Intraductal Papilloma/DCIS

Epidemiology

  • Commonly 35-60 year old women
  • DCIS comprises 15-20% of all breast malignancies (with the introduction of the screening programme)

Pathology

  • Derived from the subareolar ducts
    • Unicentric i.e. only derived from one terminal ductolobular unit
  • Papillary fronds containing a fibrovascular core
  • covered by the two layers of cells- epithelium and myoepithelium
    • these can show proliferation
  • Proliferation may be
    • Absent (Benign intraductal papilloma)
    • Usual type hyperplasia (also benign)
    • Atypical ductal hyperplasia (Atypical papilloma)
    • Ductal Carcinoma in situ (Encysted papillary carcinoma)
      • This is a true precursor of malignant disease
        • 2x relative risk with usual type hyperplasia
        • 4x RR with atypical type hyperplasia
        • 10x RR (25% over 10 years) with DCIS- if not completely resected, 75% can progress
  • NB All neoplastic cells are confined within the basement membrane
    • May involve the lobules (cancerisation) or the nipple (Paget’s)
  • Classification is based on:
    • Cytological grade
    • Histological type
    • Presence of necrosis

Microinvasive carcinoma (not technically DCIS)

  • Rare- DCIS with <1mm invasion of the basement membrane
  • Treat as high grade DCIS

Paget’s disease

  • High grade DCIS extending along the ducts to reach the nipple (NB still in situ)
  • Usually causes nipple changes
    • dryness/flaking
    • discharge- oozing bloody/serous discharge
  • Pain may or may not be present

Clinical Presentation

  • Nipple discharge
    • Serous +/- blood
  • The majority are asymptomatic and are found at screening
    • Usually small (<2cm) nodule with some calcification or haemorrhage

Diagnosis

  • Triple assessment

Treatment

  • Depends largely on the pathology involved:
    • Benign lesions are often removed to be on the safe side as there is often difficulty in distinguishing them from more atypical lesions.
    • Atypical papillomatosis/DCIS must be excised (+2cm border) and is usually further treated with a bout of radiotherapy.  Hormone treatment e.g. tamoxifen, may be of use also if the cancer is oestrogen receptor positive.

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