Radiological appearances of papillary breast lesions

Invasive papillary carcinoma of the breast

Invasive papillary carcinoma is a rare form of breast cancer that is more likely to occur in postmenopausal women. Previous studies have been limited to case reports and small retrospective studies, leading to low awareness of this type of tumor and difficult clinical management. According to the available literature, invasive papillary carcinoma exhibits unique pathological features and biological behaviors. Invasive papillary carcinoma is mostly luminal type, with a low rate of lymph node metastasis, which underlies its favorable prognosis. The effectiveness of adjuvant therapy in reducing tumor burden and improving prognosis in patients with invasive papillary carcinoma remains uncertain. Due to the rarity of the lesion, conducting prospective clinical trials is impractical. The use of biological models, such as organoids, can help alleviate the impact of the scarcity of this condition on research. In addition, invasive papillary carcinoma is affected by specific genomic events, and more extensive studies of gene expression profiling may provide molecular-level insights to make optimal therapeutic decisions.

Puzzling Papillomas: A Case of an Intraductal Papilloma Mimicking an Abscess

Intraductal papillomas (IDPs) are benign tumors found within breast ducts. Clinicians should be familiar with IDPs given their association with atypical and neoplastic lesions. In our case, the patient was initially diagnosed with and treated for an abscess given clinical symptoms of breast pain, erythema, and swelling, but upon returning to the clinic a year later due to persistent symptoms, she was found to have an IDP. This case underscores the importance of atypical imaging features and close follow-up when evaluating breast lesions.

Management of Intraductal Papilloma of the Breast Diagnosed on Core Needle Biopsy: Latest Controversies

Intraductal papillomas (IDPs), including central papilloma and peripheral papilloma, are common in the female population. Due to the lack of specific clinical manifestations of IDPs, it is easy to misdiagnose or miss diagnose. The difficulty of differential diagnosis using imaging techniques also contributes to these conditions. Histopathology is the gold standard for the diagnosis of IDPs while the possibility of under sample exists in the percutaneous biopsy. There have been some debates about how to treat asymptomatic IDPs without atypia diagnosed on core needle biopsy (CNB), especially when the upgrade rate to carcinoma is considered. This article concludes that further surgery is recommended for IDPs without atypia diagnosed on CNB who have high-risk factors, while appropriate imaging follow-up may be suitable for those without risk factors.

High-Risk Lesion Management

High-risk lesions or lesions of uncertain malignant potential are frequent findings on image-guided needle biopsy of the breast and comprise a number of distinct entities. These lesions are known for having risk of underlying malignancy and are usually associated with an increased lifetime risk for breast cancer. Surgical excision was traditionally recommended for all high-risk lesions but recent studies have demonstrated that vacuum-assisted excision or surveillance may be adequate for some lesions. While management of high-risk lesion varies among institutions, this chapter describes the management recommendations based on recent literature of the most frequent types of lesions.

Sonographic prediction of intraductal papillary carcinoma with partially cystic breast lesions

BACKGROUND

Intraductal papillary carcinoma (IDPC) is a rare but fatal disease. Preoperative ultrasound diagnosis of IDPC remains challenging and meaningful. The aim of the study was to determine an effective ultrasound model to predict intraductal papillary carcinoma (IDPC) in patients with partially cystic breast lesions on ultrasound.

METHODS

We reviewed female patients with breast nodules who underwent biopsy or surgery between 2004 and 2019, and pathological results were used as the reference standard. We finally included 21 IDPC patients with partially cystic lesions on preoperative ultrasound matched to 40 patients with intraductal papilloma. The association of ultrasound features with IDPC was analysed.

RESULTS

Posterior echo enhancement (P < 0.001), tumour size (P = 0.002), irregular shape (P = 0.003), wide base (P = 0.003), solid-mainly component (P = 0.013), rich Doppler flow (P < 0.001) and multiple lesions (P = 0.044) were associated with IDPC by univariate analysis. Based on univariate analysis, variables were included in the regression analysis to obtain independent factors. The regression analysis showed that microcalcification, multiple lesions, posterior echo enhancement, wide base of solid components and rich colour Doppler flow were predictors for IDPC (P < 0.001). The collective model of the independent factors (microcalcification, multiple lesions, posterior echo enhancement, wide base of solid components and rich colour Doppler flow) could predict IDPC with an area under the curve (AUC) of 0.99 (95% CI 0.95-1.00). The collective model had a better net benefit demonstrated by the decision curve.

CONCLUSION

Ultrasonic features may be an applicable model for predicting IDPC with partially cystic breast lesions on ultrasound and has a better potential to facilitate decision-making preoperatively.

