Papillomatosis and breast cancer: a case report and a review of the literature

European Review for Medical and Pharmacological Sciences 2000; 4: 99-103 Papillomatosis and breast cancer: a case report and a review of the literat...
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European Review for Medical and Pharmacological Sciences

2000; 4: 99-103

Papillomatosis and breast cancer: a case report and a review of the literature M. BATORI, L.S. GALLINARO, A. D’URSO, M. RUGGERI, R. LORUSSO, A. FORTE, N. FIERRO Dipartimento di Scienze Chirurgiche e Tecnologie Mediche Applicate, Div. IV Clinica Chirurgica University “La Sapienza” - Rome (Italy)

Abstract. – Papillomatosis is a relatively common (22%) benign microscopic lesion in the breast and rarely seen in women less than 30 years old. It is a papillary proliferation of the ductal epithelium which partly fills up smaller ducts and to degree distends them. The histological classification of this entity is controversial because similar or identical lesions have been classified using different terms such as epitheliosis and epithelial hyperplasia, and interpretation of published series has been difficult due to imprecise definition of this term. Clinical, radiological and histological patterns of this entity are often sufficient to raise concern as to possible malignancy. Moderate or florid hyperplasia without atypia is considered to carry slight (1,5-2 times) increase in risk of later developing cancer, while in the atypical hyperplasia the risk is four to five times that of the general population. The authors describe a case of papillomatosis recentely observed in a 67 years old female patient and, confirmed the importance to establish an accurate preoperative diagnosis. It is important that the surgeon works with the pathologist to produce clear descriptive report of epithelial changes from normal through hyperplasia to atypias in order to establish a precise surgical indication. Key Words: Papillomatosis, Breast cancer.

Introduction The continuous increasing of breast cancer incidence in the western countries has increased the necessity to identify women with a high risk of disease, who can nowadays take advantage from a careful screening and follow-up1.

In this regard, the prognostic significance of some benign breast lesions, is still subject of debate, as the lack of uniform classification criteria, and the common use to understand with the terms of “fibrocystic disease” or “chronic cystic mastitis” a wide spectrum of physiological and pathological variations makes difficult the comparison of the different studies2-3. The authors taking occasion from a case of papillomatosis in senile age of a recent observation, who presented such clinical-diagnostical aspects to make difficult the differential diagnosis with the cancer, compare the emerged data from the revision of literature with their experience, agreeing upon the real difficulty to come to an exact preoperative definition of the lesion. This is on the contrary necessary to put an exact surgical direction to curative and preventive purposes.

Clinical Case C. R., a 67 years old woman, arrived at our observation, complaining for about a year the appearance of moderately aching nodules, in the outside quadrant of the right breast. From a remote pathological anamnesis turned out only a 10 years before practised operation for a bilateral breast fibro adenoma. After an objective local examination, the right breast presented a good consolidated and epithelialized surgical cicatrice of a preceding operation with lack of teat and areola. In the corresponding of internal superior quadrant (ISQ) area, are to appreciate moderately, round, aching tumefactions of about 99

M. Batori, L.S. Gallinaro, A. D’Urso, M. Ruggeri, R. LorussoA. Forte, N. Fierro

1-2 cm in diameter of hard fibrous consistence with shaded borders, floating on superficial and deep layers. In the esternal superior quadrant (ESQ) is to palpate a more voluminous formation with a policyclic surface and with the same characteristics of the previous. The overhanging skin is undamaged and the touch temperature is negative. There aren’t perceptible lesions on the opposite breast, lack of bilateral axillary lymphoadenopathies. Among the instrumental examinations the breast radiography shows a remarkable morphological difference between the two breasts: – on the left it shows a breast with a prevalence of adipose component and the image of the fibro glandular share in the rear areolar seat and in the ESQ without micro calcifications or suspicious images; – on the right it shows the presence of multiple nodular formations, in the outside and upper quadrants, with clear borders and lobulated margins of homogeneous radiopacity, between 4 and 20 mm in diameter. In the ESQ, where the picture is clinically clearer, the formations result conglobated among them and that of the largest in diameter, some coarse calcifications are evident (Figure 1). The ecography gives a definition of the structure partly solid, partly mixed in particular that localized in ESQ, that appears anecogenous, inhomogeneous and with parietal, focal thickness of about 5 mm. Always in the ESQ, near the before described new formations, one sees a parenchymal inhomogeneity of about 30 mm, producing an acoustic hinder obstruction. In the esternal inferior quadrant (EIQ) is evident another area with an inhomogeneous ecostructure with irregular borders of about 15 mm (Figure 2). On the ground of such reports, a surgical indication is suggested, excluding a needle biopsy and on the contrary recognizing the exigency of histological extemporary examination, in order to direct the surgical tactics. The operation shows many cystic formations of different sizes, gathered in cluster with a severe surrounding phlogistic reaction interesting a large part of the glandular parenchy100

Figure 1. Rx mammography: on the right side multiple nodular formations scattered in the outside and upper quadrants, with clear borders and lobulate margins, of homogeneous radiopacity, between 4 and 20 mm in diameter. In the ESQ, where the picture is clinically clearer, the formations result conglobated among them and that of the largest in diameter, some coarce calcifications are evident.

ma. A total excission of the mass is performed and its extemporary examination only shows the presence of a flourishing papillomatosis in a diffused fibrocystic mastopathy context. The postoperatory course has been regular and patient is clinically recovered discharged and the final histopathological examination proves the extemporary one with absence of atypical symptoms (Figure 3).

