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Intracystic Papillary Carcinoma of Male Breast: A Rare Presentation of Cancer.

Article · March 2012

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Nikumbh Dhiraj B et.al.

J

• urnal of medical research and practice

JMRP March 2012 Volume no 1 Issue 2 47 Available at www.jmrp.info

Ori g

i nal Arti cl e

Intracystic Papillary Carcinoma of Male Breast: A Rare Presentation of Cancer

* Dhiraj B.Nikumbh1, J

yotsna V.Wader1, Hemant B.J anugade2, Avinash M.Mane1, Pallavi A.Shrigondekar1

Introduction:

Breast carcinoma is an uncommon in males and represents 0.6% of all breast carcinomas and less than 0.1% of all malignancies in men. Male breast cancer has an incidence of 1 per 1,00,000 per annum.1 The predominant histological type is the infiltrating duct carcinoma (IDC) accounting for 70% of all cases. Even in female patients, invasive papillary carcinoma is a rare morphological type.2 Intracystic papillary carcinoma (ICPC) accounts for 5 to 7.5% of all male breast cancers3 and only a few cases reported published in the literature so far. We report a case of intracystic papillary carcinoma (ICPC) of breast in 80 year old male patient following mastectomy for Ca breast.

Case report:

An 80 year old man presented in surgical OPD of

• ur hospital with painless round swelling in his

left breast, since 2 months duration. He had noticed a rapid increase in size since 1 month. He was tobacco chewer since 10 years. There was no history of trauma, mumps, testicular injury, cirrhosis of liver, or any other contributing family

• history. On physical examination, the patient was

averagely built and averagely nourished. The rest

• f the systemic examination was unremarkable. On

local examination, there was no gynaecomastia. A 6x7 cm well circumscribed, firm, non tender, mobile mass was noted in left upper outer quadrant (Figure 1). Nipple appears to be

• retracted. Bilateral axillary lymph nodes were not
• palpable. Right Breast was normal. Fine needle

aspiration cytology of mass revealed ductal neoplastic cells s/ o ductal carcinoma of NOS type. All the biochemical, hematological and serological investigations were within normal limit. The patient underwent simple mastectomy with axillary dissection. The specimen was sent for histopathological examination. Post operative was uneventful.

Figure 1: Gross appearance of left breast mass with retracted nipple.

Author Affi l ati ons

1 Department of Pathology,

Krishna Institute of medical sciences, Karad, Maharashtra, India –415110.

2

Department

• f

sur gery, Krishna Institute of medical sciences, Karad, Maharashtra, India –415110

Cor r e spondi ng Author

Dr.Dhiraj B. Nikumbh, M.D. Assistant professor. Department

• f

Pathology, KIMS, Karad, District - Satara, Maharashtra, India 415110. Contact no:+91- 9226894980.

Abstr act

Breast carcinoma is an uncommon neoplastic condition among men, accounting for not more than 1% of all breast cancers and less than 0.1% of male cancer deaths. Intracystic papillary carcinoma in men is an extremely rare disease with only a few case reports published in literature so far. Since papillary carcinoma has a favourable prognosis as compared to other histological subtypes, an accurate diagnosis is essential. We report a case of this rare histological type of breast cancer in 80 year old male with brief review of literature.

Ke y wor ds: - Breast neoplasms, intracystic papillary carcinoma, male breast.

ISSN NO- 2162-6391(Print) 2162-6375(Online)

Nikumbh Dhiraj B et.al.

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JMRP March 2012 Volume no 1 Issue 2 48

Gross examination:

The mastectomy specimen measured 12x11x2.5

• cms. The nipple was partially retracted and skin of

the areola was wrinkled. On serial cut section showed a large cyst measuring 5x4 cm containing dark black fluid with a tumor in it (Figure 2). Tumor measures 4x4x3 cm and showed multiple papillary excrescences with gray white friable solid mass (Figure 3). Skin was seen 0.3 cm away from tumor. Axillary dissection revealed 5 lymph nodes with larger measured 1.2 x 1 cm. Multiple sections were studied with haematoxylin and eosin.

Figure 2: Gross appearance of mastectomy specimen with a tumor on serial cut section specimens. Figure 3: Cut surface of the specimen showed intracystic gray white tumor with multiple papillary excrescences.

Light microscopy showed large cystic cavity filled with a papillary neoplasm. Fibrous cyst wall and a solid, complex papillary carcinoma projecting into the cyst lumen was noted (Figure 4). Many areas showed portion

• f

intracystic tumor with fibrovascular stroma (Figure 5). Tumor composed

• f numerous delicate, branching papillary fronds

lined by neoplastic epithelial cells (Figure 6). These columnar epithelial cells exhibited mild pleomorphic and hyperchromatic nuclei with a high nuclear cytoplasmic ratio. Mitotic figures were variably present. Adjacent areas showed stromal desmoplasia. All peripheral surgical margins, overlying skin and all 5 lymph nodes in axillary dissection were free from tumor. Based on above findings, final diagnosis of Intracystic papillary carcinoma of an 80 year old male patient was given. Patient was on regular follow up.

Figure 4: Light microscopy showed fibrous cyst wall and intracystic tumor in it (H &E stain x100) . Figure 5: Tumor composed of multiple delicate, branching fronds lined by neoplastic epithelial cells (H &E stain x100). Figure 6: Light microscopy revealed neoplastic cells with fibrovascular core and pleomorphic,hyperchromatic nuclei with high nuclear cytoplasmic ratio (H &E Stain x400) .