Shedding Light on T2 Bright Masses on Breast MRI: Benign and Malignant Causes

While T2 hyperintense masses on breast MRI are often benign, there are several malignant etiologies that can also be T2 hyperintense. Delineation between benign and malignant entities is important for the accurate interpretation of breast MRI. Common benign T2 hyperintense masses include cysts, fibroadenomas, and lymph nodes. Malignant processes that are T2 hyperintense include metastatic lymph nodes, mucinous breast carcinomas, papillary breast carcinomas, and breast cancers with central necrosis. Evaluation of the morphology and enhancement pattern of a T2 hyperintense mass can help to differentiate a benign process from a malignant one. This educational review will present both benign and malignant causes of T2 hyperintense masses on breast MRI and review common imaging findings and pertinent imaging characteristics that can be used to help accurately identify benign entities while also recognizing suspicious lesions that require additional evaluation.

Papillary Lesions of the Breast: Addition of DWI and TIRM Sequences to Routine Breast MRI Could Help in Differentiation Benign from Malignant

AIM

We aimed to investigate the magnetic resonance imaging (MRI) features of benign, atypical or malignant papillary breast lesions and to assess additional value of diffusion-weighted imaging (DWI) and turbo inversion recovery magnitude (TIRM) sequences to routine breast MRI.

BACKGROUND

Differentiation between benign and malignant papillary breast lesions is essential for patient management. However, morphologic features and enhancement patterns of malignant papillary lesions may overlap with those of benign papilloma.

METHODS

Seventy two papillary breast lesions (50 benign, 22 atypical or malignant) were included in the current study, retrospectively. We divided the patients into two groups as benign papillary breast lesions and atypical or malignant papillary breast lesions. Morphologic, dynamic, turbo inversion recovery magnitude (TIRM) values and diffusion features of the papillary lesions were compared between two groups.

RESULTS

Benign papillary lesions were smaller in size (p=0.006 and p=0.005, for radiologist 1 and 2 respectively), closer to areola (p=0.045 and 0.049 for radiologist 1 and 2 respectively) and had higher ADC values (p=0.001 for two radiologists) than atypical or malignant group. ROC curves showed diagnostic accuracy for ADC (AUC=0.770 and 0.762, p<0.0001 for two radiologists) and showed a cut-off value of ≤957 x 10-6 mm2/s (radiologist 1) and ≤ 910 x 10-6 mm2/s (radiologist 2).

CONCLUSION

MRI is a useful method for differentiation between benign and malignant papillary breast lesions. Centrally located, lesser in size and higher ADC values should be considered benign, whereas peripherally located, larger in size and lower ADC values should be considered malignant.

Papillary breast lesions detected using conventional ultrasound and contrast-enhanced ultrasound: Imaging characteristics and associations with malignancy

OBJECTIVE

This study aimed to evaluate the imaging features of papillary breast lesions detected using conventional ultrasonography (US) and contrast-enhanced ultrasound (CEUS) and to correlate the pathological results. Furthermore, the diagnostic efficiencies of these imaging features to predict the malignancy potential of papillary lesions were explored.

METHODS

The findings of the conventional US and CEUS of 74 consecutive papillary breast lesions were assessed retrospectively. The obtained data were analyzed using univariate and multivariate logistic regressions to evaluate the ability of each parameter and combined parameters in distinguishing the benign and atypical or malignant papillary lesions.

RESULTS

Among the imaging features of breast papillary lesions on conventional US and CEUS, two sonographic features (lesion size ≥1 cm and not circumscribed margin) on conventional US and four enhancement features (irregular enhancement, heterogeneous enhancement, enlargement of scope, and perfusion defect) on CEUS were found to be significantly different between the benign and atypical or malignant papillary lesions (P < 0.05). A multivariate logistic regression analysis further showed that only heterogeneous enhancement and enlarged enhancement scope were associated with malignancy. The sensitivity and specificity of heterogeneous enhancement, enlarged enhancement scope, and combined analysis for predicting atypical and malignant papillary lesions were 78.6 % and 39.1 %, 75 % and 37 %, and 75 % and 82.6 %, respectively. The combination of enhancement homogeneity and enhancement scope improved the diagnostic accuracy (AUC = 0.875).

CONCLUSIONS

The results suggested that the imaging features on conventional US and CEUS could help in identifying benign and malignant papillary lesions and predict their malignancy potential.

Spectrum of imaging findings of papillary breast disease: A radiopathological review in a tertiary center

