INTRADUCTAL PAPILLOMA

Primarius Milos Pocekovac MD, PhD

Sava Stajic MD, MSc

 Jasna Ilic MD

Dragan Stojanovic MD

What are intraductal papilloma?

Intraductal papilloma is a benign lesion of incidence around 2-3%.
They are divided into two categories: solitary (central) papilloma and  multiple (peripheral) papilloma. They can be related to ductal hyperplasia, atypical ductal hyperplasia or lobular hyperplasia.

Clinical finding of intraductal papilloma is a blood content on the nipple or a palpable mas right behind it in solitary papilloma. It is believed that the cause of bleeding is the pressure of papilloma on the firbovascular stroma which leads to necrosis and consequently bleeding.

Solitary papilloma

Solitary or central intraductal papillomas are tumors of the main lactiferous ducts, close to the nipple, that can block the canals leading to their widening. Most often they appear in women aged between 30 to 50 years. These lesions are usually smaller than 1cm in diameter, mostly 3 to 4mm. Occasionally they can be bigger from 4 to 5cm.  

Histologically, these tumors are made from multiple granulated papillas, each with a central fibrovascular stroma covered in multiple layers of epithelial calls. Between the epithelial cells and connective tissue often there is a myoepithelial cell layer.

Multiple papilloma

Multiple papillomas are found in the periphery of the breast in younger women. They are the most common cause of bloody content coming from the nipple in women aged from 20 to 40 years of age. They are usually not detectable on mammogram due to their size. They can be discovered upon ultrasound. Galactography is the most precise test, that can detect even small and non-palpable lesions, but it is invasive

Core biopsy and histological confirmation is necessary. Excision of the breast canal is the treatment of choice.

Relapse of papilloma is possible and connected to the presence of proliferative lesions of breast (including ductal hyperplasia, atypical ductal hyperplasta or lobular neoplasia) in the surrounding breast tissue. Atypia in the epithelial cells even in the in situ intraductal carcinoma (DCIS), has no prognostic significance on the outcome, when it is limited to solitary or central papilloma. Because of this if the atypia is found on excision biopsy, the surrounding tissue should be closely monitored and followed up.  

According to the consensus of American pathologists, women with intaductal papilloma have a relative risk for breast cancer 1,5 to 2 times larger for developing invasive carcinoma during their life span.

Presence of atypical ductal hyperplasia in the papilloma or the surrounding tissue is connected to the risk of relapse or even invasive carcinoma.

Risk of breast cancer is very high (7 times higher) in women with multiple or proliferative papilloma with atypia. This is also in women with positive family history.

Treatment of intraductal papilloma is a surgical excision, that includes the canal in which it is found, to avoid a large number of diagnostic procedures.

P – papilloma

Z – cavity

S – peduncle of the polyp

L – lumen of the cavity (duct) in which the polyp was situated

 D – surrounding tissue

AM – apocrine metaplasia

In patients that had a papilloma that was verified by ultrasound, mammogram and magnetic resonance imaging. She previously had an indented nipple. After surgical exploration no papilloma was found but the top of the nipple was presenting as the papilloma. A surgical reconstruction of the nipple was performed. After the control ultrasound the finding was neat.

 

Papilloma on the nipple can be solved with a ligature, after which in the following days the ligated tissue falls out together with the papilloma or one can perform an excision with local anesthesia.

Case report

Ultrasound imaging of intraductal papilloma. Female patient 41 years old, negative family history. The change is defined as a solid, hypoechogenic appearance, localized behind the areola, intraductally. Around the papilloma there is an anechogenic content in the lumen of the duct. Core biopsy was performed with histological confirmation of papilloma with no atypia.

Images a, b, c ,d. U. Patient 38 years old, negative family history. PApiloma in DD ultrasound is described as a hypoechogenic , clearly demarcated solid change, that for the most part fills the lumen of the duct, surrounded by anechogenic content in the duct itself. Some sections are presenting the presence of peri and intra papillary vascularization. Mammogram does not show the suspitous mass (BI RADS DD 2). Core biopsy as performed, histological confirmation with atypia, atypical ductal hyperplasia. Excision was the choice of treatment.

images a and b. Ultrasound presentation of papilloma in MicorPure technique can help with visualization, and elastography can be performed to test the resistance of the papilloma, which can be the determining factor in surgical treatment (elevation of resistance over 2 SR)

Image a,b,c. Papilloma present at other parts of the breast can be discovered by ultrasound (papilloma in DUK LD) Patient 51 years old with positive family history. Papilloma was tested in MicorPure technique with presentation of calcifications, elevated resistance, over 2 SR. Mammogram was performed and a suspicious lesion in the DUK LD region was described. (BI RADS LD 4). Core biopsy was performed, histology verified a papilloma with atypical lobular hyperplasia (ALH). Surgical removal was indicated, the finding was confirmed, without sings of malignant cells.

