Intraductal Papilloma Research Articles

The diagnostic challenge of a Papillary lesion of the breast in a patient with Peutz-Jeghers syndrome

Abstract Introduction/Objective Peutz-Jeghers syndrome (PJS) is an autosomal dominant disorder with elevated risk of various neoplasms, including breast cancer. The incidence of cancer among PJS patients is estimated to be 15-fold higher than the general population. The spectrum of breast lesions in PJS varies from benign papillomas to invasive carcinomas, presenting significant diagnostic complexities. The case presented here revolves around a unique papillary lesion in a PJS patient. Methods/Case Report A 40-year-old African American female, with PJS presented with a palpable abnormality in the right subareolar region with sanguineous nipple discharge. Multiple prior biopsies revealed intraductal papillomas with no atypia. Imaging showed a 7.0 cm complex solid and cystic subareolar mass, which had increased in size by 42% within a short period. Given the rapid increase in size, malignant transformation was clinically suspected. The patient underwent bilateral mastectomy. Macroscopic examination showed a 9.0 cm tan firm subareolar nodule with solid and cystic components. Histopathology revealed areas consistent with intraductal papilloma, however, additional complexities, including epithelial and myoepithelial proliferations with mild cytologic atypia, squamous, apocrine, and sebaceous metaplasia made the diagnosis challenging. No necrosis or increased mitotic activity was identified. Immunostaining for CK5/6 and p63 highlighted the myoepithelial layer, while estrogen receptor demonstrated heterogeneous positive staining. This picture raised suspicion of adenomyoepithelioma, but there was a significant overlap with intraductal papilloma. A final diagnosis of intraductal papillary neoplasm with epithelial and focal myoepithelial atypia was rendered. Results (if a Case Study enter NA) NA Conclusion This case presented a complex diagnostic dilemma. The rapid growth of the lesion, coupled with cytological atypia, raised significant concern necessitating precise differentiation between adenomyoepithelioma and intraductal papilloma. Further research is imperative to explore the pathophysiology of breast lesions in PJS, their impact on surveillance, management, potential for malignancy, and prognosis. Investigating additional diagnostic modalities and molecular markers to aid in accurate differentiation between benign and malignant papillary neoplasms in PJS patients warrants consideration.

Mutation Spectrum Comparison between Benign Breast Lesion Cohort, Unselected Cancer Cohort and High-Risk Breast Cancer Cohort.

Mutation study for high-risk breast and ovarian cancer (HBOC) has been extensively studied in patients of different ethnicities. Here we compared the germline mutation rate and mutation spectrum of patients (n = 4341) with benign breast diseases or breast cancers, with and without other risk factors. Three cohorts of Chinese patients were recruited. The first cohort, high-risk cohort (HR, n = 3935) included high-risk breast cancer patients fulfilling high-risk HBOC criteria and who are recruited at our genetics clinic. The second cohort, unselected cancer cohort (CC, n = 307) was from general recruitment of patients with breast cancer at breast surgery clinics. The third cohort, benign breast lesion cohort (NC, n = 99) comprised 99 patients with benign breast diseases such as fibroadenoma, fibroadenomatoid hyperplasia, and intraductal papilloma. Thirty HBOC related genes were sequenced on the above-mentioned patient cohorts. The germline mutation rates of HR, CC, and NC cohort were 11.9%, 6.5%, and 8.1%, respectively. In the CC cohort, 29.3% (90/307) of patients fulfilled the National Comprehensive Cancer Network (NCCN) high-risk genetic test criteria 2022 v.2. The mutation rate for this group of patients was 11.1%, similar to that of the HR cohort, while the mutation rate for those not fulfilling testing criteria was 4.6%, like that of the NC cohort. High penetrance genes (BRCA1/2, CDH1, PALB2, PTEN, and TP53) mutations were only found in the HR (10.6%) and CC (3.3%) cohorts but were not found in the NC cohort. ATM, BRIP1, RAD51C, and RAD51D mutations were identified in all cohorts. RAD51C and RAD51D mutations showed conflicting penetrance. An unexpectedly high mutation rate of total 2% was found in the NC cohort but it was only 0.3% and 0.5% in the HR cohort and CC cohort, respectively. Our results show a clinical need to enhance genetic testing of unselected breast cancer patients to identify the high-risk patients.