To evaluate the clinical and imaging findings of papillary breast neoplasm and review the pathologic correlation at a tertiary center.Retrospective study of patients diagnosed with benign and malignant papillary lesions between 2008 to 2018. 147 patients were identified with histology diagnosis of papillary lesions. The clinical, imaging, and pathological characteristics were reviewed.Patient cohort included 147 women diagnosed with papillary lesions (mean age at diagnosis 53.8 years) and were divided into 3 histology groups (benign, atypical, and malignant). Common clinical presentations were breast lump (n = 60) and nipple discharge (n = 29), 48 patients were asymptomatic.Only 37 were detected as a mass lesion on mammogram. The presence of mass lesion on mammogram was the most common feature in all 3 papillary lesion groups, and with the presence of asymmetric density, were the 2 mammographic features significantly associated (P < .05) with malignancy.All lesions were detected on ultrasound. The most common sonographic features for all 3 groups were the presence of a mass and irregular shape. Among all the sonographic features assessed, larger size, presence of vascularity and absence of dilated ducts were significantly associated (P < .05) with malignancy.Feature pattern recognition of the variety of benign, atypical and malignant papillary neoplasm on ultrasound and mammogram, with emphasis on size, presence of vascularity and dilated ducts on ultrasound and presence of mass, and architectural distortion on mammogram, is important in the assessment of patients with suspected ductal lesions to facilitate optimal treatment and surgical care.

Functional photoacoustic/ultrasound imaging for the assessment of breast intraductal lesions: preliminary clinical findings

This study aimed to identify features of breast intraductal lesions in photoacoustic/ultrasound (PA/US) imaging and compare PA/US with color Doppler flow/ultrasound (CDFI/US) in the evaluation of breast intraductal lesions. In the nine patients with 10 breast intraductal lesions and 8 patients with 8 benign lesions, total vessel scores evaluated from PA/US are significantly greater than those from CDFI/US (p=0.005). PA internal vessel scores and oxygen saturation (SO2) score are significantly increased in breast intraductal lesions than in benign lesions (p=0.016, p=0.006). With a cutoff PA score (sum of PA internal vessel score and SO2 score) of 2.5, we obtained a sensitivity of 90% and a specificity of 87.5% in differentiation of two groups. PA/US upgraded 40% of breast intraductal lesions, and downgraded 50% of benign lesions from the Breast Imaging Reporting and Data System grading results based on CDFI/US. PA/US functional imaging has the potential in differentiating breast intraductal lesions.

Using the Superb Microvascular Imaging Method in the Distinction of Intraductal Papilloma and Duct Ectasia With Secretion

OBJECTIVES

To investigate the diagnostic value of a Superb Microvascular Imaging (SMI; Toshiba Medical Systems, Tokyo, Japan) Doppler examination for distinguishing intraductal papilloma (IDP) from duct ectasia with secretion in lesions smaller than 1 cm compared to color Doppler imaging (CDI) and power Doppler imaging (PDI).

METHODS

Fifty-nine lesions were evaluated by grayscale ultrasound, CDI, PDI, and SMI. Biopsied tissue samples were analyzed. Ultrasound evaluations and Doppler examinations were performed with a Toshiba Aplio 500 device. The lesions were divided into 2 groups, secretion and IDP, according to the pathologic results. Color Doppler imaging, PDI, and SMI data were compared statistically to investigate their diagnostic values.

RESULTS

Of the 59 lesions, 22 were secretion, and 37 were IDP. The mean diameters ± SDs were 4.7 ± 0.6 mm in the secretion group and 4.9 ± 0.8 mm in the IDP group (P = .315). There was no significant difference in grayscale ultrasound features such as shape or margin between the groups (P > .05). No significant difference was found between the groups in CDI or PDI characteristics (P > .999; P = .702, respectively). The color SMI evaluation results showed no vascularity in 18 (81.8%) lesions in the secretion group. Vascularity was detected in 32 patients (86.5%) in the IDP group. In the receiver operating characteristic analysis, the areas under the curve were calculated as 0.842 (95% confidence interval [CI], 0.728-0.925) for SMI, 0.522 (95% CI, 0.388-0.654) for PDI, and 0.518 (95% CI, 0.384-0.650) for CDI.

CONCLUSIONS

Superb Microvascular Imaging is more accurate and has more diagnostic ability than CDI or PDI in distinguishing small IDPs from duct ectasia with secretion because of its ability to visualize slow flow speeds of vascular structures.

Breast Elasticity Imaging Techniques: Comparison of Strain Elastography and Shear-Wave Elastography in the Same Population

Our purpose was to compare the diagnostic performances of strain elastography (SE) and shear-wave elastography (SWE) in differentiating breast lesions by combining with conventional ultrasound (US). A total of 198 patients with 203 breast lesions underwent conventional US, SE and SWE examination using MyLab 90 and Aixplorer US systems. The SE parameters were SEscore, fat-to-lesion ratio, gland-to-lesion ratio, muscle-to-lesion ratio and SEmean, and the SWE parameters were Emax, Emean, Emin and Esd. Conventional US had the best diagnostic performance, with an area under the curve (AUC) of 0.896. Among all SE parameters, the AUCs of SEscore, fat-to-lesion ratio and SEmean were 0.802, 0.810 and 0.833. For SWE parameters, they were 0.845, 0.746 and 0.845, respectively, for Emax, Emean and Esd. When combined with US, the sensitivity and AUC of SWE seemed to be better than those of SE (96.55% vs. 93.10%, 0.958 vs. 0.947), but no statistically significant difference existed between them.

