignant cells were seen in
the surrounding fibrous stroma (Fig 7).
Figure 6 High-power photomicrograph
shows a papillary frond (short arrows) with a fibrovascular
core (long arrow). The epithelial cells are pleomorphic
(Haematoxylin-eosin stain, original magnification,
Figure 7 High-power photomicrograph
shows invasive carcinoma (arrows) extending into
surrounding fibrous stroma (Haematoxylin-eosin stain,
original magnification, x200).
Papillary carcinoma of the breast is a rare malignant tumour,
constituting 1-2% of all breast carcinomas in women .
Pathologically, papillary carcinoma has a frond-forming growth
pattern supported by a fibrovascular stalk .
The absence of a myoepithelial layer distinguishes carcinoma
from benign papillary lesion.The tumour may be solitary or
multiple. The tumour is classified as papillary ductal carcinoma
in- situ if the epithelium of a papillary carcinoma has features
diagnostic of intraductal component. If a cystic component
is present, the tumour is described as an intracystic papillary
carcinoma . Invasive papillary carcinoma
occurs infrequently, often as only a small focus of stromal
invasion and is almost always detected at the periphery of
the lesion [2,3]. Papillary
carcinoma generally occurs in older women aged 63-67 years
[2-4]. Patients with papillary
carcinoma may present with a palpable mass or bloody nipple
discharge. The tumour may also be asymptomatic and identified
at screening mammography. The tumour has a slow growth and
a better prognosis than other forms of ductal carcinomas [1-8].
Axillary nodal metastases are infrequent.
On mammography, papillary carcinoma is seen as a round,
oval or lobulated mass. The margins of the mass are usually
circumscribed but may be obscured or indistinct.
On US, the tumour may appear as solid hypoechoic mass, or
a complex mass with cystic and nodular solid components with
posterior acoustic enhancement [2-4].
Haemorrhage within the cyst is frequently present due to ruptured
capillaries within the cyst wall or haemorrhagic infarction
of the tumor cells. Colour Doppler US is helpful to demonstrate
the intramural blood flow, as in the presented case. Mammographically,
differentiation between invasive and papillary ductal carcinoma
in-situ is difficult. Papillary ductal carcinoma in-situ may
manifest as single or multiple clusters of calcifications,
sometime with dilated ducts, or single or multiple circumscribed
masses. These findings are indistinguishable from those described
in invasive papillary carcinoma [2,3,8-10].
Differentiation between in-situ and invasive papillary carcinoma
is also difficult by fine needle aspiration or core biopsy
because the centre of the lesion is often targeted, and invasion
is often found at the periphery of the tumour. Therefore,
excisional biopsy is often performed when papillary carcinoma
Because papillary carcinoma has an excellent prognosis,
the tumour may be managed by mastectomy or segmental resection.
Axillary lymph node dissection or sentinal node biopsy is
often performed in patients in whom invasion is likely [4,5,7,8].
Our presented case underwent mastectomy with axillary node
dissection which revealed no residual tumour and no nodal
metastasis in all 15 dissected nodes.
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Received 7 June 2005; accepted
for publication 23 June 2005
Correspondence: Department of Radiology, Chiang Mai University, Chiang Mai 50200, Thailand.. Tel.: 66-53-945450; Fax: 66-53-217144; E-mail: firstname.lastname@example.org (Malai Muttarak).
Please cite as: Muttarak M, Somwangprasert
A, Chaiwun B,
Intracystic papillary carcinoma of the breast, Biomed Imaging Interv J 2005; 1(1):e5
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