Papillary Carcinoma
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Tanya222-
We want to welcome you to our community. We're so sorry that you find yourself here, but we hope this can be a source of support when you need it.
Given your family history and your age at diagnosis, has your doctor suggested genetic testing? We know it's a lot to process, and you have a lot of questions, but it's important to remember that you didn't do anything to cause this. It's frustrating to not be able to understand or pinpoint why this happened, but right now, try to focus on figuring out where to go from here.
Good luck with your appointment with the surgeon on Tuesday, please keep us posted on how it goes!
The Mods
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Sorry I haven't been around! The lump in my right breast is called (I'm not sure I can remember offhand) lobular carcinoma in situ. It's not cancer, despite the name, it's abnormal cells. The surgeon said it meant I am high risk for breast cancer. Well, DUH.
This is what my breast looked like about two or three weeks after the MRI-guided stereotatic vacuum-guided biopsy:
It actually looked worse than the pictures, but I'm a lousy photographer. I was trying to hold the breast to the best sunlight angle possible.
The surgeon again went through my nipple scar. You can't see it now!
I'll see my oncologist next week; she's been on summer vacation. I'll let you all know what she says. I'll probably get genetic testing.
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No, nobody's suggested genetic testing yet, all my info (not much) has come over the phone thus far.. a nurse at my doc's office just phoned and said my mammogram was good; I guess that means there are no other spots than the main lump, that's what he wanted to check for.
I meet with my surgeon tomorrow, I'll know more then.
The first 3 days or so I really freaked out in my head, but Saturday I met with some friends who are the type who crack jokes & make me laugh, and I really do feel better from that, I feel more optimistic & just feel like getting this lump out, telling cancer where to go, and getting on with my life
Edited to add: Apparently I was told the wrong time for that app't and I missed it. It's been rescheduled for tomorrow at noon.
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I just saw the surgeon who will be doing my lumpectomy (Oct 6)
This is the pathology report she gave me. Does anyone understand the medical jargon?
"Histological examination shows a fragmented papillary lesion. Majority of the fragments are detached without underlying stroma. Few intact fragments show the lesion is surrounded by capsule-like dense fibrous tissue. The lesion is composed of proliferation of monotonous population of columnar epithelial cells showing low to intermediate nuclear grade. Mitosis is scant. The lesion has papillary, cribriform and focal solid growth patterns. Myoepithelial cells are absent both within and surrounding the papillary nodule.
Comment: the histological findings are mostly consistent with a papillary lesion. Given the absence of myoepithelial cells within and at periphery of the lesion, a papillary carcinoma is favoured; however, definitive classification of the lesion may be difficult in the limited material afforded by the biopsy. Excision of the entire lesion for a complete histological evaluation is recommended."
BUT- my family doctor had phoned me to say that the 1st lab (which is where I think these results are from) had only said "non-specific complex lesion' and the surgeon told me just now that she doesn't see that it was sent to the 2nd lab. My doc had said it was being sent to another lab in Toronto and that that lab had stated definitively that it is Papillary Carcinoma. But the surgeon's had plenty of time to receive those results, but she insisted she didn't have them.
What she said right now is that nobody is 100% certain it IS cancer until they remove the lump.
According to the report above, it seems possible that it isn't?
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The best lump is a lump in a jar.
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It's hard to figure out what that diagnostic sheet says. They never know exactly what it is until they've gone in there and taken it out and had a look around. Remember, if you have to have breast cancer, papillary cancer is one of the best kinds to have.
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Don't know why papillary is the best kind of bc. I'm stage 4 now! It's a very rare breast cancer. You may be thinking of papillary carcinoma of the thyroid which is easy to treat.
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Barbe, I take it correctly that it took 8 years for yours to go from stage 1B to stage 4? And even with a double mastectomy it recurred?
I started googling some of those medical terms & just wound up scaring myself silly as I was taking them out of context.
Just gotta sit tight for 2 weeks till the bugger comes out. Then another week to 10 days for testing results. Sigh ... the waiting!