Kaiser score diagnosis of breast MRI lesions: Factors associated with false-negative and false-positive results

PurposeWe sought factors associated with false-negative and false-positive results in the diagnosis of breast lesions using the Kaiser score (KS) on breast magnetic resonance imaging (MRI). MethodsWe retrospectively analyzed 1058 patients with 1058 breast lesions who underwent preoperative breast MRI with successful histopathologic results. Two radiologists assessed each lesion according to KS criteria, and clinicopathologic features and MRI findings were analyzed. Multivariate regression analysis was conducted to identify factors associated with false-negative and false-positive KS results. ResultsOf the 1058 lesions, 859 were malignant and 199 were benign. Particularly high misdiagnosis rates were observed for intraductal papilloma, inflammatory lesion, and mucinous carcinoma. For breast cancer, KS yielded 821 (95.6 %) true-positive and 38 (4.4 %) false-negative results. Multivariate analysis showed that smaller lesion size (≤1 cm) (OR, 3.698; 95 %CI, 1.430–9.567; p = 0.007), absence of ipsilateral breast hypervascularity (OR, 3.029; 95 %CI, 1.370–6.693; p = 0.006), and presence of hyperintensity on T2WI (OR, 2.405; 95 %CI, 1.121–5.162; p = 0.024) were significantly associated with false-negative breast cancer results. For benign lesions, KS yielded 141 (70.9 %) true-negative and 58 (29.1 %) false-positive results. Multivariate regression analysis revealed that non-mass enhancement lesions (OR, 4.660; 95 %CI, 2.018–10.762; p＜0.001), moderate/high background parenchymal enhancement (OR, 2.402; 95 %CI, 1.180–4.892; p = 0.016), and the presence of hyperintensity on T2WI (OR, 2.986; 95 %CI, 1.386–6.433; p = 0.005) were significantly associated with false-positive KS results. ConclusionSeveral clinicopathologic and MRI features influence the accuracy of KS diagnosis. Understanding these factors may facilitate appropriate use of KS and guide alternative diagnostic approaches, ultimately improving diagnostic accuracy in the evaluation of breast lesions.

Assessing the Correlation between Allostatic Load and False-Positive Image-Guided Breast Biopsies.

Background: Allostatic load (AL) is the accumulation of physiological dysregulation attributed to repeated activation of the stress response over a lifetime. We assessed the utility of AL as a prognostic measure for high-risk benign breast biopsy pathology results. Method: Eligible patients were women 18 years or older, with a false-positive outpatient breast biopsy between January and December 2022 at a tertiary academic health center. AL was calculated using 12 variables representing four physiological systems: cardiovascular (pulse rate, systolic and diastolic blood pressures, total cholesterol, high-density lipoprotein, and low-density lipoprotein); metabolic (body mass index, albumin, and hemoglobin A1C); renal (creatinine and estimated glomerular filtration rate); and immune (white blood cell count). Multivariable logistic regression was used to assess the association between AL before biopsy and breast biopsy outcomes controlling for patients' sociodemographics. Results: In total, 170 women were included (mean age, 54.1 ± 12.9 years): 89.4% had benign and 10.6% had high-risk pathologies (radial scar/complex sclerosing lesion, atypical ductal or lobular hyperplasia, flat epithelial atypia, intraductal papilloma, or lobular carcinoma in-situ). A total of 56.5% were White, 24.7% Asian, and 17.1% other races. A total of 32.5% identified as Hispanic. The mean breast cancer risk score using the Tyrer-Cuzick model was 11.9 ± 7.0. In multivariable analysis, with every one unit increase in AL, the probability of high-risk pathology increased by 37% (odds ratio, 1.37; 95% confidence interval, 1.03, 1.81; p = 0.03). No significant association was seen between high-risk pathology and age, ethnicity, breast cancer risk, or area deprivation index. Conclusion: Our findings support that increased AL, a biological marker of stress, is associated with high-risk pathology among patients with false-positive breast biopsy results.

Nonneoplastic and neoplastic sclerosing lesions of the breast.

Sclerosing lesions of the breast encompass a spectrum of benign and malignant entities and often pose a diagnostic challenge. Awareness of key morphologic features and pitfalls in the assessment of morphology and immunophenotype is essential to avoid over- or underdiagnosis and ensure optimal clinical management. This review summarizes nonneoplastic sclerosing lesions such as radial scar/complex sclerosing lesion, sclerosing adenosis, sclerosing intraductal papilloma, sclerosing variants of ductal adenoma and nipple adenoma, and fibroadenoma with extensive sclerosis, including their clinical presentation, characteristic morphology, differential diagnostic considerations, appropriate immunohistochemical work-up, when needed, and the clinical significance. In addition, atypical or neoplasticentities (such as atypical ductal hyperplasia, ductal carcinoma in situ, low-grade adenosquamous carcinoma, and fibromatosis-like metaplastic carcinoma) that can involve these sclerosing lesions are also briefly discussed.