Discussion:

Breast carcinoma is an uncommon neoplastic condition among men, accounting for not more than 1 percent of all breast cancers and less than 0.1 percent of male cancer deaths.4 Several risk factors for the development of male breast carcinoma have been identified, but elevated levels

• f estradiol and other estrogenic hormones are

definitely implicated.4 The proven risk factors are

• besity, testicular disease, Klinefelters syndrome,

Nikumbh Dhiraj B et.al.

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mumps orchitis, testicular injury, cirrhosis of liver, smoking, exogenous estrogen therapy, men working in mills (chronic heat exposure), radiation exposure etc.5 A positive family history and mutation of BRCA2 gene show definitive link to breast cancer.6 The prevalence of male breast cancer increases with age and have geographical variation.5 Intracystic papillary carcinoma (ICPC) is rare in females and excessively rare in males with handful

• f case reports in literature.7-10 It accounts for 5 –

7.5 % of all breast cancers in male.8 It is a localized, non invasive breast cancer with papillary proliferation arising within or on the wall

• f large cyst.9

It commonly presents as benign looking, well localized lump due to its underlying cystic nature. The mean age of presentation in males is 68.2 years as per Tochika et al.10 Most of the patients presented with palpable lump and few patients presented with mild pain, bloody nipple discharge and pruritus.10 Fine needle aspiration is rarely diagnostic and an excisional biopsy is usually required to establish the diagnosis.9 The cytodiagnosis in the presented case was positive for ductal carcinoma of NOS type. Histologically, papillary carcinoma is divided into intraductal and intracystic (ICPC); further subdivided into invasive and non invasive . ICPC has been divided into three subtypes – 1) pure (with or without invasion), 2) with associated intraductal carcinoma, 3) with associated usual type of invasive ductal carcinoma. In our patient, the tumor was a pure non invasive ICPC with no associated intraductal

• r

invasive breast carcinoma of usual type with no axillary lymph node involvement. In our case ER and PR was positive in tumor cells with c-ebr B2 negative. The prognosis of papillary carcinoma depends upon on the presence or absence of invasion. Non invasive papillary carcinoma can be regarded as a form of intraductal carcinoma and complete resection cures such patient, as in our case. In invasive tumors, the frequency of axillary lymph node metastasis depends on the size of invasive component and histological grade. The overall prognosis of invasive carcinoma even with nodal metastasis is favorable as per Anders et al.9 The differential diagnosis of ICPC from intraductal papilloma should be made

• n

histological specimens with a thorough sampling and microscopic features. Tsuda et al.11 reported that loss of heterozygocity (LOH) on chromosome 16q was a useful a marker for ICPC, since intraductal papilloma showed no LOH.

Conclusion:

Intracystic papillary carcinoma of male breast is an extremely rare entity with favorable prognosis. Though aspiration cytology is suggestive, histopathological diagnosis is confirmatory and invasion needs to search carefully. Much research is needed to characterize further biological and molecular properties of male breast cancer and their prognostic significance so as to desire

• ptimal treatment strategies.

References:

1.Anderson WF,Devesa S S : In situ male breast carcinoma in the Surveillance, Epidemiology and End result data base of the National Cancer Institute. C ancer. 2005; 104 : 1733- 41. 2.Ravandi – Kashani F, Hayes TG. Male breast cancer : A review of the literature. Eur J

• Cancer. 1998 : 34. 1341.

3.S inha S, Hughes RG, Ryley NG . Papillary Carcinoma in Male Breast Cyst : A Diagnostic challenge. Ann R Coll Surg Engl. 2006; 88(5): 453. 4.Rosen PP, Oberman HA. C arcinoma of the male breast. In; Rosen PP, Oberman HA(edi). Atlas of tumor

• Pathology. Tumor of the Mammary Gland. AFIP.

Washington DC; 3 rd series, Fascicle 7: 1992: 287 – 91. 5.Pant I, J

• shi C . Invasive Papillary C

arcinoma of the male breast. Report of a case and review of the

• literature. J

Cancer Res Ther. 2009; 5(3); 216-18. 6.Thorlacious S , Tryggradottir L, Olafsdottir GH, J

• nasson J

G, Ogmundusdottir HM, Tulinius H et al. Linkage to BRCA2 regions in the hereditary male breast cancer.Lancet.1995.346:544-5. 7.Arora R, G upta R, S harma A, Dindda AK. Invasive Papillary carcinoma of male breast. Indian J

• urnal of

Pathology and microbiology.2010; 53(1);135-137. 8.Gupta D,Torosian HM. Intracystic breast carcinoma in male: Unusual case presentation and literature review. Oncol Reports. 2002;9:405-7. 9.Anders B,Aguilar J , Toroba A, Martinez-G alvez M, Aguayo J .Intracystic papillary carcinoma in the male

• breast. Breast J

. 2003;9:249-50. 10.Tochika N, Takano A, Yoshimoto t, Tanaka J , Sugimoto T, Kobayashi M, et al. Intraycstic carcinoma of the male breast: Report of a case. Surg Today. 2001;31:806-9. 11.Tsuda H, Vei Y, fukatomi T, Hirohashi S . Different incidence of loss of heterozugosity on chromosome 16 q between intra ductal papilloma and intra cystic papillary carcinoma of the breast. J pn J C ancer Res. 1994 ;85;992- 6.

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