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Diagnosis Please |
1 Department of Radiology, University of North Carolina Chapel Hill, 503 Old Infirmary Bldg, CB# 7510, Chapel Hill, NC 27599-7510.
Index terms: Diagnosis please • Breast neoplasms, 05.312 • Papilloma, 05.11, 05.1298, 05.12984, 05.312
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HISTORY |
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IMAGING FINDINGS |
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DISCUSSION |
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Solitary intraductal papillomas may be pathologically related to proliferative fibrocystic epithelial hyperplasia. They are 2–3 mm and appear as broad-based or pedunculated polypoid epithelial lesions that may obstruct and distend the involved duct. They may cause cysts by obstructing the duct. They consist of a fibrovascular core covered by a double layer of breast epithelial cells, with some apocrine changes (3). They arise within 1 cm from the nipple in 90% of cases (2). According to a consensus committee of the College of American Pathologists (4), women with this lesion have a 1.5- to 2-times relative risk of developing invasive breast carcinoma in their lifetimes.
Solitary intraductal papillomas should be distinguished pathologically and clinically from papillomatosis, a condition in which multiple papillomas exist in more than one duct system and which is considered a premalignant condition. Women with multiple papillomas have a 7.4-times lifetime relative risk of developing breast carcinoma. Papillomatosis should be considered similar to lobular carcinoma in situ in the prognostic information that it provides to the patient and her physician (5). Solitary papillomas are believed to arise from the terminal portions of the ducts, while multiple papillomas, conversely, arise from the terminal ductal lobular units, which are also the most frequent sites of origin for ductal carcinoma (6).
Mammograms of women with a solitary papilloma are most frequently normal. This is probably because the lesions are small when the patients present with a nipple discharge, and they lie completely within a duct without extension into the surrounding breast. When imaging findings are present, they include solitary or multiple dilated ducts, a circumscribed benign-appearing mass, or a suspicious cluster of calcifications (7,8).
Galactography may be useful in delineating the causative lesion in a patient with a nipple discharge and a normal mammogram. This test usually reveals a filling defect or other ductal abnormality, such as ectasia, obstruction, or irregularity. These findings are nonspecific, however, in that intraductal papillary carcinomas can appear smooth, and intraductal papillomas can appear irregular (7,8).
Ultrasonography (US) of intraductal papillomas has been reported to reveal a well-defined, smooth-walled, solid, hypoechoic mass, as in this case, or a lobulated, smooth-walled, cystic lesion with some solid components (9). As with the case presented here, the dilated duct is frequently visible at US (9). The differential diagnosis for this appearance includes other solid tumors that can occur in the large ducts, specifically ductal carcinoma in situ or invasive ductal carcinoma with an in situ component. Papillary carcinomas can mimic intraductal papillomas at US. The Doppler appearance is likewise nonspecific. While papillomas demonstrate flow, any solid intraluminal mass can also do so (10).
The treatment for serous nipple discharge is duct excision. No further therapy is required for a solitary ductal papilloma, but given the increased risk of malignancy over a woman's lifetime when this lesion is diagnosed, compliance with screening recommendations for such patients is strongly advisable (2,7).
The history and imaging findings in this patient are most characteristic of a solitary intraductal papilloma. The presence of a Doppler signal excludes intraductal debris as the cause of the mass. While ductal carcinoma in situ is considerably less likely in this patient, surgical exploration of the duct is indicated to establish the definitive diagnosis.