а)

Image a,b,c,d. Ultrasound of 65 year old female, with negative family history.  Papilloma changes were noticed behind the nipple. The lesion showed increased vascularization and more elastographic resistance (4,5 SR). Mammogram was performed and the low intensity shadow behind the areola. Surgical excision was performed and histology confirmed DCIS. 

Pictures A, B and C. 60-year-old female, ultrasound, negative family history, multiple changes of papilloma type behind the areola. On mammogram there is a focal asymmetry behind the areola, without suspicious shadows (BI RADS DD 2) Surgical excision was performed and HP analysis showed papilloma without cell atypia.

 

IMPORTANT!

PLEASE HAVE THINGS YOU ARE IN THE VID!

This site is informative-educational. Our goal is to provide helpful information on symptoms and treatment of the disease to people with breast disorders. If you feel you have any of these symptoms, please contact your doctor. DO NOT use these therapies yourself without prior consultation with a doctor!

REFERENCES

1. Cilotti A, Bagnolesi P, Napoli V, Lencioni R, Bartolozzi C (November 1991). “[Solitary intraductal papilloma of the breast. An echographic study of 12 cases]”. La Radiologia Medica (in Italian). 82 (5): 617–20.

2. Cyr AE, Novack D, Trinkaus K, Margenthaler JA, Gillanders WE, Eberlein TJ, et al. Are we overtreating papillomas diagnosed on core needle biopsy? Ann Surg Oncol. 2011;18:946–951.

3. Ahmadiyeh N, Stoleru MA, Raza S, Lester SC, Golshan M (August 2009). “Management of intraductal papillomas of the breast: an analysis of 129 cases and their outcome”. Annals of Surgical Oncology. 16 (8): 2264–9

4. MacGrogan G, Tavassoli FA. Central atypical papillomas of the breast: a clinicopathological study of 119 cases. Virchows Arch 2003;443:609– 617

5. Raju U, Vertes D (1996) Breast papillomas with atypical ductal hyperplasia: a clinicopathologic study. Hum Pathol 27:1231–1238

6. Page DL, Salhany KE, Jensen RA, Dupont WD (1996)Subsequent breast carcinoma risk after biopsy with atypia ina breast papilloma. Cancer 78:258–266

7. Song-Hee Han, Milim Kim, Yul Ri Chung, Bo La Yun, Mijung Jang, Sun Mi Kim,Eunyoung Kang, Eun-Kyu Kim, and So Yeon Park– Benign Intraductal Papilloma without Atypia on Core Needle Biopsy Has a Low Rate of Upgrading to Malignancy after Excision- J Breast Cancer. 2018 Mar; 21(1): 80–86. Published online 2018 Mar 23.

8.  Tarallo, V; Canepari, E; Bortolotto, C (June 2012). “Intraductal papilloma of the breast: A case report”. Journal of Ultrasound. 15 (2): 99–101.

9. Lewis JT, Hartmann LC, Vierkant RA, et al. An analysis of breast cancer risk in women with single, multiple, and atypical papilloma. Am J Surg Pathol 2006;30(6):665–672.

10. Schacht DV, Yamaguchi K, Lai J, Kulkarni K, Sennett CA, Abe H. Importance of a personal history of breast cancer as a risk factor for the development of subsequent breast cancer: results from screening breast MRI. AJR Am J Roentgenol. 2014;202:289–292.

11. Niinikoski L, Hukkinen K, Leidenius MHK, Ståhls A, Meretoja TJ – Breast Lesion Excision System in the diagnosis and treatment of intraductal papillomas – A feasibility study- Eur J Surg Oncol. 2018 Jan;44(1):59-66.

breast surgeon
Prim. Milos Pocekovac MD, PhD

Пацијенткиње говоре

Неизмерно сам захвална Др Милошу, јер ми је скинуо највећу муку коју сам до тад имала у животу.
Милица...
име познато администратору сајта

This site is informative-educational. Our goal is to provide helpful information on symptoms and treatment of the disease to people with breast disorders.

If you feel you have any of these symptoms, please contact your doctor. DO NOT use these therapies yourself without prior consultation with a doctor!