First published online April 26, 2006
British Journal of Radiology (2006) 79, 843-849
© 2006 British Institute of Radiology
doi: 10.1259/bjr/69395941
Ultrasound spectrum in intraductal papillary neoplasms of breast
S Ganesan, MD,
G Karthik, DNB,
M Joshi, MD, DNB and
V Damodaran, MS, FRCS
Department of Radiology and Imaging, G.K.N.M Hospital and Research Centre, PN Palayam, Coimbatore – 641037, India
Correspondence: Dr Karthik Ganesan, Department of CT and MRI, Jaslok Hospital and Research Centre, 15, Dr G Deshmukh Marg, Mumbai – 400026, Maharashtra, India.
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Abstract
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Intraductal papillary neoplasms (IPNs) of breast form a wide spectrum of pathological changes with benign intraductal papilloma occupying one end of the spectrum and papillary carcinoma at the other end. Intraductal papillomas are known to occur anywhere within the ductal system and are broadly classified into central and peripheral types. Intraductal papillary carcinoma is an uncommon ductal malignancy forming papillary structures, and these lesions characteristically lack the myoepithelial layer present in benign papillary neoplasms. Three basic patterns of IPNs are recognized on ultrasound – intraductal mass with or without ductal dilatation, intracystic mass and a predominantly solid pattern with the intraductal mass totally filling the duct. Benign papillomas are known to exhibit calcifications which tend to be extremely dense and coarse. IPNs are highly vascular tumours and have a propensity to bleed spontaneously. A distinct vascular pedicle is identified within the central core of IPNs, with branching vessels arborising within the mass. In an older age group, presence of a large solid component and evidence of spontaneous intracystic bleed are more suggestive of papillary carcinomas than benign papillomas. We have serially studied 42 cases of intraductal papillary neoplasms with sonomammography and mammography from 2001 to 2004.
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Introduction
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Intraductal papillomas are common neoplasms with a relative incidence of 2–3% [1]. In elderly patients, intraductal papillomas are often asymptomatic and are seen commonly as an incidental finding in biopsy specimens [2]. Even though intraductal papillomas are primarily benign, these lesions can pose problems in view of their similarity to intraductal papillary carcinoma clinically, on ultrasound and histologically [3]. Intraductal papillary carcinoma (IPC) is a rare ductal carcinoma forming papillary structures, with reported incidence of 1–4% of breast carcinomas [4]. These neoplasms have certain characteristic imaging features which help to differentiate these lesions from other focal breast abnormalities.
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Pathological observations
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Papillomas are essentially benign proliferations of ductal epithelium. They may occur at any age between 30 years and 77 years [4], but are commonly seen between 30 years and 55 years [3]. They are known to occur anywhere within the ductal system and are broadly classified into central and peripheral types. Central types are usually solitary, while the peripherally located papillomas tend to be multiple within the terminal duct lobular unit. Lesions are often confined to a single breast, while bilateral lesions are reported in up to 14% of cases [4].
Central papillomas are subareolar in location within a major duct. On macroscopic examination, a papilloma appears as a round to oval, small mass usually measuring a few millimetres in size within a dilated duct. Larger lesions dilate the duct more and extend along the long axis of the duct presenting a spheroidal shape. With ductal obstruction, the dilated duct with a papillary lesion may resemble a cyst with an intracystic solid component, this variant being termed as an intracystic papilloma. Histologically, papillomas show hyperplastic proliferation of ductal epithelium, having an arborescent growth pattern with branching fibromuscular core of myoepithelial and epithelial cells. Lesions may be pedunculated or broad based [3, 4].
Multiple peripheral papillomas are a rare entity in which the lesions are located in the peripheral duct system within the terminal ductal lobular unit. Several adjacent ducts are involved with segmental dilatation of the ducts, often resulting in a peripherally located mass. The incidence of nipple discharge is lower in these patients compared with the papillomas in larger ducts. There is an increased risk of carcinoma in peripheral papillomas which is directly related to the degree of cellular atypia. Peripheral papillomas are often associated with coexisting malignancy with a reported incidence of 10–30% [3–6].