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Tanya, that's all correct. Mine was a slow growing ER+ which wouldn't have benefitted from chemo which only kills fast growing cells.
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So you didn't even get pressured to do chemo? That's good!
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Wouldn't work so why do chemo?
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Barb, did your oncologist tell you the chemo would not work? What was your oncotype score? I was advised by my local oncologist and the onc from Dana Farber that chemo was recommended as my oncotype score was in the high range. They used this to make their decision not that my cancer was invasive papillary carcinoma.
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Single mom there was no oncotyoe scoring 8 years ago...
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SingleMom1, please accept my heartfelt wishes. I respectfully must call to your attention that a prior post of yours had indicated that you had been diagnosed with "micropapillary" vs "papillary" carcinoma.
Please be aware that micropapillary is typically more aggressive and thus is treated as such. The ladies on this thread need to be alerted to this distinction, especially the newbies.
Hugs to you for a successful treatment journey!
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Tanya, my best wishes to go out to you and I hope you feel warmly received on this thread by your papillary sisters, including myself.
Your pathology report on your biopsy noted no substantial mitosis, so that is very encouraging. After your October surgery, a better diagnosis will be determined by a new pathology. I would encourage you to also get a 2nd opinion on your final pathology slides.
Please don't compare your case to some of the advanced papillary and micropapillary sisters who sometimes post here. Some of these advanced stage sisters had (admitted) lymphatic-vascular invasion, tumor(s) located on the chest wall, involved lymph nodes and poor surgical margins....all of which would indicate higher risk of recurrence. We are all different, but we are all connected here.
Good luck on October 6th surgery day!
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SingleMom,
Congratulations on your NED status. May I ask what subtype of BC had been found in your lung node?
What was your original invasive component? (IDC or mucinous or mixed, for examples)?
Sorry, I goofed, you had invasive papillary, NOT micropapillary. Was your papillary partiality cystic or solid papillary?
You really seem to have it together. What would you credit your NED status? You've been through a lot and I hope you stay NED forever. Good luck.
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WeAreConnected, thank you for the encouragement! You're right about not comparing, its very hard not to compare, I scare myself! You're right though, everybody's case is different!
Surgery went well Oct 6 but it kept seeping the rest of the day. I napped on the sofa & woke up to my dressing saturated (even down to the couch cushion, and it's my roommates sofa!) There was little to no pain with it but non-stop seeping freaks me out, it had been 10 or 11 hours, I freaked & went to the ER to be sure nobody was concerned why it was still bleeding.. the nurse reassured me 'oh some people just like to keep bleeding'. She changed the dressing and said the incision 'looks very good' and that my surgeon usually does a great job..
It wasn't too painful the first few days, it's more sore now 8 days later but I still haven't gotten the prescription for Tylenol 3s I was given! Its most sore if I bend over putting my shoes on or picking something up.
I was told a week to 10 days for testing; I phoned both my doc & my surgeon today but no news yet. I hate the waiting! Now I have to stew all weekend
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Tanya222
Glad to hear surgery went well. I know the waiting for results can be very hard. Hang in there. I hope you have good news.
We are connected-
Thank you for your kind words!!
I am ER positive and Hers 2 negative again based on biopsy of my lung node. I am currently on Letrozole and Ibrance. Ibrance is a new treatment approved by the FDA in 2015 for metastatic hormone positive cancer. I had an MRI today on back due to concerns of new pain. I also have full body cat scans in two weeks. Praying results will be good!!!
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I met with my surgeon & she had the pathology results - it is actually worse than we thought.
There were actually 2 lumps, not one. And there are 2 things going on, the papillary carcinoma & Ductal Carcinoma in situ.
AND - she didn't get clear margins, I have to go back in for surgery again Nov 3.
I'm kind of in shock from the news, both that there's 2 types of cancer in there and that I need surgery again!
