Ultrasound spectrum in intraductal papillary neoplasms of breast

Intraductal papillary neoplasms (IPNs) of breast form a wide spectrum of pathological changes with benign intraductal papilloma occupying one end of the spectrum and papillary carcinoma at the other end. Intraductal papillomas are known to occur anywhere within the ductal system and are broadly classified into central and peripheral types. Intraductal papillary carcinoma is an uncommon ductal malignancy forming papillary structures, and these lesions characteristically lack the myoepithelial layer present in benign papillary neoplasms. Three basic patterns of IPNs are recognized on ultrasound - intraductal mass with or without ductal dilatation, intracystic mass and a predominantly solid pattern with the intraductal mass totally filling the duct. Benign papillomas are known to exhibit calcifications which tend to be extremely dense and coarse. IPNs are highly vascular tumours and have a propensity to bleed spontaneously. A distinct vascular pedicle is identified within the central core of IPNs, with branching vessels arborising within the mass. In an older age group, presence of a large solid component and evidence of spontaneous intracystic bleed are more suggestive of papillary carcinomas than benign papillomas. We have serially studied 42 cases of intraductal papillary neoplasms with sonomammography and mammography from 2001 to 2004.     

Imaging of hereditary renal cancer

Over the past 5 years there have been dramatic developments in the extent of knowledge of hereditary renal cancers. In addition to VHL, which is associated with clear cell carcinoma, one can now list HPRC (associated with type I papillary renal cancer) and HLRCC (associated with type II papillary renal cancer). BHD and FRO are associated with chromophobe carcinoma and oncocytomas, although other histologic tumor types have been found in BHD. Medullary carcinoma of the kidney is associated with sickle cell trait. Although the genes associated with these tumors have been discovered, the exact mechanisms by which they cause renal cancer remain to be elucidated. It is quite likely that other genes also are involved in this process. Using VHL as an example, research is now underway on targeting mutant pVHL or excess HIF for diagnostic and therapeutic purposes. Understanding the mechanisms leading to cancer may open new targets of opportunity for drug development. This improved knowledge of the biogenetic pathways used to form tumors will impact the development of new therapeutic techniques for treating renal cancers in hereditary and nonhereditary forms of the disease.     

少见类型乳腺癌的影像、临床、病理及免疫组化分析

目的探讨少见类型乳腺癌影像、临床、病理及免疫组化主要特点,提高对其认识。方法回顾性分析经活检和/或手术病理证实的少见类型乳腺癌21例,观察并分析其X线、超声、相关临床、病理及免疫组化资料。结果 21例中乳头状癌4例,浸润性微乳头状癌5例,粘液癌8例,髓样癌4例。21例X线主要表现边缘模糊或浸润型肿块;超声主要表现均为不规则实性不均质低回声团,边缘欠清,病灶内及周围可见血流。总的中位发病年龄为48.7岁;淋巴结情况:乳头状癌(4/4例)及粘液癌(7/8例)未见淋巴结转移;浸润性微乳头状癌(4/5例)及髓样癌(4/4例)可见淋巴结转移。镜下病理:乳头状癌(4/4例)癌细胞形成中心见纤维血管束的乳头状结构;浸润性微乳头状癌(4/5例)癌细胞簇与间质之间形成间隙;粘液癌(8/8例)癌细胞漂浮于细胞外液粘液湖中;髓样癌(4/4例)癌细胞密集,间质纤维少,间质中淋巴细胞弥漫浸润。免疫组化:髓样癌3/4例为三阴性;乳头状癌(3/4例)、浸润性微乳头状癌(4/5例)及粘液癌(7/8例)为非三阴性;浸润性微乳头状癌(4/5例)肿瘤外侧细胞膜EMA染色阳性。结论少见类型乳腺癌各亚型间病理组织学及免疫组化具有一定特征性;浸润性微乳头状癌及髓样癌易发生淋巴结转移;但各型间影像学表现及发病年龄不具有特征性,术前影像确诊困难,主要依靠术后病理确诊。     

Sonographically-Guided 14-Gauge Core Needle Biopsy for Papillary Lesions of the Breast

Objective

We wanted to assess the need for surgical excising papillary lesions of the breast that were diagnosed upon sonographically guided 14-gauge core needle biopsy.