Distance of Biopsy-Confirmed High-Risk Breast Lesion from Concurrently Identified Breast Malignancy Associated with Risk of Carcinoma at the High-Risk Lesion Site.

High-risk breast lesions including incidental intraductal papilloma without atypia (IPA), lobular hyperplasia (LCIS or ALH), flat epithelial atypia (FEA) and complex sclerosing lesion (CSL) are not routinely excised due to low upgrade rates to carcinoma. We aim to identify features of these lesions predictive of upgrade when identified concurrently with invasive disease. Methods: A single-center retrospective cohort study was performed for patients who underwent multi-site lumpectomies with invasive disease at one site and a high-risk lesion at another site between 2006 and 2021. A multinomial logistic regression was performed. Results: Sixty-five patients met the inclusion criteria. Four patients (6.2%) had an upgrade to in situ disease (DCIS) and one (1.5%) to invasive carcinoma. Three upgraded high-risk lesions were ipsilateral to the concurrent carcinoma and two were contralateral. In the multivariate model, a high-risk lesion within 5 cm of an ipsilateral malignancy was associated with increased risk of upgrade. The 3.8% upgrade rate for high-risk lesions located greater than 5 cm from ipsilateral malignancy or in the contralateral breast suggests that omission of excisional biopsy may be considered. Excisional biopsy of lesions within 5 cm of ipsilateral malignancy is recommended given the 25% upgrade risk in our series.

Multiplicity of benign breast disease lesions and breast cancer risk in African American women.

The risk of developing subsequent breast cancer is higher in women diagnosed with benign breast disease (BBD) but these studies were primarily performed in non-Hispanic white populations. Still, these estimates have been used to inform breast cancer risk models that are being used clinically across all racial and ethnic groups. Given the high breast cancer mortality rates among African American (AA) women, it is critical to study BBD in this population, to ensure the risk models that include this information perform adequately. This study utilized data from AA women who underwent benign breast biopsies at a hospital served by the University Pathology Group in Detroit, Michigan, from 1998 to 2010. Patients were followed for subsequent breast cancers through the population-based Metropolitan Detroit Cancer Surveillance System (MDCSS). BBD lesion scores were assigned to represent the severity or extent of benign breast lesions, with higher scores indicating a greater number of distinct lesion types. Of 3,461 eligible AA women with BBD in the cohort, 6.88% (n=238) subsequently developed breast cancer. Examined individually, six of the eleven lesions (apocrine metaplasia, ductal hyperplasia, lobular hyperplasia, intraductal papilloma, sclerosing adenosis, columnar alterations and radial scars) were significantly associated with increased risk of breast cancer after adjustment for age and year of biopsy and were further considered in multiple lesion models. For every different type of benign breast lesion, subsequent risk of breast cancer increased by 25% (RR=1.25, 95% CI: 1.10, 1.42) after adjustment for age at biopsy and proliferative versus non-proliferative disease. In summary, this study affirms the increased breast cancer risk in AA women with BBD, particularly in those with multiple lesions. These findings have implications for the management of breast cancer risk in millions of women affected by BBD, a high risk group that could benefit from personalized surveillance and risk reduction strategies.

Abstract PO3-07-09: B3 breast lesions in Asian Centers: malignant upgrade rates and risk factors