Papillary lesions of the breast: a review

Papillary breast lesions are rare breast tumors that comprise a broad spectrum of diseases. Pathologically they present as mass-like projections attached to the wall of the ducts, supported by fibrovascular stalks lined by epithelial cells. On mammogram they appear as masses that can be associated with microcalcifications. Ultrasound is the most used imaging modality. On ultrasound papillary lesions appear as homogeneous solid lesions or complex intracystic lesions. A nonparallel orientation, an echogenic halo or posterior acoustic enhancement associated with microcalcifications are highly suggestive of malignancy. MRI has proven to be useful to establish the extent of the lesion. Core needle biopsy is the gold standard for diagnosis. Surgical excision is usually recommended, although treatment for papillomas without atypia is still controversial.

Unusual recurrent metastasizing benign breast papilloma: a case report

BACKGROUND

Papillary breast lesions may be benign, atypical, and malignant lesions. Pathological and clinical differentiation of breast papillomas can be a challenge. Unlike malignant lesions, benign breast papillomas are not classically associated with lymph node and distant metastasis. We report a unique case of a recurrent, benign breast papilloma presenting as an aggressive malignant tumor.

CASE PRESENTATION

Our patient was a 56-year-old postmenopausal African American woman who was followed in the breast clinic with a long history of multiple breast papillomas. She underwent multiple resections over the course of 7-9 years. After being lost to follow-up for 2 years, she once again presented with a slowly enlarging left breast mass. Subsequent imaging revealed a predominantly cystic mass in the left breast, as well as a suspicious hypermetabolic internal mammary node and a hypermetabolic nodule in the pretracheal space. Biopsy of the internal mammary node demonstrated papillary neoplasm with benign morphology and immunostains positive for estrogen receptor, progesterone receptor, and human epidermal growth factor receptor 2/Neu. Due to the clinical picture concerning for malignancy, the patient was then started on endocrine therapy with palbociclib and letrozole before surgery. She then underwent simple mastectomy and sentinel lymph node dissection with negative nodes and pathology once again revealing benign papillary neoplasm. She underwent adjuvant chest wall radiation for 6 weeks and received letrozole following completion of her radiation therapy. She was without evidence of disease 30 months after surgery.

CONCLUSIONS

We present an unusual case of multiple recurrent peripheral papillomas with entirely benign histologic features exhibiting malignant behavior over a protracted period of many years, with an invasion of pectoralis musculature and possibly internal mammary and mediastinal nodes. Her treatment course included multiple surgeries (ultimately mastectomy), radiation therapy, and endocrine therapy.

Apparent diffusion coefficient value in breast papillary lesions without atypia at core needle biopsy

PURPOSE

The main aim of the study was to assess if the mean apparent diffusion coefficient (ADC) value was significantly different between papillary lesions (PL) without atypia and PLs with atypical or malignant foci. A secondary objective was to evaluate if patients mean age, MRI BI-RADS® descriptors and assessment category were significantly different between these two PL groups.

METHODS

In this eight year retrospective study were included 122 patients (mean age, 51 years; range, 24-78) with 122 PLs without atypia at micro-histological examination after core needle biopsy (CNB) performed under sonographic guidance. All patients underwent surgical excision biopsy within 3 months after CNB. All patients underwent MRI examination before surgical excision, including STIR, DWI and Dynamic Contrast-Enhanced sequences.

RESULTS

Mean ADC value difference between PLs without and with atypia or malignant foci was statistically significant (p < 0.0001). Mean ADC value optimal threshold in order to distinguish the two groups was 1.418 × 10^-3 mm²/s. A mean ADC value ≤ 1.418 × 10^-3 mm²/s could predict atypical or malignant foci within a PL with 83.9% sensitivity and 75.8% specificity. No statistically significant difference was found with regard to patients mean age, MRI BI-RADS® descriptors and assessment category between these two PL groups.

CONCLUSIONS

Mean ADC value of PLs without atypia at CNB is an efficient tool in order to help distinguish between PLs without and with atypical or malignant foci at final pathology on surgical excision, and it could be used to help decide how to manage these lesions.

Ultrasound-guided 7-gauge vacuum-assisted core biopsy: Could it be sufficient for the diagnosis and treatment of intraductal papilloma?