Materials and Methods

Sixty-nine women (age range: 25-74 years, mean age: 51.7 years) with 69 papillary lesions (4.9%) were diagnosed and followed after performing sonographically guided 14-gauge core needle biopsies. Surgical excision was performed for 44 (64%) of 69 papillary lesions, and 25 lesions were followed with imaging studies (range: 6-46 months, mean: 17.9 months). The histologic findings upon core biopsy were compared with the surgical, imaging and follow-up findings.

Results

Core needle biopsies of 69 lesions yielded tissue that was classified as benign for 43 lesions, atypical for 18 lesions and malignant for eight lesions. Of the 43 lesions that yielded benign papilloma upon core needle biopsy, one had intraductal papillary carcinoma found upon surgery. An immediate surgical biopsy was recommended for this lesion because of the imaging-histologic discordance. No additional carcinoma was found during the imaging follow-up. Surgical excision was performed for 17 atypical papillary lesions, and this revealed intraductal (n = 6) or invasive (n = 2) papillary carcinoma in 8 (47%) lesions. Of the seven intraductal papillary carcinomas, surgery revealed invasive papillary carcinoma in one (14%).

Conclusion

Our results suggest that papillary lesions of the breast that are diagnosed as benign upon sonographically guided 14-gauge core needle biopsy can be followed when the results are concordant with the imaging findings.     

Unusual malignant tumors of the breast: MRI features and pathologic correlation

Unusual malignant breast tumors are well-differentiated subtypes of invasive ductal carcinoma, including mucinous, tubular, medullary and papillary carcinomas, and account for about 10% of malignant breast tumors. They are increasingly being encountered during magnetic resonance imaging (MRI) examinations of the breast. Therefore, breast radiologists should be aware of their appearance on MRI.This review provides an overview of MRI characteristics of a range of unusual tumors (mucinous carcinoma, medullary carcinoma, tubular carcinoma, intraductal papillary carcinoma, intracystic papillary carcinoma and invasive papillary carcinoma), highlighting specific clues for diagnosis and correlating MRI and pathologic features. Many unusual breast tumors exhibit MRI features similar to those of benign or low suspicious lesions (oval shape, well-defined margins, high signal intensity on T2-weighted images, continuous increase kinetics, i.e. type I dynamic curve), leading to a possible misdiagnosis. Nevertheless, an understanding of pathologic features of these tumors, especially tissue content (mucinous, fibrous) and growth pattern, can help to define some specific clues for their diagnosis.     

Imaging-guided core needle biopsy of papillary lesions of the breast

OBJECTIVE: Our objective was to assess the incidence of papillary lesions of the breast diagnosed at imaging-guided core needle biopsy and the need for surgical excision after a benign diagnosis. MATERIALS AND METHODS: This retrospective study included 1374 patients with consecutive suspicious breast lesions that underwent either mammography or sonographically guided large-core needle breast biopsy. Fifty-seven lesions (4%) were classified as papillary lesions. Eleven of the 57 cases were lost to follow-up (n = 6) or had not yet shown 2 years of stability (n = 5) and were excluded from this study. The remaining 46 papillary lesions constitute our study population. RESULTS: Surgical excision was performed in 17 (37%) of 46 papillary lesions. In the group of patients whose lesions were recommended for excision because carcinoma was identified at core biopsy, surgical excision revealed one false-positive and two true-positive diagnoses. In four cases, histologic diagnoses of the excisional biopsy and the core needle biopsy were discordant. One false-positive finding at core needle biopsy initially was interpreted as invasive ductal carcinoma on the basis of core needle biopsy specimens. In three false-negative findings, the initial diagnosis at core needle biopsy was upgraded after surgical excision. Two cases of papilloma with adjacent atypical ductal hyperplasia and one of atypical papilloma were upgraded to ductal carcinoma in situ after surgical excision. Imaging follow-up was performed in the remaining 29 patients. All lesions were stable or had decreased in size during the 2-year follow-up period. The negative predictive value of core needle biopsy for excluding malignancy among the papillary lesions diagnosed in our study was 93%. CONCLUSION: When the histologic diagnosis is benign, our data suggest that papillary lesions may be safely managed with imaging follow-up rather than with surgical excision. However, atypical papillary lesions or those associated with atypia require surgical excision because histologic underestimation occurs at a frequency similar to that in other atypical lesions undergoing core needle biopsy.     

