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intraductal papillary neoplasms of the breast form a wide spectrum of pathological changes , with benign intraductal papilloma on one end of the spectrum and papillary carcinoma at the other end .
intracystic papillary carcinoma ( ipc ) is a variant of papillary carcinoma and accounts for 0.5 - 1% of breast cancers [ 2 - 4 ] .
physical examination and imaging findings are not usually sufficient to distinguish between benign tumors and this malignant intracystic lesion . the imaging technique which provides the greatest information about these tumors is ultrasonography [ 1 , 2 , 5 ] .
fine needle aspiration biopsy ( fnab ) can show a malignant lesion , but it is often inaccurate and excisional biopsy is usually necessary for definitive diagnosis [ 2 , 4 , 6 ] .
ipc was originally reported as a localized non - invasive carcinoma , but is occasionally associated with ductal carcinoma in situ ( dcis ) or invasive carcinoma around the main tumor [ 2 , 3 , 7 , 8 ] .
complete excision of the cyst which should include the intracystic tumor is the treatment of choice [ 1 , 2 ] . here , a case of ipc in a 48-year - old woman
a 50-year - old woman presented to the breast diagnostic clinic with 10 months history of an enlarging right breast mass .
the mass was painless , when the patient was presented for physical examination . on clinical examination
, she had a firm , well - circumscribed mass in the central part of the right breast at 2 o'clock , 2.03.0 cm .
the mass was mobile and there was no evidence of nipple retraction , abnormal nipple discharge or skin thickening .
bilateral mammography using a dedicated free - standing unit showed an oval - shaped mass with smooth circumscribed margins in the central part of the right breast , measuring 2.0  3.0 cm , without calcification .
there were no associated findings of skin thickening , microcalcification or parenchymal distortion ( figure 1 ) .
ultrasonography using a dedicated breast ultrasound unit showed a well - circumscribed regular- shaped cystic mass with an internal hypoechoic solid component projecting into the cyst from its wall measuring 22  18 28 mm ( figure 2 ) .
fine needle aspiration biopsy cytology of the cyst revealed a bloodstained fluid that was suspicious , papanicolaou grade iii cytology .
macroscopic examination of the specimen showed a cyst 23 cm with an intracystic papillary projection ( figure 3 ) .
histopathological examination revealed a cyst with a fibrotic wall and a papillary frond with a fibrovascular core and pleomorphic epithelial cells ( figure 4 ) .
as regards the histologic findings , the breast cystic lesion corresponded to an intracystic papillary carcinoma .
the breast tissue around the margins of the cystic lesion showed no evidence of malignancy .
p53 , cyclin p1 , and c- erb- br expression was negative in our patient .
a partial mastectomy was performed for the patient and there was no evidence of dcis or invasive carcinoma on histological examination at the surgical margin .
cystic carcinoma of the breast includes a heterogeneous spectrum of tumors . these include ipc with or without invasion , ductal carcinoma with cystic degeneration , and cystic hypersecretory ductal adenocarcinoma [ 3 , 9 ] .
ipc is a rare neoplasm of the breast , so far classified as a histologic variant of dcis .
however , this is no debated since the overall clinical and radiological presentation of ipc is different from dcis and metastatic cases have been reported . according to haris
, nearly 4% to 70% of patients with ipc show dcis or invasive carcinoma around the main tumor .
ipc can be present as a pure form or associated with ductal carcinoma in situ or ductal carcinoma invasive around the tumor .
the frequency of lymph node involvement , local recurrence and distant recurrence is 0% to 11% , 3% to 70% and 0% to 4% , respectively [ 6 , 7 , 11 ] .
ipcs are reported in patients from 25 to 80 years of age , with a peak incidence in patients aged 40 to 75 years old [ 2 , 4 ] .
these tumors may have a wide spectrum of presentations varying from a focally invasive lesion to a large mass located within a cystically dilated duct .
the tumor may be small and detected only on mammography or may be large and palpable in clinical examination [ 2 , 6 , 12 ] .
it may be seen anywhere in the breast , and not only in the retroareolar region .
recently , imaging diagnostic methods and less invasive histopathological examinations have made it possible to diagnose ipc before excisional biopsy and radical surgery .