Intraductal papillary carcinoma (IPC) is an uncommon ductal malignancy forming papillary structures. Histologically papillary carcinoma shows multilayered papillary projections with microscopic frond formations extending from the vascularized stalks. These lesions characteristically lack the myoepithelial layer present in benign lesions. IPCs are reported in patients from 25 years to 89 years of age with a peak incidence between 40 years and 75 years [4]. IPCs have a wide spectrum of presentations varying from a focally invasive lesion with microscopic frond formation to a large mass located within a cystically dilated duct. Multiple lesions tend to occur within the same duct with papillary configurations.
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Ultrasound features
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Ultrasound features of intraductal papillary neoplasms (IPN) primarily depend on the gross macroscopic appearance of the lesion. Three basic patterns of IPNs are recognized on ultrasound – intraductal mass with or without ductal dilatation, intracystic mass and a predominantly solid pattern with the intraductal mass totally filling the duct [3, 7]. If the tumour is small, a focally dilated duct may be the only observation. A solitary dilated duct, even in the absence of a demonstrable intraductal mass, is highly suggestive of an intraductal papilloma, especially, if the patient is presenting with a serosanguinous nipple discharge [3]. Dilated duct with an intraductal mass or a cyst with an intracystic solid mass is the hallmark of intraductal papillomas (Figure 1
). The ductal component may vary in size from a minimally dilated duct to a large cystically dilated, obstructed duct. Similarly the intraductal soft tissue component may range in size from a very small lesion which may be impossible to image to a large mass completely filling the dilated duct or the cyst obscuring the ductal or cystic component simulating other solid masses (Figure 2) [3, 8]. Han et al analysed the relationship between the mass and the duct on ultrasound and classified the masses into four categories: type I – intraluminal mass; type II – extraductal mass; type III – purely solid mass; type IV – mixed variety [9]. Benign papillomas are known to exhibit calcifications. These calcifications tend to be dense and coarse (Figures 3–5).
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Figure 1. A focal mass arising from the ductal wall with relatively narrow base of attachment is present. Note the branching pattern and peripheral fronding typical of intraductal papilloma/papillary carcinoma (D-Duct).
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Figure 2. Papillary carcinoma. A moderately large mass is seen to almost totally fill the entire dilated duct. Relatively hypoechoic debris is seen to fill the peripheral duct adjacent to the mass. A short segment of proximal duct is noted at 10–11 o'clock position.
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Figure 3. Benign intraductal papilloma with calcification. Focal dilatation of a solitary duct with intraluminal echogenic debris. Note small focal mass with dense, coarse calcifications in the proximal duct, with ductal obstruction(small arrows).
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Figure 4. Benign calcified intraductal papilloma with adjacent oil cyst.(a) Small focal mass with coarse, irregular and dense calcifications (small arrows) adjacent to a cystic mass (C). Echogenic floating debris within the cyst with floating fat-fluid level (long arrows). (b) Colour flow studies – focal increase in flow within the mass.
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Figure 5. Calcified giant intraductal papilloma.(a) Ultrasound and (b) mammography demonstrate a large, bilobed, densely calcified mass with distal shadowing (arrows).
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Small IPNs are often mammographically negative. A minimal to moderate duct dilatation may be observed on mammography as a progressively tapering band-like density extending from the nipple-subareolar region towards the breast parenchyma for a variable distance (Figure 6). Larger lesions in a dilated duct may resemble any other focal well-circumscribed dense mass on mammography (Figure 7). Calcified IPNs exhibit dense, central, peripheral or combined form of coarse calcification similar to those seen in cases of calcified fibroadenomas (Figure 8). Boonjuwetat et al described the mammographic appearances of papillary neoplasms in a series of 15 cases. They reported that most lesions presented as solitary dense masses with no evidence of calcification in any of these lesions. A few lesions were mammographically negative either due to the size of the lesion or due to the dense parenchymal pattern [10].
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Figure 6. Benign intraductal papilloma.(a) Mammography – oblique band like density along inferolateral quadrant of the left breast. (b) Ultrasound – focal dilatation of a solitary duct with an intraluminal mass arising from the ductal wall. (c) Doppler studies – distinct vascular pedicle within the central core with branching vessels arborising within the mass.
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Figure 7. (a) Mammography – focal well circumscribed dense mass along the retroareolar region of the left breast. (b) Ultrasound – large cystic mass with echogenic debris totally filling the cyst.
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Figure 8. Mammography. Well circumscribed peripherally calcified lesion within a progressively tapering band-like density extending from the nipple-subareolar region towards the breast parenchyma.