Bilateral invasive papillary carcinoma of the breast

Papillary carcinoma, a rare malignant tumor of the breast, accounts for only 1–2% of breast tumors. It predominantly affects elderly women in the sixth decade to the eighth decade of life. The incidence of bilateral papillary carcinomas is very low, with only one case reported in the literature. However, there has been no report of a case of bilateral invasive papillary carcinoma. A case of bilateral invasive papillary carcinoma of the breasts, along with mammography and ultrasound findings, is reported here.     

Invasive papillary carcinoma of the breast: mammographic appearance

The mammographic findings in 18 patients with invasive papillary carcinoma were studied retrospectively. The mammograms of 10 patients showed a multinodular pattern, and seven patients had solitary nodules. One patient had an irregular, ill-defined mass in the retroareolar region. Two patients were found to have carcinoma in the contralateral breast, and two patients had intraductal carcinoma adjacent to the invasive papillary carcinoma. The varied mammographic features that may occur with this rare breast malignancy are discussed.     

乳腺导管内乳头状癌22例临床病理分析

目的探讨乳腺导管内乳头状癌的临床病理学特征。方法复习22例乳腺导管内乳头状癌手术切除标本的病理切片并做相应的免疫组织化学染色,结合临床资料和组织学特点进行分析。结果眼观：包块边缘呈推挤状,直径1．5—4．2cm。切面灰粉色、实性、质脆。其中,6例标本切面上可见一囊内明显的乳头状成分,质脆易碎,边界不清。镜检：表现为乳头状结构,乳头被覆单一的腺上皮,≥90％的乳头完全缺乏肌上皮层,腺上皮单层或多层,与纤维轴心垂直,瘤细胞有不同程度的异型性。免疫组织化学：Actin、SMMHC、Calponin、p63、CD10、CK5／6显示≥90％的乳头缺乏肌上皮层;乳腺导管上皮细胞AE1／AE3、CK7全部病例阳性、CEA18例病例阳性。结论乳腺导管内乳头状癌是一种罕见的乳腺低度恶性肿瘤,预后较好;诊断必须与乳腺导管内乳头状瘤鉴别,免疫组织化学在鉴别诊断中起关键作用。彻底切除肿瘤及其周围部分乳腺组织已属充分治疗。     

Papillary lesions of the breast: evaluation with stereotactic directional vacuum-assisted biopsy.

PURPOSE: To evaluate the use of stereotactic directional vacuum-assisted biopsy (SDVAB) in diagnosing and managing papillary lesions of the breast. MATERIALS AND METHODS: The authors retrospectively reviewed the mammographic and histopathologic findings of 26 cases in which papillary lesions were diagnosed at SDVAB. In all cases, subsequent surgical excision (n = 20) or long-term imaging follow-up (n = 6) was performed and correlated with findings at SDVAB. RESULTS: SDVAB of 26 lesions yielded tissue that was classified as benign in 12, atypical in six, and malignant in eight. Of the 12 lesions that were diagnosed as histologically benign at SDVAB, six were surgically excised. Of these six lesions, five yielded benign correlative results. The sixth lesion was thought to be discordant with the imaging findings, and was surgically excised and determined to be malignant. Of the six benign lesions that were not surgically sampled for biopsy, five decreased in size and one was not seen at radiographic follow-up. Of the six lesions diagnosed as atypical at SDVAB that were surgically excised, one was benign and five were atypical. None proved to be malignant. Of the eight lesions diagnosed as malignant at SDVAB, surgical excision demonstrated ductal carcinoma in situ in all eight; two also had foci of invasive carcinoma. CONCLUSION: Benign and malignant papillary lesions of the breast can be reliably diagnosed at SDVAB when the SDVAB results correlate with the imaging findings. However, the extent of malignant papillary disease may be underestimated at SDVAB; in our study, invasive carcinoma was later discovered in 25% of patients with this diagnosis.     

