Continuing Education Activity

Intraductal papilloma is a benign tumor found within breast ducts. The abnormal proliferation of ductal epithelial cells causes tumor growth. A solitary intraductal papilloma is usually found centrally posterior to the nipple, affecting the central duct. Multiple intraductal papillomas are located peripherally in any breast quadrant, affecting the peripheral ducts. This activity reviews the cause, pathophysiology, and presentation of patients with intraductal papilloma and highlights the interprofessional team's role in its management.

Objectives:

• Assess the histopathology of intraductal papilloma.
• Evaluate the presentation of intraductal papilloma.
• Identify the treatment of intraductal papilloma.
• Communicate the importance of improving care coordination among interprofessional team members to improve patient outcomes affected by intraductal papilloma.

Introduction

Intraductal papilloma is a benign tumor found within breast ducts. The abnormal proliferation of ductal epithelial cells causes growth. A solitary intraductal papilloma is usually found centrally posterior to the nipple, affecting the central duct. Multiple intraductal papillomas are located peripherally 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 ocasionally palpable. However, most patients with intraductal papillomas are asymptomatic. Small intraductal papillomas often 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 and 55. Its occurrence 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. Peripheral papillomas, in contrast, are usually smaller and can be multiple.[8] Intraductal papilloma can be found in both large ducts of the subareolar region and the terminal duct lobular unit more peripherally. Intraductal papilloma is histologically characterized by a fibrovascular core covered with epithelial and myoepithelial cells. Various changes can accompany intraductal papilloma, including 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 are most commonly seen in perimenopausal patients. However, it may also be seen incidentally with ultrasound in younger asymptomatic patients. Intraductal papilloma, when multiple, typically arises from the terminal duct lobular unit. They are less frequently presented with nipple discharge and more often as a palpable mass.[1]

Evaluation

Intraductal papilloma can be mammographically occult. It may present as a round or oval mass with a well-circumscribed or indistinct margin when seen mammographically. It may be associated with microcalcifications. Under ultrasound, the mass is commonly found near the nipple. The tumor is in a dilated duct and often shows 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 an accurate diagnosis.[1] Different biopsy methods include core needle, vacuum-assisted, and open tissue biopsy. Core needle and vacuum-assisted biopsy are preferred over fine-needle aspiration because more tissue samples are obtained for pathologic analysis. Fine needle aspiration uses a thinner needle, creating the chance of 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 a lumpectomy with complete papilloma removal, 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 a papilloma. Malignant nonpapillary tumors such as medullary carcinoma can present with central necrosis or ductal extension mimicking a papillary carcinoma. Ultimately, the diagnosis of intraductal papilloma requires tissue sampling for definitive diagnosis.[1]

Prognosis

The prognosis is overall excellent with intraductal papilloma. In 1 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, 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] In 1 study, local recurrence after surgical excision is as low as 2.4%.[13]

Complications

No significant complications are seen with intraductal papilloma—complications, when present, are seen after biopsy or 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 malignant, 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 mammograms 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 abnormalities early. The nurse should also encourage women to undergo screening mammograms. At the same time, the primary care provider should encourage the patient to follow up with regular breast exams.

Outcomes

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

Review Questions

• Access free multiple choice questions on this topic.
• Comment on this article.

References

1.

Eiada R, Chong J, Kulkarni S, Goldberg F, Muradali D. Papillary lesions of the breast: MRI, ultrasound, and mammographic appearances. AJR Am J Roentgenol. 2012 Feb;198(2):264-71. [PubMed: 22268167]

2.

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. Eur J Cancer Prev. 2019 Nov;28(6):515-521. [PubMed: 30681416]

3.

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;265(2):379-84. [PubMed: 22952379]

4.

Tran HT, Mursleen A, Mirpour S, Ghanem O, Farha MJ. Papillary Breast Lesions: Association with Malignancy and Upgrade Rates on Surgical Excision. Am Surg. 2017 Nov 01;83(11):1294-1297. [PubMed: 29183534]

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Tsilimigras DI, Ntanasis-Stathopoulos I, Bakopoulos A, Schizas D, Kalfa M, Karyda I, Papaioannou D, Klapsinou E, Salla C, Sergentanis TN, Moschovi M. Intraductal papilloma of the breast in an 11-year-old male patient: a case report. Pediatr Surg Int. 2017 Jun;33(6):727-730. [PubMed: 28353086]

6.

Karadeniz E, Arslan S, Akcay MN, Subaşi ID, Demirci E. Papillary Lesions of Breast. Chirurgia (Bucur). 2016 May-Jun;111(3):225-9. [PubMed: 27452933]

7.

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 J Surg. 2010 Feb;34(2):261-5. [PubMed: 19997916]

8.

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. Am J Surg Pathol. 2006 Jun;30(6):665-72. [PubMed: 16723843]

9.

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. J Breast Cancer. 2018 Mar;21(1):80-86. [PMC free article: PMC5880969] [PubMed: 29628987]

10.

Bennett IC, Saboo A. The Evolving Role of Vacuum Assisted Biopsy of the Breast: A Progression from Fine-Needle Aspiration Biopsy. World J Surg. 2019 Apr;43(4):1054-1061. [PubMed: 30617562]

11.

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. Ann Surg Oncol. 2018 Oct;25(10):2917-2924. [PMC free article: PMC8323014] [PubMed: 30014456]

12.

Kiran S, Jeong YJ, Nelson ME, Ring A, Johnson MB, Sheth PA, Ma Y, Sener SF, Lang JE. Are we overtreating intraductal papillomas? J Surg Res. 2018 Nov;231:387-394. [PMC free article: PMC6173197] [PubMed: 30278958]

13.

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. 2017 Jun 23;39(6):429-433. [PubMed: 28635232]

14.

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 Plast Surg. 2017 Dec;41(6):1334-1341. [PubMed: 28779408]

Disclosure: Allen Li declares no relevant financial relationships with ineligible companies.

Disclosure: Lindsey Kirk declares no relevant financial relationships with ineligible companies.