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IPNs are highly vascular and have a propensity to bleed spontaneously. Spontaneous haemorrhage into a dilated duct characteristically produces a fluid–debris level due to the denser cellular components settling down to the dependant position. The supernatant serum is anechoic while the dependant cellular debris is echogenic. Presence of fluid–debris level in a cyst, representing spontaneous bleed into the cyst, is virtually suggestive of a mural proliferative lesion (Figures 9 and 10) [11]. IPNs have a characteristic flow pattern on colour flow studies. A distinct vascular pedicle is identified in IPNs within the central core with branching vessels arborising within the mass. Colour flow studies are sensitive in identifying even very small IPNs, in view of its characteristic vascularity (Figure 11). Intraductal papillomas and papillary carcinomas have considerable overlap in imaging features and it may not be possible to differentiate them on ultrasound. In an older age group presence of a larger solid component and evidence of spontaneous intracystic bleed are more suggestive of papillary carcinomas than benign papillomas (Figure 12) [9].
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Figure 9. Intracystic papillary carcinoma. A moderately large cystic mass in the central breast region with large intracystic solid component is present. The mass is attached to the wall by a broad base and shows irregular branching pattern with peripheral fronding.(D – Cystically dilated duct).
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Figure 10. Colour flow studies in intraductal papillary neoplasms(IPNs). Distinct vascular pedicle within the central core with branching vessels arborising within the mass.
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Figure 11. Benign intraductal papilloma in a cystically dilated duct. Cystically dilated duct with a small focal mass attached to the ductal wall with a narrow base between 10 and 11 o'clock position. A short segment of dilated proximal duct is identified with dependant echogenic debris with layering effect forming a fluid-debris level.
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The differential diagnosis of IPNs depends upon the basic imaging appearances. Presence of sectoral dilatation of ducts with no demonstrable intraductal mass has to be differentiated from mammary duct ectasia, which is a chronic inflammatory condition. Bleeding into a duct, inspissated material in mammary duct ectasia and ductal carcinoma in situ may produce dilated ducts with intraductal filling defects resembling IPNs. Mammary ductectasia is often bilateral and tends to affect multiple ducts. In intraductal carcinoma, ductal dilatation is unilateral, sectoral and irregular with ductal wall thickening. Colour flow studies reveal lack of flow in inspissated intraductal debris. Increased or variable periductal flow may be present in intraductal carcinomas while the IPNs reveal the characteristic arborescent vascularity. A cystically dilated duct may resemble a simple cyst when the intracystic component is very small. This has to be differentiated from other cystic masses like a simple cyst, complex cyst, haematoma, abscess and fat necrosis. A dilated duct with an intraductal solid component consisting of a central core and peripheral fronds, with characteristic flow on colour flow studies, is virtually diagnostic of IPNs. When the mass is large enough to fill the dilated duct or the cyst, it may not be possible to delineate the peripheral ductal or cystic component. These lesions have to be differentiated from other solid masses [3].
Fine needle aspiration cytology (FNAC) or core biopsy is required in all cases to arrive at a definitive diagnosis even though the imaging findings are suggestive of IPNs. FNAC from non-palpable small masses and from the solid component in large cystic lesions can be performed under ultrasound control. At our institution, small papillary lesions within a minimally dilated duct, observed as incidental findings in an asymptomatic patient on sonomammography are not subjected to FNAC or core biopsy. These patients are advised serial follow up with sonomammography. Larger lesions, lesions with atypical characteristics and lesions in symptomatic patients are subjected to FNAC and core biopsy. The criteria for calling a core B3 are the following: papillary lesion, atypical intraductal epithelial proliferations, radial scar, lobular neoplasia and fibroepithelial lesions. Lee et al reported that the B3 core group is a more heterogeneous group and has a lower rate of malignancy on further biopsy. However, they concluded that the majority of lesions categorised as B3 required excision [12]. Agoff et al evaluated the need for surgical excision in intraductal papillary neoplasms and suggested that all such lesions with atypical ductal hyperplasia required excision owing to the high rate of associated neoplasia [13]. Although some lesions categorised as B3 lesions on core biopsy may be re-categorised on excision biopsy as B2 lesions, all lesions categorised as B3 and above are subjected to excision biopsy at our institution.
Received for publication November 24, 2004.
Revision received May 16, 2005.
Accepted for publication June 1, 2005.
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Abstract
Introduction
