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CASE REPORT
Year : 2021  |  Volume : 19  |  Issue : 4  |  Page : 287-289

A diagnostic challenge of breast lump


Department of General Surgery, Dr. Mehta Hospital, Chennai, Tamil Nadu, India

Date of Submission16-May-2021
Date of Decision18-Jun-2021
Date of Acceptance22-Jun-2021
Date of Web Publication07-Dec-2021

Correspondence Address:
Dr. Jayabal Pandiaraja
26/1, Kaveri Street, Rajaji Nagar, Villivakkam, Chennai - 600 049, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cmi.cmi_56_21

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  Abstract 


Intracystic papillary carcinoma breast is an uncommon breast cancer consisting of 0.5%–1.0% of all breast cancers. Papillary carcinoma is a rare type of breast carcinoma which is divided into two types, which are intraductal and intracystic papillary carcinoma. Intracystic papillary carcinoma may present as pure intracystic carcinoma or may be associated with in situ carcinoma. Here, we report a case of intracystic papillary carcinoma of both breasts which created diagnostic dilemma.

Keywords: Breast, in situ carcinoma, intracystic carcinoma, papillary carcinoma, wide local excision


How to cite this article:
Pandiaraja J. A diagnostic challenge of breast lump. Curr Med Issues 2021;19:287-9

How to cite this URL:
Pandiaraja J. A diagnostic challenge of breast lump. Curr Med Issues [serial online] 2021 [cited 2022 Jan 22];19:287-9. Available from: https://www.cmijournal.org/text.asp?2021/19/4/287/331833




  Introduction Top


Intraductal and intracystic variants are the two subtypes of papillary breast cancer. Intracystic papillary breast carcinoma is a rare variant of breast carcinoma consisting of <1.0% of all breast cancers.[1] It is further divided into pure intracystic carcinoma and those associated with in situ carcinoma.[2]


  Case Report Top


A 70-year-old female presented with a history of a lump in both breasts for 4 months. There was no history of pain in the lump or nipple discharge. The patient denied a history of loss of appetite and loss of weight. She is a known case of hypothyroidism on treatment. There was no significant history suggestive of breast cancer in the family. On clinical examination, both breasts revealed breast lumps of 4 cm × 4 cm in the right and 2 cm × 2 cm in the left. Both the breast lump is located in the upper and outer quadrant of the breast. The mass was variegated inconsistency and mass moves along with the breast tissue. There was no evidence of bilateral axillary lymphadenopathy.

Baseline blood investigations were unremarkable. Ultrasonography of both breasts showed a multilobulated hypoechoic lump of 4 cm × 4 cm in the right breast and hypoechoic lump of 2 cm × 2 cm in the left breast. There was no evidence of bilateral axillary lymphadenopathy. Fine-needle aspiration cytology (FNAC) showed benign aspirate on both sides probably fibrocystic breast disease [Figure 1]. Image-guided Tru-cut biopsy showed benign proliferative breast lesions of both breasts probably duct adenoma [Figure 2]. Whether it should be treated like benign or malignant based on imaging and histopathological examination?
Figure 1: Fine-needle aspiration cytology showed benign aspirate on both sides probably fibrocystic breast disease.

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Figure 2: Image-guided Tru-cut biopsy showed benign proliferative breast lesion of both breasts probably duct adenoma.

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Workup and clinical course

The patient underwent excision of a breast lump on both sides. Postoperative histopathology showed intracystic papillary carcinoma with invasive carcinoma on the right side. Superior and deep resected margins showed involvement by tumor cells. Section from left breast showed an invasive tumor in cribriform pattern and solid areas with intracystic papillary carcinoma [Figure 3]a and [Figure 3]b. On both sides, estrogen receptor and progesterone receptor were positive and Her/2neu was negative on immunohistochemistry.
Figure 3: (a) Postoperative histopathology showed intracystic papillary carcinoma with invasive carcinoma on the right side. Superior and deep resected margins showed involvement by tumor cells. (b) Section from left breast showed an invasive tumor in cribriform pattern and solid areas with intracystic papillary carcinoma.

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Postoperatively, the patient was evaluated with whole-body positron emission tomography (PET)-computed tomography showed metabolically active ill-defined soft tissue in the upper outer quadrant of the right breast and retroareolar quadrant of both breasts, suggestive of residual malignancy. There was no significant metabolically active axillary, deep pectoral, and internal mammary lymph node. PET also confirmed there was no evidence of metabolically active distant metastasis. The patient was counseled for breast conservation surgery, but the patient not willing. Hence, we proceeded with simple mastectomy with sentinel lymph node biopsy. Postoperative specimen showed bilateral high-grade intracystic papillary carcinoma with fibrocystic disease. There was no evidence of residual tumor. All resected margin free of tumor [Figure 4]. Bilateral axillary lymph node showed free of tumor.
Figure 4: Postoperative MRM specimen showed bilateral high-grade intracystic papillary carcinoma with fibrocystic disease. There was no evidence of residual tumor. All resected margin free of tumor.