I will type out what the pathology report says:
"Right breast lumpectomy
-Solid papillary carcinoma (6mm) with foci suspect for invasion (completely excised)
-Encapsulated papillary carcinoma (7mm, completely excised)
-Extensive ductal carcinoma in situ, in 20/20 slides, estimated at least 5.2cm in maximum dimension, involving multiple margins (superior, inferior, anterior, lateral), <1mm from posterior, medial margins
-Calcifications associated with neoplastic and non-neoplastic areas
Comment: Papillary carcinomas (solid and encapsulated) are categorized as non-invasive entities in the WHO classification. This remains controversial. There are irregular foci that are suspicious for invasion around the edges of the ill-defined capsule of the solid papillary carcinoma. The differential diagnosis includes entrapment within the capsule, rather than true invasion. This case is sent for an expert opinion and an addendum with the final diagnosis and synoptic data will be issued when the consultant's report arrives."
When I left the surgeon's office their washroom was out of order and right across the street is the hospital so I ran in there and who do I run into buying lunch was my family doctor, he is a teaching doctor in there. I showed him the report & said I was in shock a bit, and he said 'you'll be fine' and that in 5 years I'll have all but forgotten about this, I said 'I'll never forget all this nightmare' but he was very reassuring.. "you'll be fine".. oddly enough I didn't have tears in my eyes when I left the surgeon's office (she's very brusque & abrupt) but I did a tiny bit after I talked to him! Funny how someone being so calm & reassuring can have that effect!
Any thoughts?
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DCIS is known as a precancer which I think is silly. Like being a little bit pregnant!
I didn't have clear margins with my lumpextomy either which is why I had my double mast. Didn't want to get cancer in the other breast later and have to go through surgery again!!
As for not being invasive - I can vouch that it can be as I'm stage IV!
Keep us posted. You are not alone, sweetie.
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Tanya-there are a couple of pieces of good news in there. First, the frankly cancerous tumors (solid and encapsulated papillary carcinomas) were completely removed. Second, your case was sent on for expert assessment. More eyes, and more brainpower, on an issue is a good thing. You will get more information, including hormone receptor status, stage and grade of your tumors. That information will help you and your treatment team come up with a plan of action for you. You will feel much better once you have the plan in place. The waiting is the worst!!
I know what you mean about tearing up ... When I was getting ready for chemo, I had a meeting with the managers that were going to fill in for me to tell them that I would be in and out for the next four months and why, and to discuss workflows, etc. I was fine as long as we were discussing facts and percentages, but as soon as they expressed sympathy, I was bawling. Sheesh...
Your doc is right. You will be ok, and we will be here for you. This is a bump in the road. A crappy one, but a bump.
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Thanks for the replies barbe and limnogal!
I was/am a bit confused as to how it says it was completely excised and yet it has "irregular foci suspicious for invasion", "ill-defined" etc .. doesn't that contradict? And isn't 5.2cm a darn big bugger??!!
I don't know, I'm probably nit-picking in my semi-freaked out state!
Also w/ the 1st surgery she elected not to remove any lymph nodes which I didn't really want to consent to anyhow, but again this time she may. She will consult with some sort of panel of other doctors to get their advice on sentinel nodes or not..
That was me w/ the 2 doctors today limnogal! With the brusque surgeon I was fine, she talks too loud for me which I hate but I wasn't getting upset; then when I ran into my super-nice doctor who talks so softly and was so reassuring, I had a bit of tears in my eyes when I started walking home, wasn't bawling by any means, but it's a paradoxical reaction for sure!
And he said chemo isn't recommended so nobody will be pressuring me on that like they did with my mother. I told myself years ago I'd never do chemo if I got cancer, I just don't want to be pressured about it.
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Tanya, Limno is right. All cancer is crap, but the worst of it is probably out of you already. You are not alone. Try to get a good night's sleep and will catch up to you when I can log on with my laptop. Your papillary tumors were very small and they're gone now. I'll have more info for you after I check my old notes & files. Rest easy now. Hugs!!
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SingleMom, best wishes on your new tests. I know that feeling. Praying for both you and Barbe.
