Intraductal Papilloma


Article Author:
Allen Li


Article Editor:
Lindsey Kirk


Editors In Chief:
Marc Robins
William Tarver


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes


Updated:
3/6/2019 10:01:48 AM

Introduction

Intraductal papilloma is a benign tumor found within breast ducts. The abnormal proliferation of ductal epithelial cells causes the growth. A solitary intraductal papilloma is usually found centrally posterior to the nipple affecting the central duct. Multiple intraductal papillomas are located peripherally, found in any breast quadrant affecting the peripheral ducts.[1] Women of all ages can develop intraductal papillomas. Breast tumor risk factors include contraceptive use, hormone replacement therapy, lifetime estrogen exposure, and family history.[2]

Patients with symptoms often present with spontaneous bloody or clear nipple discharge. An intraductal papilloma may be occasionally palpable. However, most patients with an intraductal papilloma are asymptomatic. Small intraductal papillomas often will show no signs or symptoms. [1]

Working up an intraductal papilloma is imperative due to the possibility of harboring occult carcinoma. [3] It is classified as a high-risk precursor lesion due to its association with atypia, ductal carcinoma in situ (DCIS), and carcinoma. [1] Surgical excision with complete tumor removal is the recommended treatment. [4] 

Etiology

Intraductal papilloma is classified as a high-risk precursor lesion. This classification is due to its association with atypia, DCIS, and carcinoma. Intraductal papilloma is a benign breast tumor. [1] Breast tumor predisposing risk factors include contraceptive use, hormone replacement therapy, lifetime estrogen exposure, and family history. [2]

Epidemiology

Intraductal papilloma can occur in women of all ages but most commonly between 35-55 years of age. Its occurence in men remains low. [5]  Intraductal papilloma makes up less than 10% of benign breast lesions and less than 1% of malignant breast tumors. [6]

Histopathology

Intraductal papilloma diagnosed on core biopsy can have surgical excisional upgrade to atypical ductal hyperplasia, DCIS, and carcinoma. [1] Breast lesions diagnosed as benign papillomas on core needle biopsy had a 6.3% risk of being malignant. [7] Central papillomas are usually solitary and large in size. Peripheral papillomas, in contrast, are usually smaller and may be multiple in number. [8] Intraductal papilloma can be found in both large ducts of the subareolar region and the terminal duct lobular unit (TDLU) more peripherally. Intraductal papilloma is histologically characterized by a fibrovascular core covered with both epithelial and myoepithelial cells. A variety of changes can accompany intraductal papilloma which includes sclerosis, epithelial or myoepithelial hyperplasia, atypical proliferation, and squamous or apocrine metaplasia. [9]

History and Physical

Intraductal papillomas when solitary may present as bloody or clear nipple discharge. They are usually centrally located behind the nipple and most commonly seen in perimenopausal patients. However it may also be seen incidentally with ultrasound in younger asymptomatic patients. Intraductal papillomas when multiple typically arise from the TDLU. They are less frequently presented with nipple discharge, and more often as a palpable mass. [1]

Evaluation

Intraductal papilloma can be mammographically occult. When seen mammographically it may present as a round or oval mass with a well-circumscribed or indistinct margin. It may be associated with microcalcifications. Under ultrasound, the mass is commonly found near the nipple. The tumor will be in a dilated duct and will often show flow on color or power Doppler. On galactography, intraductal papilloma appears as an intraluminal filling defect with ductal dilation leading up to the mass with an abrupt ductal cutoff. MRI findings include an enhancing round or ovoid intraductal mass with likely either washout or plateau kinetics. [1]

Tissue sampling in addition to imaging is necessary for the diagnosis of intraductal papilloma. Radiologic findings and pathologic tissue findings need to be concordant for accurate diagnosis. [1] There are different types of biopsy methods which include core needle, vacuum assisted, and open tissue biopsy. Core needle and vacuum assisted biopsy are preferred over fine needle aspiration due to more tissue sample obtained for pathologic analysis. Fine needle aspiration uses a thinner needle creating the chance for insufficient tissue sampling. [10] Open tissue biopsy is not preferred as it is a surgical approach. It is more invasive and may lead to chronic pain and increased patient anxiety and depression. [11]

Treatment / Management

Treatment of intraductal papilloma involves surgical excision and complete removal of the tumor. This is due to the possibility of upgrading to atypical ductal hyperplasia or DCIS upon excision.[1] Surgical excision in the form of lumpectomy with complete removal of the papilloma is recommended.[6]

Differential Diagnosis

Both benign and malignant lesions can mimic intraductal papilloma. Inspissated material or debris within a dilated duct can mimic papilloma. Similarly, fat necrosis with cystic and solid areas can mimic an intracystic papillary lesion. The absence of intralesional color flow on ultrasound favors benignity. Phyllodes tumor is a benign but high risk lesion that can similarly look like papilloma. Malignant nonpapillary tumors such as medullary carcinoma can present with central necrosis or ductal extension mimicing a papillary carcinoma. Ultimately, the diagnosis of intraductal papilloma will require tissue sampling for definitive diagnosis. [1] 

Prognosis

Prognosis is overall excellent with intraductal papilloma. In one particular study, 88.9% of the intraductal papillomas were found to be without atypia while 9.2% showed atypia. The upgrade rate on pathology was low found to be 7.3%: 1.3% for invasive cancer, 2.7% for DCIS, and 3.3% for atypical ductal hyperplasia. [12] Surgical excision with complete tumor removal is the recommended treatment. [4] Local recurrence after surgical excision is low,  as low as 2.4% in one study. [13]

Complications

No significant complications are seen with intraductal papilloma. Complications when present are seen after biopsy or after surgical excision. Postprocedural complications may include bleeding, infection, pain, fat necrosis, and possible cosmetic deformity to the breast. [14]

Deterrence and Patient Education

Breast tumor risk factors both benign and maligant include contraceptive use, hormone replacement therapy, lifetime estrogen exposure, and family history. [2] Women should be encouraged to undergo annual screening mammograms. The American College of Radiology and Society of Breast Imaging recommends annual screening mammogram beginning at age 40 for women of average risk. 

