failed to poste the photos and try again.

Your diagnosis

Differential diagnoses

What immunostains will be useful?

 使用ER帮助诊断乳头状病变，来自陈国璋教授的讲课资料。

Papilloma or Papillary DCIS / intracystic papillary carcinoma?
--One of the most difficult diagnostic problems
--Solving problem by immunohistochemistry:
    Abundant myoepithelial cells in the cores of papillae in papilloma, but not in the papillae of papillary carcinoma [Note: Myoepithelium is absent around the cyst in intracystic papillary carcinoma]
    CK5 (preserved in papilloma)
    ER (uniform strong staining favors carcinoma)

 To Dr. Abin:

Agree that myoepithelial markers are useful for the differential dx of papillary lesions.

I am not sure the ER, as I mentioned that I have no experience about ER in papillary lesion. My impression is that epithelial cells in most papilloma cases are also positive for ER. Could you let me know the original study (not text book) papers or study results. Hope to learn the differences in details about the positive rate of ER ,and extention and intensity of the stains among papilloma, atypical papilloma, and papillary DCIS in these studies.

Thanks

cqz

 WHO: Introductal papillary neoplasms: it mentioned the following 5 types

Central papilloma

Peripheral papilloma

Atypical papilloma

Intraductal papillary carcinoma

Intracystic papillary carcinoma

I copied the original sentence from WHO book about the definition of intraductal papillary carcinoma:

Intraductal papillary carcinoma's diagnosis requires that 90% ir more of the papillary processes are totally devoid of a myoepithelial cell layer regardless of presence or absence of notavle epithelial proliferation, and/or that any of the recognized patterns of low grade DCIS occupies 90% or more of the lesion.

So the lesions between atypical papilloma and intraductal papillary carcinoma will be called as DCIS involving or arising from papilloma, even though it is not mentioned in WHO book. But it has be used for a long time in the literature and in the clinical diagnosis.

So DCIS involving papilloma and intraductal papillary ca are the same disease process with the different degree. The botoom line  is that they are kinds of of DCIS with the same clinical managment.

Hope it can help,

 To Abin and Lili:

ER for differential dx of papillary lesion.

I asked one of our previous GYN/Breast fellow who did a lot of research in papillary lesions and works as a breast pathologist in another institute now. I copied her response below.

回赵老师：请原谅我不求甚解，我是学习了陈国璋教授的讲课资料后，在实际工作中验证并接受了这个观点。不仅是乳头状病变，ER对UDH和低级别DCIS的鉴别也有帮助。我只有陈国璋教授的资料，其他的数据和文献就无法提供啦。

sorry again

Usual ductal hyperplasia: Key features
“Mixed and disorderly”
Interspersed spaces vary in size and shape; spaces tend to be peripherally located
Cells often have indistinct cell borders, and are unevenly spaced
Nuclei are often oval, with grooves and pseudoinclusions
Nuclei show streaming
May have some admixed apocrine cells
Cytokeratin profile: mixed (CK5+, CAM5.2+)
ER: heterogeneous
Low-grade DCIS: Key features
“Uniform”
Interspersed spaces, if present, are round and rigid
Cells often have distinct cell borders, and are evenly spaced
Nuclei are often round, with hyperchromasia
Pagetoid spread (lifting up residual luminal cells), if present, favors diagnosis of DCIS
Cytokeratin profile: one type of cells -- glandular cells (CK5-, CAM5.2+)
ER: usually uniform strong

 Papilloma-atypical papilloma-papillary ca

UDH-ADH-DCIS

No solid research data support that IHC stains are usful for the differential dx. Several years ago there were some studies indicating the IHC including high molecular cytokeratin may be useful. In term of my knowledge few people use IHC for differential dx of these lesions in the US now. Of cause you can continue to use them if you feel they have some usage in your clinical practice. You can summary your data for a publication if the results are good.

Thanks

I put another breast lesion here.

50 year women with breast mass  

 回赵老师：我也是在临床与实验病理学杂志的一篇综述上，看到有关ER在DCIS和良性增生病变鉴别中的作用。在实际工作中我也使用，当然还有CK高一起染色。ER的确在我遇到的DCIS和囊内乳头状癌中弥漫一致阳，在乳头状瘤中是间隔阳性。

刚公布的病例，由于位于临近乳头部（不是就在乳头处吧？），低倍给我的感觉要考虑乳头部腺瘤，但高倍似乎都是高柱状上皮，囊内乳头状癌要考虑，建议IHC做肌上皮标志，包括CK高。

期待最后诊断。

谢谢赵老师指教。

For above case (three photos):

This is myoepithelial marker p63 stain photos.

What is your diagnosis or diferential diagnosis?

abin译：

这是本例（33、34楼的三张图）的p63免疫染色。您的诊断和鉴别诊断？

 第33、34和36楼：

组织学和IHC符合囊内乳头状癌。这些图未显示浸润。

同意楼上，要排除皮肤附件来源的癌。

谢谢。

 哈哈！大家讨论的太精彩了！受益匪浅！谢谢！该例也加精了。

欢迎继续讨论。