Characterisation of breast papillary neoplasm on automated breast ultrasound

Intraductal papillary neoplasms of the breast form a wide spectrum of pathological changes with benign intraductal papilloma and papillary carcinoma. They can occur anywhere within the breast ductal system. This review illustrates some characteristic appearances of breast papillary neoplasms on coronal planes reconstructed by automatic breast volume scan. Such manifestations are not uncommon in papillary neoplasms, and familiarity will enable confident diagnosis.Papillary lesions of the breast are a heterogeneous group of breast lesions, including intraductal papilloma, atypical papilloma and intraductal papillary carcinoma [1,2]. Although the management of intraductal papillomas is varied, surgical excision is generally recommended as a precaution against the risk of a subsequent carcinoma [3,4]. Recently, some studies have suggested that patients with a tumour measuring <1.5 cm and an ultrasound Breast Imaging—Reporting and Data System (BI-RADS) category of 3 or 4a can be potentially selected for vacuum-assisted biopsy, but only if the tumour does not extend into the branching ducts [5,6]. Ueng et al [2] recommended that localised papillary lesions should be excised completely with a small rim of uninvolved breast tissue without any prior needle instrumentation if and when the papillary nature can be determined by imaging. Therefore, a careful imaging evaluation is necessary because it could help to identify the papillary neoplasm nature and select the high-risk lesions for proper treatment.Ultrasound has a greater sensitivity for detecting all papillary lesions than mammography [7]. Recently, automated breast ultrasound scanners have been developed, and the ultrasound volume data set of the whole breast can be acquired in a standard manner [8]. They have already shown potential for characterisation of breast tumours [9,10]. However, these studies did not detail the ultrasound features of intraductal papillary neoplasms on automated breast ultrasound. The reconstructed coronal views are also expected to provide more information and thus help to differentiate these lesions from other focal breast abnormalities.     

Solid papillary breast carcinoma with mucinous differentiation

A case is reported of a solid variant of infiltrating papillary carcinoma of the breast with mucinous differentiation in a 74-year-old woman. Macroscopically, the tumor was solid and lobular, 4.5 cm in diameter. Light microscopy showed solid papillary invasive carcinoma mixed with infiltrating ductal carcinoma, not otherwise specified. Abundant intracellular and extracellular acid mucin produced by the solid papillary tumor cells was proven histochemically by: PAS, PAS-D, mucicarmine and alcian blue. Immunohistochemically, the papillary carcinoma cells were strongly reactive to estrogen receptors, and weakly to moderately reactive to smooth muscle actin. We suggest that papillary carcinoma of the breast could have potentially high degree of aggressiveness, and that differential diagnosis of these rare tumors might be a histopathological problem.     

CT对膀胱癌术前评估与术后随访的意义

目的：探讨膀胱癌术前分期与术后随访中CT的价值。材料与方法：分析39例膀胱癌CT资料,将其分为4型,并与手术、病理对照基底浸润深度、邻近侵犯和术后复发的表现。结果：乳头状有蒂5例,非乳头状有蒂6例,乳头状宽基底5例,非乳头状宽基底13例;浸润粘膜层5例,粘膜下层及浅肌层各6例,深肌层5例,浆膜或纤维膜及膜外3例;邻近侵犯16例;术后复发/再发17例,输尿管扩张8例,淋巴结转移3例。结论：膀胱癌浸润粘膜层与粘膜下层表现相似;浅肌层和深肌民支受侵可参考间接征象有助于诊断;浆膜或纤维膜及膜外受侵时,其表面不光滑呈齿状或纤维条索状粘连;膀胱癌腔内最常侵犯输尿管入口;薄层扫描能显示胶胱壁受侵。     