Abstract Background Lesions of uncertain malignant potential in the breast (B3 lesions) are composed of a wide spectrum of pathologies with differing risks of breast cancer. With the widespread implementation of screening programs globally, the incidence of these lesions has increased substantially. Asian women tend to have smaller and denser breasts than Western women, making identifying and treating these lesions more challenging. Previous papers quote an upgrade of B3 lesions to malignancy such as ductal carcinoma in situ (DCIS) or cancer at rates of 9.9% to 35.1%. Malignant upgrade on final histology increases patient anxiety and healthcare costs as a second surgical intervention is often required for pathological clearance or lymph node staging. This study aimed to assess the malignant upgrade rate of B3 lesions in Asian women and to evaluate any key factors that may predict the risk of a malignant upgrade. Materials and Methods A retrospective multicentre international study was done on patients at Seoul National University Hospital (SNUH), South Korea, from April 2021 to 2023, and Tan Tock Seng Hospital (TTSH), Singapore, between March 2006 and 2023. Patients who were diagnosed with a B3 lesion on initial breast core needle biopsy and underwent surgical open excision were included in the study. Results A total of 1049 patients were diagnosed with B3 lesions, with 154 (14.7%) upgrading to malignancy. The most common malignancy was DCIS, 118 (76.6%), followed by invasive ductal carcinoma (IDC), 20 (13.0%) and papillary carcinoma, 4 (2.6%). Within the types of B3 lesions, the malignant upgrade rates were found: atypical ductal hyperplasia (ADH), 88/252 (35%); intraductal papilloma (IDP) with atypia, 16/55 (29%); lobular neoplasia (LN), 9/34 (26%); and radial scar (RS), 5/21 (24%). Most patients had both ultrasound and mammographic evaluation, and all lesions in the study were graded BIRADS 4A and above. Univariate analysis showed that age >50 (OR 2.30 [1.61-3.31], p< 0.001), BMI >23 (OR 2.21 [1.20-4.12], p=0.01), post-menopausal status (OR 2.43 [1.34-4.34], p< 0.001), lesion being identified on mammography (OR 3.00 [2.04-4.51], p< 0.001) and presence of microcalcifications on mammography (OR 0.63 [0.41-0.98], p=0.04) were risk factors for malignant upgrade. Conclusion Based on our analysis of Asian women, post-menopausal patients with microcalcifications on mammography and a B3 biopsy result should be treated with a higher degree of suspicion for underlying malignancy. Surgical excision with adequate margins should be routinely considered for B3 lesions such as ADH, IDP with atypia, LN and RS. Avoidance of surgery or vacuum-assisted removal can be considered for younger patients with only ultrasound findings and diagnosis of FEA and IDP. Table 1. Malignant upgrade after excision Table 2. Clinical characteristics of all patients according to malignant upgrade Table 3. Univariate and multivariate analysis for malignant upgrade Citation Format: Wei Wen Ang, Ji-Jung Jung. B3 breast lesions in Asian Centers: malignant upgrade rates and risk factors [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO3-07-09.

Abstract PO5-20-11: Synchronous Breast Cancer and Pheochromocytoma: A Case Series

Abstract Background: Pheochromocytomas are rare, although literature suggests a rising incidence due to the widespread use of sensitive imaging modalities. Synchronous presentation of breast cancer with a pheochromocytoma is exceedingly rare with only one case documented in the literature. We present two cases of malignancy in the breast in which pheochromocytomas were incidentally detected during workup and management with vastly different presentations. Case Presentation: Two patients presented with breast cancer and were secondarily diagnosed with pheochromocytoma. Patient 1 is a 48-year-old postmenopausal female with a history of intraductal papilloma four years prior, who presented with right breast nipple discharge. Diagnostic mammogram showed a right breast mass and biopsy confirmed an intraductal papilloma with intermediate-grade DCIS, ER+/PR-. She had no family history of cancer or PGL/PPC. During a scheduled lumpectomy, she developed hypoxia, hypotension, and flash pulmonary edema requiring intubation and ECMO with prolonged ICU stay and long recovery with tracheostomy for four months. Contrast-enhanced CT of her abdomen showed a 9 cm right adrenal mass. Serum and urine metanephrines were markedly elevated, and it was determined that she had an adrenal crisis secondary to undiagnosed pheochromocytoma. She completed treatment for DCIS with lumpectomy and radiation and is currently on adjuvant anastrozole. She additionally had an adrenalectomy for pheochromocytoma, which was found to be stage PASS 2. Subsequent genetic testing confirmed the absence of germline mutations associated with hereditary PGL/PPC or breast cancer. Patient 2 is a 57-year-old female presenting with a history of left breast mass she first noted a year ago, with newly found nipple retraction and skin changes. Biopsy showed invasive ductal carcinoma of the breast, G3, Stage IIIA, pT3N2aM0, ER 95%/PR-/Her2- (IHC 0). Staging PET scan showed a 3.4 cm hypermetabolic left adrenal mass in addition to the breast mass and left axillary adenopathy. Serum and urine metanephrines were elevated, and pheochromocytoma was diagnosed. Family history was positive only for pancreatic cancer in a maternal aunt. Comprehensive genotype testing was negative for hereditary breast cancer and PGL/PCC syndromes. She was concomitantly treated with a radical mastectomy for breast cancer and a left adrenalectomy and tolerated the procedure well as she received perioperative alpha-adrenergic blockade with doxazosin. She has received chemotherapy and radiation for breast cancer treatment and is currently on adjuvant anastrozole. The adrenal mass was confirmed to be a pheochromocytoma PASS 2-3. Discussion: We present two unique cases of breast cancer and pheochromocytomas discovered in tandem with variable clinical manifestations. It is extremely uncommon to have a presentation of primary breast malignancy concomitantly with pheochromocytoma, and we demonstrate two cases that occurred within months of one another at our facility. During the first case, metastatic workup was not indicated for DCIS. However, during the seemingly benign lumpectomy procedure, the patient experienced significant complications, leading to intense ICU management, intubation, and tracheostomy. In the second case, a metastatic workup was completed due to locally advanced breast cancer where the adrenal mass was detected and a pheochromocytoma was diagnosed prior to surgery. This allowed both cancers to be resected simultaneously and safely. This series demonstrates the importance of keeping pheochromocytomas in the differential during the workup of adrenal masses prior to surgical interventions. Additionally, they demonstrate how the usual workup and management of breast cancer does not take into account these rare but significant diagnoses, and that can result in fatal consequences. Citation Format: Nikita Dahake, Abhimanyu Tushir, Aruna Padmanabhan. Synchronous Breast Cancer and Pheochromocytoma: A Case Series [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO5-20-11.

