New Primary: Papillary Carcinoma With Microinvasion
So next month I would have celebrated ten years since my IDC dx and subsequent BMX with recon...
But a few months ago I noticed two tiny nodules in the skin above my suture line. Had them biopsied.
The path report came back positive for papillary carcinoma with microinvasion.
MO is not advocating for radiation, but is sending me to the RO to get more info so I can make an informed decision.
At stake are my saline implants, and my very wonky Ehlers-Danlos skin with faulty collagen and connective tissue.
She also wants to start me on Tamoxifen. I failed both Arimidex and Femara the first time around; the SEs were too disabling to continue. I quit after 18 months with her approval.
My head is spinning, but I don't regret getting off the AIs back then.
She has never had a patient who had a BMX, implants, and a new primary papillary carcinoma show up ten years later.
I guess that makes me special... 
Comments
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Blessings, congrats on almost reaching your 10-year mark, but sorry you're back. It's common for papillary lesions to recur in peripheral areas of breasts, so please don't knock yourself. You may also wish to read the "Papillary Carcinoma" thread for more information. Best Wishes!
"Due to the high upgrade rate of atypical papillary lesions to carcinoma (42%), EXCISION of ALL atypical papillary lesions with wide excision margin is recommended for cases with pathologic diagnosis of atypical papillary lesion on core-needle biopsy."
https://researchexperts.utmb.edu/en/publications/atypical-papillary-lesions-after-core-needle-biopsy-and-subsequen"DIFFERENTIAL CD133 EXPRESSION DISTINGUISHES MALIGNANT..."
Chih-Hung Lin et al. Virchows Arch. 2015 Feb."
"CD133 expression in papillary carcinomas was significantly lower than that in benign and atypical papillomas (p < 0.001). CD133 expression in invasive carcinoma NST was also significantly higher than that in papillary carcinomas. Our data suggests that absence of expression of CD133 can be a useful marker in the differential diagnosis between malignant papillary lesions and their benign or atypical mimics. The characteristic loss of CD133 expression in papillary carcinomas of the breast also indicates that these lesions are distinct from other types of breast cancer."
https://pubmed.ncbi.nlm.nih.gov/25433813/Paul E. Goss claims:
"More than 50% of breast cancer recurrences and deaths occur five or more years after completing tamoxifen treatment."
-- Goss PE, Ingle JN, Pater JL, et al. Late extended adjuvant treatment with letrozole improves outcome in women with early-stage breast cancer completing 5 years of tamoxifen. J Clin Oncol. 2008
https://www.newswise.com/articles/femara-helps-protect-against-return-of-breast-cancer-even-when-treatment-starts-several-years-after-completing-tamoxifen-therapy0 -
You might be wise to seek 2nd opinions on both pathology and oncology to avoid over or under-treatment. Usually the invasive component Trump's papillary in treatment.
"Using markers of invasion, Rakha et al. found that EPC exhibited an expression pattern of invasion-associated markers between ductal carcinoma in situ and invasive ductal carcinoma, concluding that this tumour has unique biological features (10). Encysted papillary carcinoma is genetically closer to ductal carcinoma in situ than to invasive ductal carcinoma, which may explain the indolent behaviour of this tumour (11). The WHO recommends encapsulated papillary carcinoma to be staged and treated like a ductal carcinoma in situ as the behaviour of this tumour is usually indolent.,"
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC61309...
"Despite the widely accepted understanding of invasion as an unequivocal invasion of nonspecialized stroma by conventional non-papillary-type carcinoma, the definition of invasion in PC remains confusing..."
https://slap-patologia.org/wp-content/uploads/2014/04/encapsulated-papillary-ca.pdf
"Although immunohistochemistry is helpful in evaluation of benign and atypical lesions it has a limited utility in differentiating the majority of PC as non-invasive or invasive disease. Pathologists should be aware of the various entities and the differential diagnosis of each entity, the existence of lesions with overlapping features and should follow the updated guideline recommendation for their diagnosis and management. These rare lesions usually require additional diagnostic work-up and difficult cases should trigger consensus opinion or expert referral."
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Spectrum of Papillary Breast Lesions According to World Health Organization Classification of Papillary Neoplasms of Breast
https://www.cureus.com/articles/42481-spectrum-of-...
Diagnostic challenges in papillary lesions of the breast
"Some authors even tried to DEFINE STROMAL INVASION IN EPC BY THE PRESENCE OF MALIGNANT PAPILLARY CLUSTERS 10mm OR MORE BEYOND THE CAPSULE, which may emphasise our old perception of the biological value of the capsule in EPC. Typical EPC may also be associated with focal conventional type non-papillary invasive carcinoma ..."
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Hi, obsolete - oh, I definitely don't knock myself for this latest dx... even if I'd completed five full years of the AIs (with no quality of life) there's no guarantee this new primary wouldn't have appeared anyway.
Thank you SO much for the articles. My background and training is in medical counseling, so I'm definitely a researcher. I'll dive into those links, as well as the threads on papillary carcinoma.
Guess I've got my work cut out for me!
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hi some advice needed regarding papillary breast carcinoma situ. Diagnosed with precancerous from breast biopsy doctors seems very positive saying it’s precancerous etc etc now surgery next week but the letter saying small possibility it will be invasive! I don’t know how they can be so sure and positive prior to surgery and now I’m worried it’s not precancerous and it’s much worse any experience on this? Please help x
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Hi LauraJJJ, so glad you found us, but sorry you have reason to be here. Please be advised that an "in situ" dx is very favorable within the papillary family because the tumor cells would be located inside the duct.