Our congratulations to the 71 individuals who submitted the most likely diagnosis (solitary intraductal papilloma) for Diagnosis Please, Case 8. Their names and locations, as submitted, are as follows:
Gholamali Afshang, MD, Tinley Park, Ill
Myeong Im Ahn, MD, Suwon, Korea
David R. Anderson, MD, Richmond, Va
Roger L. Antonelli, MD, Dayton, Ohio
Lionel Arrivé, MD, Paris, France
A. Rhett Austin, MD, Kingsport, Tenn
Leon Axel, PhD, MD, Philadelphia, Pa
Edward L. Baker, MD, San Francisco, Calif
Kenneth Baliga, MD, Rockford, Ill
Zubin N. Balsara, MD, Fort Smith, Ark
Cynthia Barone, DO, Colts Neck, NJ
Dr Rita Blom, Errington, British Columbia, Canada
Barbara Boyle-Preston, MD, Moraga, Calif
Eric L. Bressler, MD, Minnetonka, Minn
Steve Burbidge, MD, St Louis Park, Minn
Brian J. Burke, MD, Manhasset, NY
Can Cevikol, Antalya, Turkey
Hearns W. Charles, MD, New York, NY
Royce A. Chrys, MD, Oakland, Calif
Wiluck Chu-Ongsakul, MD, Bangkok, Thailand
Ercument Ciftci, MD, Houston, Tex
Martin I. Cohen, MD, Westlake Village, Calif
Paul H. Ellenbogen, MD, Dallas, Tex
Seyed A. Emamian, MD, PhD, Washington, DC
Andrew J. Fisher, MD, St Louis, Mo
Jonathan Foss, MD, St Louis, Mo
Arnold C. Friedman, MD, New York, NY
Douglas Gardner, MD, Windsor, Ontario, Canada
Daniel S. Gordon, MD, Sanford, NC
Ferris M. Hall, MD, Boston, Mass
David C. Harrison, MD, Cambridge, Mass
Rufus W. Head, MD, N Bridgton, Me
Helen T. Ho, MD, Chicago, Ill
Carlos Holguera Blazquez, MD, Madrid, Spain
Marc J. Homer, MD, Boston, Mass
Kamil Karaali, Antalya, Turkey
Okkes Ibrahim Karahan, MD, San Antonio, Tex
Douglas S. Katz, MD, Mineola, NY
Arlene M. Klink, MD, Scotch Plains, NJ
Knaji Kojima, MD, Marugame, Japan
Dr Mani, NBS, Chandigarh, India
Paulo Marcio da Silveira Brunato, Florianopolis, Brazil
Hidetoshi Miyake, MD, Oita, Japan
Sergio J. Moguillansky, MD, Rio Negro, Argentina
Vung Duy Nguyen, San Antonio, Tex
Kiyoshi Ohshiro, Okinawa, Japan
Ulisses C. Parente, MD, Minas Gerais, Brazil
Steven Perlmutter, MD, Mineola, NY
John M. Plotke, MD, Naperville, Ill
Shawn P. Quillin, MD, Charlotte, NC
M. R. Ramakrishnan, MD, Big Stone Gap, Va
Enrique Remartinez Escobar, MD, Melilla, Spain
Derek J. Roebuck, FRACR, Hong Kong, China
Joel Rubenstein, MD Steven M. Schultz, MD, Ft Worth, Tex
Joel Schwartz, MD, Irvington, NY
A. Utku Senol, Antalya, Turkey
Matt Shapiro, MD, Boxborough, Mass
Michael S. Stecker, MD, Iowa City, Iowa
Marius Stellmann, MD, Rotenburg, Germany
Jacob Szejnfeld, Sao Paulo, Brazil
J. Takasugi, Mercer Island, Wash
Antonio Talegón Meléndez, Seville, Spain
Parash Singh Talwar, MD, Elmhurst, Ill
Douglas L. Teich, MD, Hermosa Beach, Calif
Carlos Triana Rodriguez, Santafe de Bogata, Colombia
Edwin J. R. van Beek, MD, PhD, Amsterdam, The Netherlands
Paulo Vieira da Rosa, MD, Florianopolis, Brazil
Leonard A. Wald, MD, Norwalk, Conn
Joseph T. Wroblicka, MD, Iowa City, Iowa
Masanobu Yasuda, MD, Kanagawa, Japan
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Footnotes |
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Received January 29, 1998;
revision requested March 18, 1998; revision received May 6, 1998;
accepted July 7, 1998.
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References |
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