|Year : 2015 | Volume
| Issue : 4 | Page : 1029
A case of invasive papillary breast carcinoma: Fierce façade with favorable prognosis
D Vani, S Geetanjali, Giri M Punja, M Bharathi
Department of Pathology, Mysore Medical College and Research Institute, Mysore, Karnataka, India
|Date of Web Publication||15-Feb-2016|
Department Of Pathology, Mysore Medical College And Research Institute, Mysore - 570 001, Karnataka
Source of Support: None, Conflict of Interest: None
Invasive papillary carcinoma of the breast is a rare, distinct variant comprising approximately less than 1-2% of all newly diagnosed cases of breast carcinoma and is usually found in postmenopausal women with a more favorable prognosis. We report an unusual case in a 45-year-old perimenopausal female who came with a complaint of lump in right breast for duration of 1 year. A simple mastectomy was undertaken for histopathological study and immunohistochemistry (IHC) which showed characteristic features of an invasive papillary breast carcinoma. We present this case in view of its rarity and to highlight this clinicopathological subtype for its good prognosis and to avoid overtreatment.
Keywords: Breast cancer, invasive papillary carcinoma, perimenopausal, p63
|How to cite this article:|
Vani D, Geetanjali S, Punja GM, Bharathi M. A case of invasive papillary breast carcinoma: Fierce façade with favorable prognosis. J Can Res Ther 2015;11:1029
| > Introduction|| |
Invasive papillary carcinoma is a rare variant of breast cancers accounting for less than 1-2% of all invasive cancers. , Most of them are seen predominantly in postmenopausal women and have good prognosis.  Clinically, these tumors are often asymptomatic or present with bloody nipple discharge, an abnormal mass, or radiographic abnormalities.  Grossly, it appears to be a well-circumscribed mass. Histopathologically, they are characterized by proliferation of cells around fibrovascular cores, surrounded by thick fibrotic wall. 
These tumors lack myoepithelial cell layer (MCL) within the papillae or at the periphery of the tumor with areas showing stromal invasion or invasion into lymphovascular space.  Distinction of benign from malignant lesions can be difficult on hematoxylin and eosin (H and E) staining. The demonstration of myoepithelial cells by immunohistochemistry (IHC) using actin, CK5/6, and p63 can prove to be very useful.  Herein, we report this case because of its rarity.
| > Case report|| |
A 45-year-old woman came to our hospital with complaints of lump in the right breast for the past 1 year, gradually increasing in size. There was no history of associated pain, nipple discharge, or significant family history. On systemic examination, she was not a known case of hypertension (HTN), diabetes mellitus (DM), ischemic heart disease (IHD), or pulmonary tuberculosis. Routine blood and urine tests were within normal limits. Serological studies for human immunodeficiency virus (HIV) and hepatitis B surface antigen (HBsAg) were found to be nonreactive.
A single, large, firm to hard, nodular, well-circumscribed palpable lump measuring 8 × 7 cm involving central, lower inner, and outer quadrants with no nipple retraction or discharge was observed. Examination of bilateral axilla revealed no palpable lymph nodes.
Fine needle aspiration smears were highly cellular and showed features of atypical ductal hyperplasia.
Ultrasonography revealed a large, lobulated, well-delineated, heterogeneously hypoechoic solid and cystic lesion with intralesional vascularity suspicious of malignancy.
The patient was taken up for simple mastectomy and specimen was sent for histopathological examination.
Gross examination of the excised specimen showed a relatively well-circumscribed, grey-white mass measuring 8 × 8 cm with areas of cystic degeneration, necrosis, and hemorrhage [Figure 1].
|Figure 1: Well-circumscribed, grey-white mass with areas of necrosis, hemorrhage, and cystic degeneration|
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A highly cellular tumor comprised of pleomorphic ductal epithelial cells arranged predominantly in papillary pattern with fine fibrovascular core invading into stroma [Figure 2]. The papillae were lined by tumor cells with high nucleocytoplasmic ratio and hyperchromatic nuclei along with areas of hemorrhage and necrosis. Proliferation of these tumor cells were also seen within the cystic spaces. Ductal carcinoma in situ (DCIS) component was noted at places. All other margins, nipple, and areola were free from tumor invasion. A diagnosis of invasive papillary carcinoma of right breast was done.
p63, a special immune marker for myoepithelial cells, was used for confirmation [Figure 3].
|Figure 2: Pleomorphic ductal epithelial cells arranged in papillary pattern with fine fibrovascular core invading into stroma|
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| > Discussion|| |
The term papillary lesions of the breast encompass a morphologically heterogeneous group of lesions and pose difficulty in differentiating benign from malignant lesions. 
Malignant papillary neoplasms of breast includes a number of microscopically distinct lesions such as DCIS arising in intraductal papilloma, papillary DCIS, encapsulated papillary carcinoma, solid papillary carcinoma, and invasive papillary carcinoma. , All malignant papillary proliferations of the breast lack an intact MCL within the papillae or at the periphery of the tumor, which is an important feature allowing distinction from benign intraductal papillomas. 
Invasive papillary carcinoma is one of these morphologically distinct subtypes of papillary carcinoma which usually affect older women in postmenopausal period; average being around 60 years and comprising less than 1-2% of all the breast cancers. 
The differentiating feature of the invasive papillary carcinoma from the encapsulated intracystic papillary breast carcinoma includes its invasive nature into the stroma, higher nuclear grade, and necrosis. 
IHC for myoepithelial cells and basement membrane is essential for the diagnosis of invasive cancers. The myoepithelial cells are absent in invasive carcinomas. There are many known myoepithelial markers such as S-100, calponin, CD10, smooth muscle myosin heavy chain, alpha-smooth muscle actin, maspin, p63, and high molecular weight cytokeratin with different sensitivities and specificities. Of these, p63 and smooth muscle myosin are more specific. A special myoepithelial marker, p63, stains the cell nucleus only. 
The overall prognosis of invasive papillary carcinoma is better than commoner types of breast carcinoma such as infiltrating ductal carcinoma of not otherwise specified (NOS) type.
| > Conclusion|| |
We highlight this rare variant of invasive breast cancer presenting with unusually large tumor size. Even though it commonly occurs in postmenopausal woman, it can rarely appear in perimenopausal age group.
Regardless of its invasive nature, it carries an excellent prognosis; and thus, awareness of this entity is important to avoid overtreatment. Accurate diagnosis of papillary lesions remains challenging only by standard H and E staining. IHC for myoepithelial cells is a useful diagnostic tool in differentiating benign from malignant lesions with implication on management.
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[Figure 1], [Figure 2], [Figure 3]