How many tissue samples in your tumor biopsy? What's the estimated tumor size?
Most of the time any invasive papillary cells or conventional invasive (IDC-nst) cells would be located in the nearby outside stroma or peripheral areas of the papillary tumor with minimal extension, IF an invasive component even exists.
So the chances of any invasive cells would have been observed in your initial biopsy pathology. But there's only a slight chance there might be minimal micro-invasions or small clusters of invasions which the biopsy missed, which can rarely occur. After your surgical pathology is completed, you can also ask for 2nd opinion pathology reviews
Good luck with your surgery, and please let us know how it goes. Best wishes!
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Obsolete: thank you again for the articles. Most of them focused on a primary first cancer in an intact breast, so I'll have lots of questions for my MO.
Even though I had clear margins on the two samples taken during my first biopsy, the Radiation Oncologist wanted wider margins, and I had a wide excision biopsy last Wednesday.
The surgeon was the same plastic surgeon who did my reconstruction ten years ago. He took a very large tissue sample (approximately 4" wide, in an elliptical shape) and removed all the tissue from the skin down to the surface of the implant. He removed subdermal tissue, as well as scar tissue and muscle in the capsule, and stitched the capsule back together. He said he wanted to give the pathologist as much tissue to work with as possible.
Now we wait for the new path report. Hopefully, he'll have it by my Post-Op appointment on Wednesday.
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Oh my, Blessings, you recently had some serious surgery there, so I hope your recovery is going well for you.
Your team was wise to aim for wide margins, and then some, because sneaky little papillary tumors can be known for appearing in multiples. I had once been told by a pathologist that papillary multiples tend to recur especially along the chest wall and outside periphery areas.
A 2nd opinion seasoned breast surgeon said that small papillary tumors (<5mm) don't always show on MRI, due to papillary tumor cystic content, which is a bummer. However it's supposedly very rare for any invasive papillary cells to present in the lymph nodes, unless there are aggressive conventional malignant (IDC-NST) cells in the mix.
In almost 8 years, I know of only 2 cases on these boards where papillary (with invasive component) recurrence went regional, but in both cases either the surgery got seriously screwed up or the hormone treatment got messed up. Both cases were outliers, and both were the chest wall location.
It is very stressful while awaiting pathology and healing from surgery concurrenly. Please let us know how you make out and best wishes for positive healing and peace of mind. Hugs to you.
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Hi, obsolete
Oh my gosh…. Where did the time go?
An update: my wide excisional biopsy last fall revealed *additional* papillary carcinoma in the tissue sample, I think for a total of four foci. There was, thankfully, no vascular microinvasion.
You mentioned recurrences in the chest wall and in the outside periphery – that's what concerns me now. In 2011, my final pathology report showed no evidence of cancer. None. Zip. Zilch. Nada.
I was told that the tumors had been captured in one or more of the seven different diagnostic procedures/biopsies I had prior to mastectomy. At that point, post-surgery and post-final path report, I felt pretty confident that I was starting with a relatively clean slate.
This time, though, the little white pill (Tamoxifen) is all that's between me and a recurrence.
I was offered radiation, but I have multiple medical issues that would have resulted in potentially permanent side effects. I declined. I've been on Tamoxifen for six months, and am tolerating it.
I just had my six-month appointment with the MO, and she said there was no other way of detecting future lumps besides self-exams. Of course, that makes me want to check my breasts every hour, but I resist.
Thank you again for all your good information! I hope you are doing well…
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1986Laurajjj – if you see this post, can you let us know how your surgery went?
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Hello Blessings, good to hear you're doing well. Same here, thank you.
You evidently had dodged 4 bullets with your excisions. With micro-invasion, it had been caught just in time. (See encouraging stats at link below). Don't worry, these rare oddball BC can do weird things & misbehave in some of us. (I also had small multi-focal Grade-2 IDC & Invasive Mucinous tumors scattered about with Grade-3 DCIS). Almost 9 years later, I am doing fine "thus far", but I do monthly self-checks looking for any little buggers. My pathologist had warned my chances of recurrence will continue to increase yearly until...
Still you might need to press your team to identify exact subtype of Papillary Carcinoma (Intracystic or Encapsulated or Solid Papillary?) and your type of invasive component (conventional IDC-NST or Papillary cell invasion or Mucinous Carcinoma invasion?) Even though treatment might probably not change, nailing down your specific pathology within the "Papillary spectrum" might help give you more reassurance on the slight likelihood of recurrence.
Some people (including breast surgeons & oncologists) think Papillary Carcinoma is only one indolent subtype, but it's actually a "spectrum" of Papillary BC disease. In case you also had Solid Papillary with Invasion (IDC & Mixed Mucinous), below is the latest 2022 published info which you might find helpful. There aren't many of us, so it's nice to stay in touch. Stay well. 😀
"SOLID PAPILLARY CARCINOMA OF THE BREAST"
Toyaja Jadhav, Shashi Shekhar Prasad, etc
https://pubmed.ncbi.nlm.nih.gov/23020734/
RADIATION TREATMENT GENERATES CANCER STEM CELLS FROM LESS AGGRESSIVE BREAST CANCER CELLS, STUDY SUGGESTS
University of California, Los Angeles (UCLA), Health Sciences
https://www.sciencedaily.com/releases/2012/02/120213185115.htm
RADIATION-INDUCED REPROGRAMMING OF BREAST CANCER CELLS
Chann Lagadec et al. Stem Cells.
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