The aim of this study was to evaluate whether ultrasound-guided 7-gauge vacuum-assisted core biopsy is sufficient for the diagnosis and treatment of intraductal papilloma and to evaluate the lesion characteristics and histologic features affecting the excision rate of papilloma with vacuum-assisted core biopsy. Between March 2008 and October 2016, 2816 patients underwent US-guided, 7-gauge vacuum-assisted core biopsy (VACB). In them, 101 (3.6%) were demonstrated to have intraductal papilloma by pathology. The accurate diagnostic rate and excision rate of intraductal papilloma after vacuum-assisted core biopsy were evaluated by open surgical biopsy or follow-up US. The lesion characteristics and histologic features were analyzed to identify factors affecting the excision rate of papilloma after VACB. Of the 101 intraductal papillomas, 83 (82.2%) cases were benign papilloma. Two cases were intraductal papilloma accompanied by invasive carcinoma. Sixteen (15.8%) cases were with signs of atypical hyperplasia. In them, one intraductal papilloma accompanied by severe atypical hyperplasia underwent further surgery, and it was demonstrated to have intraductal papilloma accompanied by invasive carcinoma. The accurate diagnostic rate of intraductal papillomas by 7-gauge VACB was 99.0% (100/101). There was no recurrence or malignant transformation in 85.1% (86/101) intraductal papillomas after 7-gauge vacuum-assisted core biopsy. Intraductal papilloma with largest diameter <1 cm, with clear margin, without branch involvement or calcification had a significantly higher excision rate. Seven-gauge VACB is an effective method for the diagnosis of intraductal papilloma of the breast. If histopathological examination confirms a benign character of the lesion, surgery may be avoided but regular follow-up is recommended. If histopathological examination confirms a papilloma with moderate to severe atypical hyperplasia, it was strongly recommended for surgical excision. Lesion characteristics and histologic features could affect the excision rate of intraductal papillomas with VACB.

Magnetic resonance imaging features for differentiating breast papilloma with high-risk or malignant lesions from benign papilloma: a retrospective study on 158 patients

Background

Benign breast papilloma is currently managed with conservative management with close observation. In contrast, papilloma with high-risk or malignant lesions warrants surgical excision. The purpose of our study was to investigate magnetic resonance imaging (MRI) features of breast papilloma and to identify imaging diagnostic indicators for papilloma with high-risk or malignant lesions.

Methods

MRI features of 175 surgically confirmed papillomas on 158 patients were retrospectively reviewed. The 175 cases included 132 cases of benign papilloma and 43 cases of papilloma with high-risk or malignant lesions. The MRI features of these lesions were classified into three types: mass, non-mass enhancement (NME), and occult lesion. The occult lesion was defined as the presence of only ductal dilation without any enhanced lesions on MRI. For a mass lesion, the mixed mass-NME lesion was considered if linear, segmental or regional enhanced lesion was found adjacent to the mass. Clinical and MRI features were compared by univariate and multivariate analysis between the benign papilloma and the papilloma with high-risk or malignant lesions.

Results

Multivariate logistic regression analysis demonstrated that clinical characteristics including being or older than 50 years (odds ratio [OR] = 4.506), having bloody nipple discharge (OR = 4.499), and concurrent breast cancer (OR = 5.083) were significant indicators for papilloma with high-risk or malignant lesions. On MRI, most papillomas presented as mass (n = 135, 77.1%), and fewer as NME (n = 37, 21.1%) and occult lesion (n = 3, 1.7%). For the mass lesion, the logistic regression analysis demonstrated that a mass size exceeding 10 mm (OR = 2.956) and mixed mass-NME lesion (OR = 4.143) were independent risk indicators for a papilloma with high-risk or malignant lesions. For the NME lesion, the segmental or regional distribution was more commonly observed in the papilloma with high-risk or malignant lesions (61.5%) than the benign papilloma (12.5%) (P = 0.006). All the cases of occult lesions were benign papillomas.

Conclusions

MRI features including a mass size exceeding 10 mm, mixed mass-NME lesion, and NMEs with segmental or regional distribution indicate a papilloma with high-risk or malignant lesions.

Diagnostic evaluations of ultrasound and magnetic resonance imaging in mammary duct ectasia and breast cancer

The objective of the present study was to evaluate the diagnostic efficiency of ultrasound (US) and magnetic resonance imaging (MRI) in the diagnosis and differential diagnosis of mammary duct ectasia (MDE) and breast cancer. This retrospective study was performed on 35 patients with MDE and 105 patients with breast cancer using US and MRI. Imaging features, semi-quantitative and quantitative parameters were analyzed to determine their diagnostic value for MDE and breast cancer. The average age of patients with breast cancer was increased compared with that of patients with MDE. There were no significant differences in local packages with or without tenderness ratio (P=0.259) and grade of color Doppler flow imaging (P=0.273) between the two groups. However, the morphological changes were significantly increased in breast cancer compared with MDE. In addition, there were significant diagnostic differences in US and MRI between breast cancer and MDE, including resistance index, US elastography, time-signal intensity curve, apparent diffusion coefficient, early-stage enhancement ratio, peak-of-enhancement ratio and T_peak (P<0.05). However, there were no observable significant diagnostic differences between US, MRI and US with MRI for MDE and breast cancer (P=0.103, P=0.263 and P=0.403 respectively). Diagnosis of MDE and breast cancer requires full evaluation of multiple parameters and morphological changes of US and MRI to increase the diagnostic efficiency. US, MRI and US with MRI were all of diagnostic value for MDE and breast cancer, while US with MRI had the highest efficacy.