Clustered breast calcifications

In a consecutive series, clustered breast calcifications were classified according to their radiographic appearance. Rounded and 'cloudy' calcifications, and calcifications showing sedimentation were virtually always associated with benign disorders. All other types of clustered calcifications implied a substantial risk of carcinoma. Furthermore, calcifications appearing or increasing during an observation period (median 24 months) implied a larger risk than those remaining unchanged. Guidelines for the management of patients with clustered breast calcifications are given.     

Vacuum-assisted breast biopsy on digital stereotaxic table of nonpalpable lesions non-recognisable by ultrasonography

The aim of this study was to evaluate accuracy of 11 G vacuum-assisted percutaneous biopsy (VAPB) carried out on digital stereotaxic table, on breast non-palpable lesions (NPLs), non-visible by US. Prospective study on 132 consecutive NPLs (126 patients) not reliably found by US; 82% showed microcalcifications. Surgical confirmation was obtained in all malignant cases and when VAPB reported atypical lesion (ductal or lobular), radial scar or atypical papillary lesion. All patients with benign results were included in a mammographic follow-up programme. Two cases could not be dealt with due to technical difficulties. One to 26 cylinders were obtained from the remaining 130 NPLs. Sixty-four lesions were surgically confirmed. Forty-six of the 47 malignancies were correctly diagnosed. In one case of a malignant tumour, an atypical lesion was classified with VAPB. All cases of histologically verified lobular carcinoma in situ, atypical ductal or lobular hyperplasia, radial scar or atypical papillary lesion were correctly diagnosed preoperatively. The remaining lesions were benign in VAPB, and after 1 year of follow-up, no false negative has been found. Based on this short-term follow-up, absolute sensitivity was 97.9%, absolute specificity 84.3% and accuracy was 99.2%. For predicting invasion, accuracy was 89.1%. Vacuum-assisted percutaneous biopsy is a very accurate technique for NPLs which are not detectable by US. It can replace approximately 90% of DSB with no important complications, avoiding scars and providing a higher level of comfort.     

乳腺癌超声分型与病理组织学分型的对照研究

目的:探讨乳腺癌超声分型与病理组织学分型之间的关系及临床意义。方法:对119例术后证实为乳腺癌患者术前的彩色多普勒超声声像图进行分型,并与病理分型对照,分析各型乳腺癌的超声图像特点及其与病理组织学诊断的符合率。结果:119例乳腺癌患者超声发现病灶126个,根据声像图表现分为5型:Ⅰ型(结节型)10例,病理为非浸润性癌1例,早期浸润性癌1例,混合性癌1例,浸润性癌7例,本型超声与病理诊断符合8例(80%)。Ⅱ型(团块型):ⅡA型(边界清晰型)3例,病理为髓样癌3例;ⅡB型(边缘毛糙型)104例,病理为非浸润性癌4例,早期浸润癌6例,浸润性非特殊类型癌93例,罕见型癌1例。超声与病理诊断符合率为98.1%(105/107)。Ⅰ型与Ⅱ型超声与病理诊断符合率比较差异有统计学意义(χ2=167.744,P0.01);Ⅲ型(囊实型)3例,病理为囊内乳头状癌2例,浸润性癌1例。超声与病理诊断符合2例。Ⅳ型(导管型)4例,病理为导管内原位癌1例,早期浸润癌1例,浸润性癌2例。超声与病理诊断符合2例。Ⅴ型(弥漫型)2例,病理诊断早期浸润性癌1例,浸润性导管癌1例。超声与病理诊断符合1例。结论:乳腺癌超声分型与病理分型密切相关,肿块的超声形态特点对组织学分类有提示作用。     