Using the DNA Integrity Number to Analyze DNA Quality in Specimens Collected from Liquid-Based Cytology after Fine-Needle Aspiration of Breast Tumors and Lesions

Introduction: Cancer genome analysis using next-generation sequencing requires adequate and high-quality DNA samples. Genomic analyses were conventionally performed using formalin-fixed paraffin-embedded sections rather than cytology samples such as cell block or smear specimens. Specimens collected from liquid-based cytology (LBC) have the potential to be sources of high-quality DNA suitable for genetic analysis even after long-term storage. Methods: We collected breast tumor/lesion fractions from 92 residual LBC specimens using fine-needle aspiration (FNA) biopsy, including breast carcinoma (1 invasive carcinoma and 4 ductal carcinomas in situ), papillomatous lesion (5 intraductal papillomas), and fibroepithelial lesion (19 phyllodes tumors and 53 fibroadenomas) samples, and others (1 ductal adenoma, 1 hamartoma, 1 fibrocystic disease, and 7 unknown). DNA was extracted from all samples and subjected to DNA integrity number (DIN) score analysis. Results: Average DIN score collected from 92 LBC specimens was significantly higher score. In addition, high-quality DNA with high DIN values (7.39 ± 0.80) was successfully extracted more than 12 months after storage of residual LBC specimens. Conclusion: Residual LBC specimens collected from FNA of the breast were verified to carry high-quality DNA and could serve as an alternate source for genetic analysis.

Management of Breast Intraductal Papilloma Diagnosed on Core Needle Biopsy: Excision or Follow-up?

Introduction Management of intraductal papillomas (IDPs) diagnosed on core needle biopsy (CNB) remains controversial.We report our experience of IDPs identified on CNB, our institutional rates of upgradation to atypia/malignancy as well as radiologic/pathologic features that may allow selection for surgery as well as those for safe observation. Methods The study is a retrospective review of patient records from 2012 to 2019, at a tertiary care hospital in Pakistan. Data was analyzed using Statistical Package for Social Sciences (SPSS), version 21.0 (IBM Corp., Armonk, NY). Associations between various patient factors were assessed using Pearson's chi-square test. Results This study included a total of 55 female patients with IDPs, with a mean age of 54.67 ± 15.57 years. On CNB, 69.1% (n = 38) of patients had IDP without atypia while 30.9% (n = 17) had IDP with atypia, with single IDPs being the most common lesions on excisional biopsy. Overall, of all CNB-diagnosed IDPs, only 4/55 (7.3%) demonstrated upgradation (3/4 to DCIS, 1/4 showed atypia) on excisional biopsy, and all these upgraded cases had failed to demonstrate atypia on initial CNB. Conclusion CNB-identified cases of IDPsare rarely upgraded on excision and thus routine excision in all cases may be unnecessary. Appropriate patient selection based on radiology-pathology findings should be done. Those with suspicious findings on imaging as well as those that demonstrate atypia on CNB must be excised.

The Diagnostic Value of microRNA Expression Analysis in Detecting Intraductal Papillomas in Patients with Pathological Nipple Discharge.