Barbe, there's an old interesting thread on this site about tiny margins on the chest wall after mastectomy. I'll look for it. Was your invasive component conventional IDC (matured DCIS)? Papillary is rarely the original invasive component, I've read in a few studies.So very mysterious.
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Weare I was all papillary. Very rare first diagnosis (less than 2% of all BCs) and even rarer recurrence. There was only THREE postings on Google for breast papillary cancer when I was first diagnosed. All for the same 83 year old woman!
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WeAre, thanks for the well-wishes! It's more the DCIS I'm scared of now!
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WeAreConnected, you've mentioned invasive papillary and micropapillary cancers, can you explain the difference? Thanks.
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Cubbie, invasive micro-papillary carcinoma is another uncommon variant of papillary carcinoma, but its papillary architectural growth pattern is different and much smaller in size (micro). Unfortunately, it's usually a much more aggressive beast. Lymph node mets are said to be common with IMPC. More info at the link posted below. Good luck in your treatment!
Barbe, you appear to be among the rarest of rare papillary presentations. Healing hugs are sent your way!
Tanya, I do hope that things will begin to settle down for you soon. I'm truly sorry that you weren't originally blessed with clear margins. DCIS pre-cancer is found with about 2/3 - ¾ of solid papillary tumors, so your scattered DCIS is now safely within your breast ducts. If you haven't already had a MRI, please consider asking for one before your next surgery. But be aware that papillary lesions under 5mm are not always visible on MRI, my doctors had warned. There are good reasons why some papillary patients consider mastectomy. It is common to have more than one subtype of cancer with papillary. Were your 2 tumors classified as Luminal A or Luminal B tumors? Also a tumor's mitotic rate is a most important prognostic factor. But BC tumors are also heterogenous.
Papillary still remains highly controversial. Pathologists are trained differently and seem to classify findings differently with infrequent BC sub-types. Invasive carcinoma, if it occurs with papillary, tends to initially grow around the peripheral outer edge of the papillary tumor's capsule. However, the extensions of any papillary tumor's invasion into its nearby stroma are often very minimal. Many papillary tumor's appear to be ill-defined. Think of the papillary tumor residing inside a rusty pipe (breast duct), which has small rusty cracks & crevices and possibly leaking water droplets (invasive cells) into its rusty metal shell (capsule), while still not penetrating through the metal pipe's shell. Water could possibly later begin to leak "through the metal pipe itself" into the surroundings (true frank invasion).
Tanya, your scenario is quite familiar....the entrapment of invasive cells within the papillary capsule itself, which were actually residing within the breast duct. If that doesn't confuse the pathologists as to how to classify those so-called conventional invasive cells within the capsule wall itself..... Such entrapped cells seem to be getting ready to become invasive, but not yet actually invasive into the area of tissue that is sitting outside the capsule. The truth is that pathologists still appear to agree "to disagree" as to how to classify such odd-ball cells sitting within the wall of the papillary tumor's capsule. The 4 pathologists from 4 institutions who had looked at my case could not agree, regardless of what the WHO stated in its guidelines. That's maybe why your pathology reported "irregular foci suspicious for invasion". Papillary tumors can be a pathological headache at times, which is maybe also why many breast surgeons don't strongly push for the highly expensive Oncotype Dx assays for papillary carcinoma and because most papillary tumors are slow growing (thus, most papillary tumor cells consequently score low on Oncotype testing due to being highly ER+). Genomics does not seem to have had accumulated enough pathology data thus far to warrant spending BIG $ on the Oncotype Dx test for papillary. I would skip it and instead focus on ER+ % value instead, but that's only my humble opinion.
It's sometimes recommended to obtain other opinions yourself on papillary pathology, even if the pathologists will ultimately agree to disagree, due to the high degree of subjectivity in pathology. Knowledge is power for the patient. Learn as much as you can so that you can adequately advocate for yourself.