Normal and pathological breast, the histological basis

Breast tissue is heterogeneous, associating connective and glandular structures, which grow and change cyclically under hormonal regulation. Hormones are also thought to be the main determinant of the major benign and malignant pathologies encountered in the breast. Benign lesions are more frequent and fibrocystic changes are by far the most common among them. They usually associate different entities, (adenosis, fibrosis, cysts and hyperplasia) but vary in intensity and extension. Thus, their clinical and radiographic presentation is extremely different from one patient to another. Adenofibroma is the most frequent tumour. It also undergoes modifications according to hormonal conditions. About 90% of malignant tumours are primary carcinoma. The incidence of intra-ductal carcinoma has risen dramatically since the development of screening because of its ability to induce calcification. Two mechanisms could be involved in the formation of calcification: one active (tumour cell secretion of vesicles), the other passive (necrotic cell fragments are released). Invasive carcinoma comprises numerous histological types. Stromal reactions essentially determines their shape: a fibrous reaction commonly found in ductal carcinoma creates a stellate lesion while other stroma, inflammatory (medullary carcinoma), vascular (papillary carcinoma) or mucinous determine nodular lesions whose borders push the surrounding tissue. The histological features which give rise to the radiographic pattern will be emphasised.     

Radiological appearances of papillary breast lesions

This review illustrates the varied appearances of benign and malignant papillary breast tumours, as identified by a breast cancer-screening programme. The commonest mammographic appearance of a papillary tumour is as a soft-tissue mass, with calcification present in less than half of cases. When calcification is present the pattern is variable, but clusters of pleomorphic calcification can occur, sometimes resembling the mammographic appearance of invasive ductal carcinoma. Ultrasonography of papillary lesions typically shows a solid, oval, intraductal mass, often associated with duct dilatation. A cystic component is also commonly seen, and lesions may appear hypervascular on colour Doppler ultrasound. Magnetic resonance imaging (MRI) has a high sensitivity, but low specificity for detecting papillary tumours, and is useful in establishing the extent and distribution of lesions in patients with multiple papillomatosis. Despite a benign histology on core biopsy, an argument exists for complete surgical excision of all papillary tumours, as a significant proportion of papillomas will contain foci of atypia or overt malignant change.     

Thyroid masses: MR imaging and pathologic correlation

The authors explored the capability of high-field-strength surface coil magnetic resonance (MR) imaging in disclosing the gross pathologic characteristics of thyroid masses (especially pseudocapsular and hemorrhagic degeneration). Twenty-four patients were examined, including 12 with papillary carcinoma, eight with adenoma, and four with adenomatous goiter. All patients underwent surgery within 2 days after MR imaging. Specimens were cut and correlated directly with MR images. The appearance of the pseudocapsule was classified into four types: A, intact and even thickness around the tumor; B, only partially present or even absent; C, intact but with uneven thickness; D, partially destroyed by tumor. MR imaging findings corresponded precisely with those of gross pathologic examination in all cases but four of adenoma. Type A pseudocapsules were found only in adenoma and type D only in papillary carcinoma. Although the number of cases in the series was limited, the authors conclude that MR images reflect gross pathologic findings well and that some characteristic findings are suggestive of benign or malignant disease.     

Small renal cell carcinoma: MRI with pathologic correlation

The MRI features of small renal cell carcinomas (RCCs) were retrospectively reviewed and correlated with histology in 24 patients. MRI features on both T1- and T2-weighted images were classified into hypointensity, isointensity, and hyperintensity. Each tumor was pathologically classified into four types: alveolar, papillary, tubular, and cystic. These findings were correlated with MR signal intensities. Alveolar tumors showed hypointensity to isointensity on T1-weighted image and isointensity to hyperintensity on T2-weighted image. In contrast, all papillary tumors showed hypointensity on T2-weighted image. Four of six tumors with hypointensity on T2-weighted image were caused by hemosiderin deposition, hemorrhage, and necrosis. However, there were two papillary RCCs that showed hypointensity on T2-weighted image despite no hemosiderin deposition and no hemorrhage. We conclude that papillary RCC is associated with T2-hypointense appearance as well as hemosiderin deposition, hemorrhage, and necrosis.