Patients with pathological nipple discharge (PND) often undergo local surgical procedures because standard radiologic imaging fails to identify the underlying cause. MicroRNA (MiRNA) expression analysis of nipple fluid holds potential for distinguishing between breast diseases. This study aimed to compare miRNA expression levels between nipple fluids from patients with PND to identify possible relevant miRNAs that could differentiate between intraductal papillomas and no abnormalities in the breast tissue. Nipple fluid samples from patients with PND without radiological and pathological suspicion for malignancy who underwent a ductoscopy procedure were analyzed. We used univariate and multivariate regression analyses to identify nipple fluid miRNAs differing between pathologically confirmed papillomas and breast tissue without abnormalities. A total of 27 nipple fluid samples from patients with PND were included for miRNA expression analysis. Out of the 22 miRNAs examined, only miR-145-5p was significantly differentially expressed (upregulated) in nipple fluid from patients with an intraductal papilloma compared to patients showing no breast abnormalities (OR 4.76, p = 0.046), with a diagnostic accuracy of 92%. miR-145-5p expression in nipple fluid differs for intraductal papillomas and breast tissue without abnormalities and, therefore, has potential as a diagnostic marker to signal presence of papillomas in PND patients. However, further refinement and validation in clinical trials are necessary to establish its clinical applicability.

Treatment Strategy for Breast Benign Intraductal Papilloma: A Meta-Analysis.

Currently, the optimal treatment approach for breast benign intraductal papilloma (IDP) diagnosed via biopsy remains uncertain. There is ongoing debate regarding the feasibility of clinical follow-up and the criteria for selective surgical excision. This study aims to conduct a meta-analysis to determine the rate of upgrade from breast benign IDP and identify predictive factors associated with the conversion of benign IDP to high-risk lesions or carcinoma, which could guide healthcare practitioners in selecting the appropriate clinical treatment strategy. We conducted a comprehensive search across multiple databases (PubMed, Web Of Science, Cochrane Library, and Embase) for studies published between 2012 and 2023 that evaluated upgrade rates and predictive factors of breast benign IDP diagnosed via biopsy. In addition, we included studies that reported on the clinical follow-up of patients with breast benign IDP. In total, 32 studies comprising 7371 cases of biopsy-diagnosed breast benign IDP were included. Among these cases, 720 demonstrated an upgrade to high-risk lesions or carcinoma, resulting in an upgrade rate of 6.94% [95% confidence interval (CI): 3.0-8.0%]. A subgroup of 1713 patients was clinically followed up, demonstrating an average follow-up duration of 30.95 months. Among them, 26 cases experienced an upgrade to high-risk lesions or carcinoma, yielding an upgrade rate of 1.51% (95% CI 0.00-2.00). Furthermore, we identified nine predictive factors associated with the upgrading of breast benign IDP, which included age at diagnosis, personal history of breast cancer, family history of breast cancer, multiple IDPs, lesion size ≥ 10 mm, palpable mass, calcification, and the presence of mass and asymmetry in mammographic findings. Although the conversion rate of breast benign IDP to high-risk lesions or carcinoma is relatively low, timely identification of predictive factors associated with benign IDP upgrades may help selecting the optimal clinical treatment strategy, such as surgery for patients with benign IDP presenting one or more predictive factors, while clinical follow-up for those without specific risk factors.

Intraductal Papilloma of the Breast: A Case Report

Intraductal papilloma of the breast is a rare benign tumour. The polypoid lesions arising from the nipple surface include papillomas and fibroepithelial stromal polyps. These lesions must be distinguished from malignant nipple lesions, such as Paget’s disease of the nipple or malignant breast conditions involving the nipple. Solitary papillomas (solitary intraductal papillomas) are single tumours that often grow in the large milk ducts near the nipple. They are a common cause of clear or bloody nipple discharge, especially when it comes from only one breast, and can be felt as a small lump behind or next to the nipple. Papillomas may also be found in small ducts in areas of the breast farther from the nipple. Multiple papillomas, which are growths that are less prone to generate nipple discharge, were present in this case. In papillomatosis, there are very small areas of cell growth within the ducts, but they aren’t as distinct as papillomas are. In order to distinguish between these disorders, a thorough clinical examination and imaging are essential. This case report describes a 36-year-old female who presented with swelling from the left nipple. Sonography of the left breast revealed a dilated duct in the left retro-areolar region with a focal isoechoic component within the duct {American College of Radiology Breast Imaging Reporting and Data System (ACR BI-RADS 4B)}. The patient underwent core excision of the duct, and histopathological analysis confirmed the diagnosis of papilloma with changes of adenosis without atypia.