Papillomatosis and breast cancer: a case report and a review of the literature

Figure 2. Ecography: in the ISQ is evident another area with an inhomogeneous ecostructure with irregular borders of about 15 mm.

Figure 3. Dilatated ducts in wich proliferate papillomatosis structures dendriform with a stromal vessel connective axis coated by a monosratal ephitelium of cylinder cells (ductals) (EE 100x).

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M. Batori, L.S. Gallinaro, A. D’Urso, M. Ruggeri, R. LorussoA. Forte, N. Fierro

Discussion Breast papillomatosis defined also epitheliosis or epithelial hyperplasia, is a proliferation of the ductal epithelium, plugging the lumen of the littlest ducts till to spread it out4. Women in perimenopause are prevailingly affected, also if in 1980 Rosen and coll 5 described a kind of “juvenile papillomatosis”. During the fine needle ago-biopsy (FNAB) its incidence varies between 20 and 30 % and can be associated to cystic disease pictures or to breast fibrosis or to sclerosing adenosis6,7. The histological aspect is dominated by the presence of epithelium, stratified on more files to plug the lumen of the little ducts. Extended and ovoidal cells, typically disposed in irregular spaces, mostly constitute such epithelium8,9. Nuclear atypies aren’t to observe and rare is the presence of a mitosis or of necrotic areas, while frequent is the presence of little amasses of histiocytes with foamy cytoplasm. Sometimes it is also associated to little amasses of calcium sediments8. The epithelial hyperplasia can be divided in three different degrees: light, moderate and strong. We talk of light hyperplasia when the number of cellular layers above the basal membrane varies between 2 and 4 layers; of moderated hyperplasia when the number of the layers varies between 5 and 10; and of strong hyperplasia when the cells are disposed on more than 10 layers1. Sometimes it’s very difficult to distinguish the epithelial hyperplasia from a ductal carcinoma10. The nuclear and cytological characteristics are helpful for a differential diagnosis as well as the characteristic forms of intercellular spaces, but in some cases the differential diagnosis is extremely difficult, when not impossible. In these cases the pathologists adopt the term of atypical epitheliosis 8,11. It’s important to consider that the epithelial hyperplasia is insignificant on a clinical level, concerning macroscopically not valuable lesions, that are always recognized histological as an occasional report, than associated to macroscopically valuable lesions as the fibro adenoma or the breast cysts12. The theory that the benign pathology of breast increases the risk of a carcinoma was supported for many years 13,14 . In 1985, Dupont and Page6 have quantified the associ102

ation between the subspecies of benign pathology and breast carcinoma, and observed that the risk is minimum for the not diffused pathology, but moderately increasing for the diffused one without atypies and higher for the atypical hyperplasia. In particular the risk of the development of a metachronous breast cancer appears increased of about 1,5-2 times regards the normal gland in the moderate epithelial hyperplasia and 45 times in the hyperplasia with signs of atypie. Further studies, also confirming a correlation between an epithelial hyperplasia with or without atypies and breast cancer report some relative risks inferior to that observed by Dupont and Page15-17. The discordance can be ascribed to a different histological classification of the lesions used in the different institutes15. Recent studies confirmed the association between the proliferative diseases without atypies and atypical hyperplasia with the following risk of the breast carcinoma1. But the detailed characteristic of the atypical hyperplasia that gives the highest risk remains unclear. This should be higher above all among women in premenopause and with a familiarity to a breast carcinoma16. The formulation of a guideline for the screening of the breast carcinoma in the presence of such lesion seems important. Only with a close collaboration of surgeon, radiologist and anatomopathologist is possible to show the presence of cellular atypies and to recognize the factors that can alter the progression of an atypical hyperplasia to breast carcinoma. The therapeutic administration we followed in the exposed case was based on two criteria. First on the careful surgical indication in front of diagnostic doubt in a patient with a previous proliferative pathology, avoiding the possibility to make a preliminary biopsycal test, that for the extension of the lesion could give false negatives. Second on the choice of the operation on the bases of the postoperative response, in our case a simple subcutaneous mammectomy. The operation is larger than the real necessity but it permitted or to annul or to avoid that neoplastic risk we have seen to accompany and have also an importance on these benign lesions.

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