Papillary Lesions of the Breast: An Update

CONTEXT

-Papillary lesions of the breast, characterized by the presence of arborescent fibrovascular cores that support epithelial proliferation, constitute a heterogeneous group of neoplasms with overlapping clinical manifestation and histomorphologic features, but may have divergent biological behavior. These lesions are exclusively intraductal neoplasms, although an invasive carcinoma may rarely have a predominantly papillary architecture. Although recognition of a papillary architecture is typically not challenging, the histologic distinction of these entities is not always straightforward. Historically, different terminologies and variable criteria have been proposed for a given entity by various authorities. The difficulty in classifying these lesions has been further confounded by the scarcity of data and the heterogeneity across different studies with regard to the molecular genetic characteristics of this group of lesions.

OBJECTIVE

-To provide an overview focusing on the current concepts in the diagnosis and classification of papillary lesions of the breast incorporating recent molecular genetic advances.

DATA SOURCES

-Data were obtained from pertinent peer-reviewed English-language literature.

CONCLUSIONS

-The recent evolution of molecular techniques has enhanced our knowledge of the pathogenesis of papillary carcinomas of the breast. This, along with emerging outcome studies, has led to prognosis-based reclassification of some of these entities. Additional studies focusing on the molecular signatures are needed to identify potential decision tools to further stratify these lesions with respect to prognostic significance.

Automated Breast Volume Scanning: Identifying 3-D Coronal Plane Imaging Features May Help Categorize Complex Cysts

The study described here sought to identify specific ultrasound (US) automated breast volume scanning (ABVS) features that distinguish benign from malignant lesions. Medical records of 750 patients with 792 breast lesions were retrospectively reviewed. Of the 750 patients, 101 with 122 cystic lesions were included in this study, and the results ABVS results were compared with biopsy pathology results. These lesions were classified into six categories based on ABVS sonographic features: type I = simple cyst; type II = clustered cyst; type III = cystic masses with thin septa; type IV = complex cyst; type V = predominantly cystic masses; and type VI = predominantly solid masses. Comparisons were conducted between the ABVS coronal plane features of the lesions and histopathology results, and the positive predictive value (PPV) was calculated for each feature. Of the 122 lesions, 90 (73.8%) were classified as benign, and 32 (26.2%) were classified as malignant. The sensitivity, specificity and accuracy associated with ABVS features for cystic lesions were 78.1%, 74.4% and 75.4%, respectively. The 11 cases (8.9%) of type I-IV cysts were all benign. Of the 22 (18.0%) type V cysts, 16 (13.1%) were benign and 6 (4.9%) were malignant. Of the 89 (72.9%) type VI cysts, 63 (51.7%) were benign and 26 (21.3%) were malignant. The typical symptoms of malignancy on ABVS include retraction (PPV = 100%, p < 0.05), hyper-echoic halos (PPV = 85.7%, p < 0.05), microcalcification (PPV = 66.7%, p < 0.05), thick walls or thick septa (PPV = 62.5%, p < 0.05), irregular shape (PPV: 51.2%, p < 0.05), indistinct margin (PPV: 48.6%, p < 0.05) and predominantly solid masses with eccentric cystic foci (PPV = 46.8%, p < 0.05). ABVS can reveal sonographic features of the lesions along the coronal plane, which may be of benefit in the detection of malignant, predominantly cystic masses and provide high clinical values.

Lesions of uncertain malignant potential in the breast (B3): what do we know?

Breast lesions classified as of uncertain malignant potential (B3) on biopsy form a diverse group of abnormalities, which pose a diagnostic and management challenge. In this paper, we discuss the imaging and pathology features as well as the management of the most controversial B3 lesions, consisting of papillary lesions, complex sclerosing lesions/radial scars, lobular intraepithelial neoplasia, and atypical epithelial proliferation of ductal type. As there is an association with malignancy at the time of diagnosis, as well as an increase in the risk of subsequent development of cancer, a multidisciplinary discussion is almost always required to tailor treatment.

Are Irregular Hypoechoic Breast Masses on Ultrasound Always Malignancies?: A Pictorial Essay

Irregular hypoechoic masses in the breast do not always indicate malignancies. Many benign breast diseases present with irregular hypoechoic masses that can mimic carcinoma on ultrasonography. Some of these diseases such as inflammation and trauma-related breast lesions could be suspected from a patient's symptoms and personal history. Careful ultrasonographic examination and biopsy could help to differentiate these from malignancies.