Breast cancer associated with intraductal papilloma

Background. Intraductal papilloma (IDP) is not usually considered as an obligate precancerous lesion since the cases of its progression into cancer are exceedingly rare.Aim. To analyze the impact of IDP on the risk of breast cancer in the future.Materials and methods. This retrospective study included patients aged 22–82 years operated on for IDP (n = 304) and other benign breast tumors (n = 304) between 2014 and 2022. We checked these patients in the cancer registry of Primorsky Regional Oncology Dispensary to find out whether any of them developed any type of cancer, including breast cancer. Then we calculated the odds of developing breast cancer in both groups.Results and conclusion. We found that paients with a history of IDP are 2.4 times more likely to develop breast cancer. The incidence of other cancer types did not differ significantly between the two groups. Our findings are consistent with the results of similar foreign studies and might indicate that IDP and breast cancer share the same etiological factor. They can also highlight specific characteristics of asymptomatic IDP.

Rates of upgrade to malignancy in surgical excision of intraductal papillomas of the breast: A retrospective cohort study

Background/Aim: Intraductal papillomas (IDP) of the breast, though benign, share an association with the duct epithelium, similar to some breast malignancies. Percutaneous biopsies often fail to fully characterize these lesions. The decision to perform surgical excision for IDP of the breast is frequently based on the presence of atypia observed during percutaneous biopsy. However, consensus remains lacking regarding the management of IDP of the breast without atypia. This study was undertaken to share findings on IDP, contributing to a better understanding of their nature and guiding treatment approaches. Methods: We conducted a retrospective evaluation of data from 42 female patients diagnosed with intraductal papilloma through percutaneous biopsy, who subsequently underwent surgical excision between January 1, 2015, and August 25, 2023. Patients not diagnosed with intraductal papilloma, those with prior breast malignancy diagnoses, and those identified incidentally during other surgical procedures were excluded from the study. Data recorded included patient ages, the largest lesion diameters measured by ultrasonography, the percutaneous biopsy method (Fine needle aspiration biopsy [FNAB] or Core needle biopsy [CNB]), atypia status observed during percutaneous biopsy, histopathological features observed during surgical excision, and lesion diameter in cases where malignancy was upgraded. If ductal carcinoma in situ (DCIS) or invasive cancer was identified in the surgical excision specimen, it was classified as an upgrade. Results: The median age of the patients was 48.5 years (range: 12.9 years). FNAB was performed in ten cases (23.8%), while CNB was used in 32 cases (76.2%). There was no significant difference in the detection of atypia when comparing FNAB and CNB (P=0.57). Eight patients (19%) were diagnosed with atypical intraductal papilloma. Among them, three patients with atypia and two patients without atypia exhibited an upgrade to malignancy. The study revealed a malignancy upgrade rate of 37.5% for IDP with atypia and 5.9% for those without atypia. Furthermore, the average age of patients with malignancy upgrades was higher than that of patients with benign lesions (P=0.02). Conclusion: In light of the malignancies detected in cases of breast IDP, even in the absence of atypia, opting for surgical excision, particularly in older patients, can help prevent the oversight of these cancers.

Increased risk of upstage when combinations of breast lesions of uncertain malignant potential are found on core needle biopsy: The need for surgical excision

BackgroundManagement of breast lesions of uncertain malignant potential diagnosed at core needle biopsy (CNB) is controversial due to variable upstage rate (UR) with surgical excision (SE). MethodsWe performed an IRB-approved retrospective analysis of adult women who underwent CNB demonstrating atypical ductal hyperplasia (ADH), flat epithelial atypia, radial scar, or intraductal papilloma then SE between 2010 and 2022. We evaluated CNB pathology for combination diagnoses (CD), defined as multiple primary lesions or primary with lobular neoplasia (LN), and surgical pathology for upstage. Results719 patients were included. UR was 12.2% (88/719). CD experienced higher UR than pure (17.7% (45/254) vs. 9.2% (43/465), p ​= ​0.001). ADH/LN had the highest UR of all CD (34.6% (9/26), p ​= ​0.001). Increased size (15.6 vs. 10.5 ​mm, p ​< ​0.001), distance from nipple (79 vs. 66 ​mm, p ​< ​0.001), and personal history of breast cancer (p ​= ​0.04) were associated with UR. ConclusionsCD was associated with increased UR. ADH/LN had the highest UR.