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Patient consent

A written informed written consent was obtained from the patient for publication of the case in a medical journal.


  Discussion Top


Papillary carcinoma breast is one of the diseases with diagnostic difficulty. All suspected breast cancer should undergo a triple assessment. However, the triple assessment of intracystic papillary carcinoma is relatively challenging.[3] On ultrasound, intracystic papillary carcinoma may appear as a hypoechoic mass. This mass may have a projection from the wall of the cyst. Sometimes, it may appear as a solid pattern with intraductal or intracystic mass.[4]

The mammographic appearance of intracystic papillary carcinoma is less specific. Small intracystic papillary carcinoma is often undetectable on mammography. A large mass may resemble a well-circumscribed dense mass.[5] A false-negative result with FNAC is relatively frequent. Papillary breast carcinoma is rarely detected based on FNAC or Tru-cut biopsy. The reason behind this is, most of the invasion is not located in the center rather than in the periphery. However, an Ultrasound (USG)-guided biopsy from the solid components relatively has a better yield. FNAC cannot differentiate between in situ and invasive papillary carcinoma.[6]

It is mostly estrogen receptor and progesterone receptor-positive and Her/2neu negative and hence has a good prognosis.[7] Wide local excision is recommended treatment for the patient with atypia in Tru-cut biopsy, high-risk lesion, and positive malignant cells and discordance of the image with histopathology.[8] The papillary carcinoma usually has a staged surgical management. In a staged procedure, excision biopsy may be followed by wide local excision/mastectomy and addressing the axilla depending on nodal involvement. Papillary breast cancer shows up to 14% axillary metastasis. Hence, axillary lymph node dissection is recommended for papillary breast cancer if axillary nodes are suspicious on imaging, else a sentinel lymph node biopsy or low-level sampling can be done in case of negative axilla (clinically and radiologically negative).


  Conclusion Top


Intracystic papillary breast cancer is one of the rare variants of breast cancer. The clinical manifestations, radiological investigations, and Tru-cut biopsy may be misleading. Papillary carcinoma should be considered one of the differential diagnoses of the breast with cystic changes which is usually has a short history or reappearance after one or two aspirations. The FNAC and image-guided Tru-cut biopsy are not much useful in differentiating between fibrocystic breast disease and papillary breast carcinoma. Only surgical excision confirms the suspected papillary breast carcinoma.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Hu ZI, Liu C, Fisher PR, Cohen JA. Intracystic papillary carcinoma of the breast in a male patient. Rare Tumors 2016;8:6050.  Back to cited text no. 1
    
2.
Vani D, Geetanjali S, Punja GM, Bharathi M. A case of invasive papillary breast carcinoma: Fierce façade with favorable prognosis. J Cancer Res Ther 2015;11:1029.  Back to cited text no. 2
    
3.
Ingle SB, Murdeshwar HG, Siddiqui S. Papillary carcinoma of breast: Minireview. World J Clin Cases 2016;4:20-4.  Back to cited text no. 3
    
4.
Ciurea A, Calin A, Ciortea C, Dudea SM. Ultrasound in the diagnosis of papillary breast lesions. Med Ultrasono 2015;17:392-7.  Back to cited text no. 4
    
5.
Umanah IN, Okpongette AS. Intracystic papillary carcinoma of the breast in a 21-year old premenopausal Nigerian woman: A case report. Rare Tumors 2009;1:e50.  Back to cited text no. 5
    
6.
Rakha EA, Ahmed MA, Ellis IO. Papillary carcinoma of the breast: Diagnostic agreement and management implications. Histopathology 2016;69:862-70.  Back to cited text no. 6
    
7.
Mogal H, Brown DR, Isom S, Griffith K, Howard-McNatt M. Intracystic papillary carcinoma of the breast: A SEER database analysis of implications for therapy. Breast 2016;27:87-92.  Back to cited text no. 7
    
8.
Solorzano CC, Middleton LP, Hunt KK, Mirza N, Meric F, Kuerer HM, et al. Treatment and outcome of patients with intracystic papillary carcinoma of the breast. Am J Surg 2002;184:364-8.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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