the mammographic finding of ipc is usually a well - circumscribed , high - density mass .
ipc usually presents as a smooth sharply circumscribed mass without an irregular or nodular contour , exceptwhen the tumor breaks through the wall of the cyst to invade the adjacent parenchyma [ 2 , 12 , 13 ] .
ultrasonography is the preferred imaging method to distinguish cystic from solid masses of the breast and to differentiate simple cyst from cysts with intracystic tumoral lesions [ 12 - 15 ] .
ultrasonography usually shows complex cystic and solid masses that have mild to moderate posterior acoustic shadowing or posterior acoustic enhancement [ 5 , 13 , 16 ] . in rare cases ,
color doppler ultrasound is a useful diagnostic method to distinguish between the solid portion of the cystic lesion and echogenic internal debri .
magnetic resonance ( mr ) imaging of the ipc shows mural nodules and internal septa .
mr imaging of the large ipc might show a multicystic appearance [ 13 , 14 , 18 , 19 ] .
it is well documented that mr imaging is more sensitive in detecting dcis around the ipc than other imaging methods .
in younger patients , however , the presence of high background signals sometimes make it difficult to demonstrate the dcis with mr because of the high contrast of mr [ 19 , 20 ] .
it is feasible to perform a preoperative ultrasound - guided fine needle aspiration biopsy cytology ( fnabc ) or core biopsy of the cystic and solid component for cytological and histological studies .
the aspirated fluid is often bloody , although the bloody aspirate is not pathoganomonic for ipc .
although ultrasound and aspiration biopsy are usually the first steps in the diagnosis of ipc , cytological examination also has high false - negative results due to necrotic materials , degenerative changes in the diagnostic cells and abundant obscuring blood in the cystic lesion [ 14 - 16].core needle biopsy is a useful tool for diagnosis of ipc , although it is important to keep in mind that core needle biopsy of the central solid portion of the mass can not distinguish between in - situ and invasive lesions at the periphery of ipc . on pathologic examination , most tumors have a soft or friable consistency , and have a spherical circumscribed contour .
ipc usually appears as a mass with cystic component , which might have a papillary , nodular or shaggy internal surface .
there is usually fibrotic tissue in the wall of the cyst , which limits invasion into the surrounding parenchyma .
most ipcs are characterized by well- circumscribed nodules surrounded by a fibrous capsule and large vessels might be seen within the papillary nodules or the internal septa of intracystic lesion .
hemorrhagic areas within the solid components of the tumor and blood within the cystic spaces are often recognized .
pathologically , intracystic papillary carcinoma can show four cellular patterns : cribriform , compact columnar epithelial , stratified spindle cell , or a transitional cell form resembling urothelium , or a combination of two or more of these patterns may be seen .
ipc may be associated with foci of dcis or invasive cancer , and necrosis is often a prominent feature when an associated invasive component is present [ 2 , 7 , 8 ] .
the treatment of ipc is similar to other forms of breast cancer in which lumpectomy , segmentectomy and mastectomy are reliable actions .
sentinel node biopsies or axillary dissections are often performed for evaluation of axillary lymph nodes .
it is important for the surgeon to know that approximately half of all patients with ipc are associated with dcis or invasive carcinoma to design an appropriate surgical treatment [ 2 , 7 ] .
partial mastectomy without axillary lymph node dissection is the standard treatment for patients with non - invasive ipc , while patients with invasive ipc usually undergo mastectomy with lymph node dissection .
the prognosis for ipc is usually very good with disease - specific survival rates approximately 100% . in cases with a large amount of nuclear atypia
intracystic carcinoma of the breast is a rare form of breast carcinoma . among allmalignant breast tumors 
 , this lesion has an incidence of 0.2 - 0.5% . 
 these neoplasms have certain characteristic imaging findings which help to differentiate these lesions from other focal breast abnormalities.this report is on the case of a 48-year - old woman with a palpable , painless lump in her right breast . 
 mammography demonstrated an oval well - circumscribed mass without calcification . 
 breast ultrasonography showed a cystic lesion with an intracystic solid component projecting from its posterior wall . 
 cyst aspiration revealed a hemorrhagic fluid and a suspicious cytology . 
 excisional biopsy revealed papillary carcinoma suggesting of intracystic papillary carcinoma .