Case Report: Sclerosing Intraductal Papilloma Upgrade to Invasive Ductal Carcinoma
A 46 year old female presented with a new left breast mass measuring 0.8 cm in greatest dimension (image 1,2, and 3). She subsequently underwent ultrasound-guided core needle biopsy of the mass yielding a partially sclerosing intraductal papilloma (image 4). Surgical referral was made for excision. In the interim prior to planned lumpectomy, the patient was found to have elevated LFT’s leading to subsequent imaging demonstrating multiple liver and lung masses with malignant pleural effusions. Biopsy of the liver lesions proved to be metastatic neuroendocrine tumor. In light of this diagnosis, the planned papilloma excision was then cancelled, and the patient was recommended to return for observation with follow-up mammography in 6 months. She returned 9 months after the initial biopsy. Mammographic imaging demonstrated a spiculated high density mass measuring 2.5 cm in the upper outer quadrant of the left breast with prior biopsy clip centered within the lesion (image 5 and 6). Ultrasound demonstrated an irregular hypoechoic mass with angular margins and antiparallel orientation (image 7). Subsequent biopsy was positive for invasive ductal carcinoma Nottingham grade III, ER+/PR+/H2N-. Subsequent CT and bone scan discovered stage IV breast cancer with bone metastasis, later biopsy proven. Given the patient’s medical status with metastatic neuroendocrine tumor and being a poor anesthesia candidate, the patient only received chemotherapy and endocrine therapy. Papillary lesions have a wide range of pathological possibilities with the consensus treatment being surgical excision due to the 3.1% rate of upgrade to invasive carcinoma at surgical excision. There is also a belief that core needle biopsy may provide inadequate sampling leading to a false negative diagnosis. This leads to a large number of benign lumpectomies. Many studies propose further characterization and decision-making based on the pathology of the lesions, with versus without atypia and how it was diagnosed, whether incidentally, by findings on mammography, or on biopsy of microcalcifications. This case is unique in that we have proven sclerosing papilloma that is not resected secondary to concurrent health issues; later becoming invasive ducatal carcinoma. Often papillomas are resected, limiting the followup for such lesions and their risk for malignant degeneration.