FRI211 Recurrent Hypertensive Crises In A Patient With A Large Pheochromocytoma; A Complicated Intensive Care Unit Course

Abstract Disclosure: S. Sokoloff: None. A. Iwamaye: None. Introduction: Hypertensive crisis is a well-known complication of surgery in patients with pheochromocytomas. However, as demonstrated in this case, these crises can be triggered by even routine intensive care unit procedures if sufficient alpha blockade has not been achieved. Thus, prevention of these episodes in the critical care setting presents a therapeutic challenge. Case: A 47-year-old female with a medical history of hypertension and intraductal papilloma presented for right lumpectomy for recent increase in papilloma size. General anesthesia and a laryngeal mask airway (LMA) were used. Intraoperatively, hypertensive crisis developed with systolic blood pressure of three hundred and oxygen saturation of forty percent. Hypoxia persisted after LMA was exchanged for endotracheal intubation and ECMO initiation was necessary to restore oxygenation. The patient was admitted to the Intensive Care Unit and blood pressure normalized postoperatively. Echo showed normal ejection fraction with an incidental finding of a peri-hepatic mass. This prompted evaluation for pheochromocytoma, which was biochemically confirmed with plasma free metanephrine and normetanephrine of 13,900 (&amp;lt;= 57 pg/mL) and 2,560 (&amp;lt;= 148 pg/mL), respectively. Abdominal CT-scan showed an 8.0 x 7.0 x 8.0 cm right adrenal mass. MIBG showed increased activity in the mass without evidence of metastatic disease. Doxazosin was initiated for alpha blockade. One week postoperatively, ECMO was weaned off and the patient was extubated. Shortly after extubation, a second hypertensive crisis occurred with an increase in systolic blood pressure to over two hundred and a decrease in oxygen saturation to forty percent. Re-intubation was unsuccessful and cricothyrotomy was required. Both nitroprusside and clevidipine failed to reduce blood pressure and a labetalol infusion was necessary to end the episode. The patient underwent surgery for cricothyrotomy to tracheostomy conversion two days later. By that point, labetalol had been weaned off and doxazosin had been titrated to three mg every twelve hours. A titratable IV phentolamine infusion was used for further alpha blockade intra-operatively and normotension was maintained. Over the next two weeks, adequate alpha blockade was achieved with titration of doxazosin dosage to thirteen mg two times daily. Uncomplicated adrenalectomy was then completed. Pathology showed a pheochromocytoma with retained SDHB, focal positivity for ACTH, and without capsular or vascular invasion. Conclusion: Routine critical care procedures such as extubation can trigger hypertensive crises in patients with pheochromocytomas. These episodes may be resistant to multiple intravenous anti-hypertensive agents. Titratable intravenous phentolamine can be used as a precautionary measure during necessary procedures if adequate alpha blockade with oral agents has not yet been achieved. Presentation: Friday, June 16, 2023

A rare case report on Intraductal papilloma of nipple in a young female – radiographical and histopathological correlation

A rare case report on Intraductal papilloma of nipple in a young female – radiographical and histopathological correlation

The "Trunk sign": A novel X-ray sign in galactography of patients with nipple discharge suggesting malignancy.

The etiology of nipple discharge is often unclear, and there are few studies exploring diagnostic approaches of nipple discharge. Galactography is a common method for clinical diagnosis of patients with nipple discharge. Therefore, this study aimed to evaluate the use of galactography in differentiating between benign and malignant lesions in patients with nipple discharge. A retrospective study of 161 patients with nipple discharges, who were evaluated with galactography and underwent surgery in Qilu Hospital of Shangdong University between January 2018 and December 2019, was conducted. Baseline characteristics were obtained from their electronic records including age, menstruation status, physical examination, galactography, cytology, and pathology. There were 110 cases of benign disease, 12 cases of high-risk disease, and 39 cases of malignant disease. With respect to benign diseases there were 26 (23.6%) patients with hyperplasia and ductal ectasia, and 94 (76.4%) with intraductal papilloma. With respect to high risk diseases, there were 2 (16.7%) patients with atypical intraductal papilloma and 10 (83.4%) with atypical hyperplasia. With respect to malignant lesions, 19 (48.7%) patients had intraductal carcinoma, 4 (10.3%) had solid papillary carcinoma, and 16 (41.0%) had invasive carcinoma. The significant findings of our study are as follows: patients with malignant diseases had a higher proportion of concomitant masses (74.4% vs 41.7% vs 22.7%, P < .001), positive spill cytology (51.3% vs 41.7% vs 2.7%, P < .001), and trunk signs (71.8% vs 33.3% vs 10.9%, P < .001). A forest plot revealed that trunk signs were related to an increased risk of malignant diseases in almost all the subgroups. Galactography is important for the differential diagnosis of benign and malignant lesions in nipple discharge, and the "Trunk sign" is an important radiographic sign of malignant lesions. Combining galactography with other methods is advisable to improve the accuracy of diagnosis in patients with nipple discharge.