I'm posting snips BELOW (from a most frank and informative 2008 review of papillary carcinoma). I hope it helps. Healing hugs …
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[SNIPS]
2008 Department of Pathology, Chang Gung University College of Medicine, Taoyuan, Taiwan (Dr Ueng)
http://www.thefreelibrary.com/Papillary+neoplasms+of+the+breast:+a+review.-a0230152017
It should be kept in mind that, even when an entire sample is submitted for pathologic evaluation, only a single slide of each block is evaluated: Our sampling is not exhaustive and could easily miss areas of invasive carcinoma [conventional IDC or tubular or mucinous or mixed] hidden deeper in the blocks.
Intraductal papillary carcinomas account for 2% of all breast cancers. (47) Most occur during the fifth and sixth decades of life. It is important to distinguish solitary, central papillary carcinomas from the multifocal, peripheral type, as the latter may require a wider excision because of the more extensive distribution of the process.... The epithelial cells supported by the fibrovascular stalks can display a variety of proliferative patterns, including cribriform, solid, micropapillary, or stratified spindle-cell patterns (Figure 7, A through D). The neoplastic cells often appear deceptively bland and are categorized as low grade. High-grade intraductal papillary carcinomas do occur, albeit with lower frequency.
One of the problematic areas in interpretation of these lesions is how to manage a lesion in which there is complete absence of an ME cell layer, even around the cystically distended duct in which the papillary lesion is proliferating. Does the absence of an ME cell layer around a duct constitute or reflect invasion? This problem is often compounded when needle instrumentation results in partial spillage of the duct content into the surrounding stroma.
Variants of Intraductal Papillary Carcinoma.--Intracystic (Encapsulated) Papillary Carcinoma.--Intraductal papillary carcinomas that are solitary, and frequently, centrally located, have also been designated intracystic (encysted) papillary carcinomas by some authors. (29,56,57) The term intracystic may be appropriate for lesions that grossly exhibit a cystic space around the papillary proliferation; however, it serves no distinctive purpose because,morphologically, all intraductal papillary carcinomas are located within a variably dilated cystic duct.
The term encapsulated papillary carcinoma has been coined for papillary carcinomas that appear circumscribed and encapsulated but which lack demonstrable ME cells around the cystically dilated duct. (58,59) The possibility that a subset of circumscribed papillary carcinomas lacking a demonstrable peripheral ME cell layer may actually represent invasive papillary carcinomas has been raised by some authors. (59,60) In our opinion, however, these tumors are well delineated and behave indolently and are best regarded as intraductal papillary carcinomas for management purposes, particularly if persistence of a basement membrane around the duct can be ascertained with collagen IV or laminin immunostains.
Nassar et al (61) described 19 circumscribed solid papillary carcinomas that appeared noninvasive on H&E morphology alone. No immunohistochemical stains were performed to assess the ME cell layer. No metastatic disease was found in the lymph node dissections performed for 12 of the patients (63%). The 12 patients were alive with no evidence of disease at a mean follow-up of 5.7 years, and 6 were dead (32%) of unrelated causes at a mean of 11.5 years, indicating that most papillary carcinomas that appear to be in situ by H&E morphology are clinically indolent and behave like noninvasive carcinomas.
Most papillary carcinomas are noninvasive ; however, a small proportion of papillary carcinomas have unequivocal associated stromal invasion. The invasive foci generally display the morphology of an infiltrating duct carcinoma lacking papillary features (Figure 9, A and
. Morphologic variants include tubular carcinoma and infiltrating duct carcinoma not otherwise specified (NOS) [aka conventional IDC]. The size of the invasive focus may range from microinvasive to substantial and grossly visible. (61,66) The term solid papillary carcinoma (SPC) was first proposed by Maluf and Koerner (64) to describe a variant of intraductal papillary carcinoma [aka encapsulated papillary], which is characterized by a compact cellular proliferation within multiple nodules that represent dilated ducts (Figure 8, A through C). The neoplastic tumor cells are low to intermediate grade and appear to be streaming, so that the lesion resembles florid intraductal hyperplasia at low magnification. However, the homogeneity (monotony) of the neoplastic cells, as well as the presence of significant mitotic activity in some cases, are clues to the diagnosis of SPC. Rare cases of similar tumors with axillary lymph node metastasis have been reported in the literature. (29,62,63)
The ultimate outcome, even with nodal metastasis, has been reported as favorable, with 100% disease-specific survival rate within 10 years of follow-up. (29,63) It is possible that these cases may have had occult foci of invasion undetected by the sampling, that a separate occult primary tumor had existed, or that the lymph node tumor could actually have represented a carcinoma arising from a glandular inclusion (although this would be, admittedly, quite rare). Another possibility is that many of these lesions receive a needle core or aspiration biopsy before excision. Most of these lesions are also located in the nipple/subareolar region, where a rich lymphatic network exists. It is conceivable that manipulation and instrumentation of these often large and friable lesions may dislodge tumor cell fragments into the lymphatic channels from where they can be easily transported to the axillary nodes; the nodal involvement may reflect benign transport in, at least, some cases.