Breast Papillomas

The detection of intraductal breast papillomas can be difficult; however, it is very important for diagnosis and treatment. Although intraductal papillomas are usually benign growths, a small percentage may be malignant. No imaging modality can distinguish between benign and malignant papillomas; that is done only with a biopsy. The symptoms vary greatly, ranging from asymptomatic to nipple discharge to a palpable mass. Multiple modalities, including mammography and ductography, have been used to identify papillomas, while magnetic resonance imaging is used to further evaluate known papillomas. Sonography has been proven crucial in identifying these masses, thereby providing information for proper treatment including ultrasound-guided biopsies. The uses of various sonographic techniques, such as color Doppler, harmonic imaging, ballottement, use of stand-off pads, echo palpation, and elastography, have improved the detection of these masses.

Diagnostic dilemmas in Intraductal papillomas of the breast - Experience at Sultan Qaboos University Hospital in the Sultanate of Oman

Objectives:

The aim of this retrospective study was to correlate the significance and accuracy of the colour of nipple discharge and breast ultrasound imaging in the diagnosis of intraductal papilloma.

Methods:

This is a retrospective study of 34 patients who underwent 36 microdochectomies in Sultan Qaboos University Hospital (SQUH) in the Sultanate of Oman, over a 4 year period of January 2009 till December 2012. The confounders considered were patient age, physical examination findings, nipple discharge cytology result, ultrasound results and biopsy report following microdochectomy. Comparisons analysis, charts and graphs were made using the SPSS software (version 20).

Results:

The mean age of the patients was 44(27-73) years old. Twenty-seven out 36 (75%) patients had presented with nipple discharge, 14 out 27 (52%) had blood stained nipple discharge and 13(48%) with coloured discharge (yellow, brown and green), 9 patients had no discharge. The final histopathology showed intraductal papilloma 13 (36%), duct ectasia 18(50%), DCIS 1 (2.7%), fibrocystic disease 3(8.3%) and LCIS 1(2.7%). Thirteen out of 36 had intraductal papilloma on final histopathology. The correlation between blood stained discharge and final histopathology of intraductal papilloma was insignificant (p=0.44).

Conclusion:

Nipple discharge is irrelevant to the diagnosis of intraductal papilloma. Spontaneous nipple discharge regardless of color is to be referred to breast surgeon and to be assessed with triple assessment. Surgery remains the mainstay of treatment.

Breast Lesions during Pregnancy - a Diagnostic Challenge: Case Report

BACKGROUND

Palpable masses of the breast often occur during pregnancy and should be further investigated. The standard diagnostic during pregnancy is an ultrasound combined, if needed, with a core needle biopsy. Most lesions are benign in younger women but, nevertheless, the incidence of pregnancy-associated breast cancer is 1 in 3,000 deliveries and rising.

CASE REPORT

We report the case of a 24-year-old patient diagnosed with a palpable breast lesion at 37 weeks of gestation. An ultrasound was performed and the lesion was rated BI-RADS 4. The initial core needle biopsy showed a ductal carcinoma in situ. After delivery and ablactating, a mammography, breast magnetic resonance imaging and a second ultrasound-guided biopsy was performed. Due to the inconclusive imaging and histological results, a wide excision was performed and a juvenile papillomatosis was confirmed. No further resection was necessary as the initial margins were sufficient.

CONCLUSION

This case suggests that the diagnosis of masses of the breast during pregnancy and lactation can be quite difficult. Diagnosis should be confirmed by an excision biopsy and by histological examination through an experienced pathologist. As a significant proportion of papillomas contain malignant regions, an argument exists for the complete excision of all papillary tumours.

MRI characteristics of intraductal papilloma

BACKGROUND

Intraductal papilloma (IDP) is the most common pathological finding in women with pathological nipple discharge. Magnetic resonance imaging (MRI) has shown potential for characterizing breast tumors; however, MRI findings of IDPs are inconclusive, and certain diagnostic standards are lacking.

PURPOSE

To characterize the MRI features of IDP from a relatively large cohort.

MATERIAL AND METHODS

We retrospectively reviewed from 358 women with IDPs that were confirmed by histopathology. The clinical and imaging findings in 70 patients who underwent preoperative MRI were analyzed. MRI analyses included morphology and dynamic contrast-enhanced MRI.

RESULTS

In 70 patients, 77 IDPs were detected on MRI, which revealed the following three patterns: small luminal mass papillomas; tumor-like papillomas; and MRI-occult papillomas. Fourteen IDPs involved small, oval, smooth, and contrast-enhanced masses at the posterior end of the enlarged duct corresponding to small luminal mass papillomas. Seven IDPs had large diameters along the direction of the breast duct, indicating the typical MRI findings for IDP. Of 47 tumor-like papillomas, 16 cases showed large diameters along the direction of the breast duct and close to the nipple (within 4 cm), seven cases resembled invasive breast cancer on MRI, and the remaining 24 were (24/47) undistinguishable from other benign breast diseases. Sixteen IDPs were MRI-occult papillomas that could not be distinguished from the surrounding benign disease by either contrast-enhanced MRI or fat-suppressed T2-weighted MRI.