Enhancing Healthcare Team Outcomes

Healthcare professionals should educate patients about breast cancer and other breast lesions. The nurse is in a prime position to teach the patient about breast exams, which may help detect any breast abnormalities early. In addition, the nurse should encourage women to undergo screening mammograms. At the same time, the patient should be encouraged to follow up with regular breast exams by the primary care provider.

Outcomes

For women who undergo excision of the intraductal papilloma, the outcomes are excellent. All women should be encouraged to undergo screening mammograms. The American College of Radiology and Society of Breast Imaging recommends annual screening mammogram beginning at age 40 for women of average risk. 


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Intraductal Papilloma - Questions

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What is the most likely diagnosis in a 64-year-old female with bloody nipple discharge from the right nipple?



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Which of the following are signs and symptoms of an intraductal papilloma?



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A 41-year-old female has unilateral bloody nipple discharge. Exam shows a 1 cm mobile mass beneath the nipple. Excisional biopsy shows minimal atypia with multiple fibrovascular cores that are lined with epithelial cell layers. The findings are all within the duct without invasion. What is the most probable diagnosis?



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What is the most common cause of spontaneous bloody nipple discharge?



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A 33-year old African-American female presents with a 2-month history of unilateral bloody nipple discharge from her left breast. She denies any other symptoms. She is on no medications. The physical exam is unremarkable. What type of lesion is suspected?



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Intraductal Papilloma - References

References

Eiada R,Chong J,Kulkarni S,Goldberg F,Muradali D, Papillary lesions of the breast: MRI, ultrasound, and mammographic appearances. AJR. American journal of roentgenology. 2012 Feb     [PubMed]
Tran HT,Mursleen A,Mirpour S,Ghanem O,Farha MJ, Papillary Breast Lesions: Association with Malignancy and Upgrade Rates on Surgical Excision. The American surgeon. 2017 Nov 1     [PubMed]
Jung SY,Kang HS,Kwon Y,Min SY,Kim EA,Ko KL,Lee S,Kim SW, Risk factors for malignancy in benign papillomas of the breast on core needle biopsy. World journal of surgery. 2010 Feb     [PubMed]
Holley SO,Appleton CM,Farria DM,Reichert VC,Warrick J,Allred DC,Monsees BS, Pathologic outcomes of nonmalignant papillary breast lesions diagnosed at imaging-guided core needle biopsy. Radiology. 2012 Nov     [PubMed]
Lewis JT,Hartmann LC,Vierkant RA,Maloney SD,Shane Pankratz V,Allers TM,Frost MH,Visscher DW, An analysis of breast cancer risk in women with single, multiple, and atypical papilloma. The American journal of surgical pathology. 2006 Jun     [PubMed]
Poehls UG,Hack CC,Wunderle M,Renner SP,Lux MP,Beckmann MW,Fasching PA,Nabieva N, Awareness of breast cancer incidence and risk factors among healthy women in Germany: an update after 10 years. European journal of cancer prevention : the official journal of the European Cancer Prevention Organisation (ECP). 2019 Jan 23;     [PubMed]
Bennett IC,Saboo A, The Evolving Role of Vacuum Assisted Biopsy of the Breast: A Progression from Fine-Needle Aspiration Biopsy. World journal of surgery. 2019 Jan 7;     [PubMed]
Spivey TL,Gutowski ED,Zinboonyahgoon N,King TA,Dominici L,Edwards RR,Golshan M,Schreiber KL, Chronic Pain After Breast Surgery: A Prospective, Observational Study. Annals of surgical oncology. 2018 Oct;     [PubMed]
Karadeniz E,Arslan S,Akcay MN,Subaşi ID,Demirci E, Papillary Lesions of Breast. Chirurgia (Bucharest, Romania : 1990). 2016 May-Jun;     [PubMed]
    [PubMed]
Han SH,Kim M,Chung YR,Yun B,Jang M,Kim SM,Kang E,Kim EK,Park SY, Benign Intraductal Papilloma without Atypia on Core Needle Biopsy Has a Low Rate of Upgrading to Malignancy after Excision. Journal of breast cancer. 2018 Mar     [PubMed]
Kiran S,Jeong YJ,Nelson ME,Ring A,Johnson MB,Sheth PA,Ma Y,Sener SF,Lang JE, Are we overtreating intraductal papillomas? The Journal of surgical research. 2018 Nov     [PubMed]
Wang WY,Wang X,Gao JD,Wang J,Liu JQ,Wang X,Zhao DB, [Analysis of the clinicopathological characteristics and prognosis in 674 cases of breast intraductal papillary tumor]. Zhonghua zhong liu za zhi [Chinese journal of oncology]. 2017 Jun 23     [PubMed]
van Turnhout AA,Fuchs S,Lisabeth-Broné K,Vriens-Nieuwenhuis EJC,van der Sluis WB, Surgical Outcome and Cosmetic Results of Autologous Fat Grafting After Breast Conserving Surgery and Radiotherapy for Breast Cancer: A Retrospective Cohort Study of 222 Fat Grafting Sessions in 109 Patients. Aesthetic plastic surgery. 2017 Dec     [PubMed]

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