Some authors reserve the term invasive papillary carcinoma to invasive carcinomas with an exclusively papillary pattern; these have been reported to account for less than 2% of all breast carcinomas (66-68) with a higher frequency of occurrence in postmenopausal and nonwhite women. (66) It is reasonable to speculate, however, that many invasive papillary carcinomas described in older studies may have included intraductal papillary carcinomas that appeared invasive in an expansile fashion, intraductal papillary carcinomas with associated invasive ductal carcinoma, and possibly even invasive micropapillary carcinomas. (66)
Epithelial Displacement After Needle Instrumentation Procedures
Epithelium displaced by a needle core or aspiration biopsy has been described in intraductal papillomas as well as in intraepithelial (in situ) and invasive neoplasms. The epithelium can be dislodged and displaced into the surrounding stroma, often in the needle tract, and even into adjacent lymphatic channels. (69) Displaced epithelium can even be transported to axillary lymph nodes. (69,70) It is important to be aware of the possibility of displacement after needle aspiration or core biopsy to distinguish displaced epithelium from true stromal or lymphovascular invasion. Papillary lesions, because of their inherent friability, are particularly prone to epithelial displacement after needle instrumentation procedures. (71)
The diagnosis of microinvasive or early invasive carcinoma associated with intraductal papillary carcinomas is frequently challenging, and the presence of displaced epithelium can cause much confusion in this setting. The history of a recent needling procedure, presence of prior biopsy site changes, degenerative changes in the "invasive" cell clusters, and absence of reactive, altered stroma surrounding the fragments of epithelium are clues indicating epithelial displacement (Figure 10, A and
. SUMMARY
The assessment of papillary lesions continues to be one of the most challenging areas in breast pathology. … Epithelial displacement by needling procedures is not infrequently encountered because of the increasing popularity of these procedures, and the pathologist should be aware of this possibility. We are particularly concerned about the possibility that areas interpreted as invasion in association with the solid, encapsulated papillary carcinomas may, in fact, reflect dislodged tumor cells; because there are no ME cells around cells dislodged from a papillary DIN (DCIS) into the surrounding stroma, it is impossible to exclude true invasion. A rather long follow-up is necessary to confirm the true nature of such areas.
Variants of intraductal papillary carcinoma (DIN 1-3, papillary type), such as solid papillary carcinoma and encapsulated papillary carcinoma, have recently been implicated as possible low-grade invasive carcinomas based on the absence of ME cells around the circumscribed nodules; however, the fact that the majority of such lesions behave indolently should always be kept in mind to avoid the overtreatment of such patients.
Optimally, in our opinion, localized 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.
http://www.thefreelibrary.com/Papillary+neoplasms+of+the+breast:+a+review.-a0230152017
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Well that's just silly. Imaging won't diagnose papillary Carcinoma! In fact when I had a needle biopsy in January they said benign. I asked to have the grape sized tumour taken out and guess what? Cancer!!! They went back and checked the biopsy and said oops that's cancer too!!!!! My surgeon was furious. With a papillary first diagnosis they should have been really careful when they checked the sample.
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