CONCLUSION

Small luminal mass papillomas or tumor-like papillomas with the largest diameters along the direction of the breast duct and close to the nipple (within 4 cm) might be the typical MRI findings for IDPs.

Clinical and imaging characteristics of papillary neoplasms of the breast associated with malignancy: a retrospective cohort study

Papillary neoplasms of the breast comprise a broad range of pathologies ranging from papillomas to papillary carcinomas and have been associated with breast cancers. In this study, we evaluated the clinical, mammographic and sonographic features of papillary breast neoplasms from benign papillary breast lesions to malignancy-associated papillary lesions. A total of 194 lesions in 179 patients were analyzed, including 117 benign papillomas, 24 atypical papillomas, 41 benign papillomas with malignancies and 12 papillary carcinomas found between January 2003 and August 2011 in our institution. Statistically significant clinical factors included patient age (p = 0.001), lesion multiplicity (p = 0.009) and peripheral location (p = 0.003). Among these factors, the odds ratio for malignancy was 8.9 for bilateral multiple lesions. Visibility (p = 0.001) and density (p = 0.039) were significant factors for malignancy in mammograms, and echo patterns (p = 0.006), boundary (p = 0.001) and vascularity (p = 0.005) were significant features on ultrasound that differentiated malignancies from benign lesions. Overall, when papillary breast lesions are located bilaterally and peripherally in older patients, they are correlated with breast cancers. Additionally, for papillary breast lesions that appear highly dense on mammograms and/or exhibit positive vascularity on ultrasound, the probability of malignancy is relatively high.

Breast papillary lesions: an analysis of 70 cases

Introduction

Papillary breast lesions are rare and constitute less than 10% of benign breast lesions and less than 1% of breast carcinomas.

Objective

To analyse the clinical presentation, preoperative evaluation, and surgical and anatomopathological characteristics of the patients operated on for papillary breast lesions.

Material and Methods

Retrospective descriptive and analytical study. We analysed the database of patients with definitive histopathological diagnosis of papillary breast lesions operated on at our institution from January 2004 to May 2013.

Results

During the period described, 70 patients with histopathological diagnosis of papillary breast lesions were operated upon. The median age was 50 years (19–86 years). Thirty-seven patients (52.8%) were symptomatic at diagnosis. Preoperative ultrasound was reported to be altered in all patients. A mammography showed pathologic findings in only 50% of cases. All patients underwent partial mastectomy, after needle localisation under ultrasound, if the lesion was not palpable on physical examination. The final pathological diagnosis was: benign papillary lesion in 55 patients (78.6%) and malignant in 15 patients (21.4%). Adjuvant treatment was performed in all malignant cases. Median follow-up was 46 months (3–115 months).

Conclusions

Patients with papillary breast lesions presented with symptoms in half of all cases. There was a high frequency of malignancy (21.4%), therefore surgical resection was recommended for papillary breast lesions.

Usefulness of contrast-enhanced ultrasonography for intracystic breast tumors: a report of three cases

Cystic breast lesions are caused by a wide spectrum of breast diseases and can range from simple cysts to malignant tumors. Ultrasonography is a good tool for evaluation of the morphology and vascularity of cystic breast lesions. We report three patients in whom contrast-enhanced ultrasonography (CEUS) was used to evaluate intracystic tumors. One of the three patients was diagnosed with intracystic papilloma. Compared with conventional ultrasonography alone, CEUS more clearly demonstrated that the solid component within the mass was lobulated with a narrow base. The other two patients were diagnosed with intracystic papillary carcinoma, and CEUS clearly revealed the presence of widely elevated solid components within both masses, suggesting malignancy. Therefore, CEUS simplified morphological evaluation by enhancing the solid components within the cystic masses.

Rare breast tumors: Review of the literature

Breast cancer tumors have different morphological phenotypes and specific histopathological types with particular prognostic and clinical characteristics. The treatment of rare malignant lesions is frequently controversial due to the absence of trials to determine the optimal managements. This review describes the spectrum of rare breast tumors indicating the clinical, epidemiological and treatment characteristics.

Characterisation of breast papillary neoplasm on automated breast ultrasound

Intraductal papillary neoplasms of the breast form a wide spectrum of pathological changes with benign intraductal papilloma and papillary carcinoma. They can occur anywhere within the breast ductal system. This review illustrates some characteristic appearances of breast papillary neoplasms on coronal planes reconstructed by automatic breast volume scan. Such manifestations are not uncommon in papillary neoplasms, and familiarity will enable confident diagnosis.

Intraductal papilloma of the breast: A case report

Intraductal papillomatous lesions in the breast may be manifestations of different histological types of tumors, including papillomas and intraductal papillary carcinomas. Intraductal papillomas are relatively rare, with an incidence of 2-3%. They are benign tumors that arise from the mammary duct epithelium. We observed a tumor of this type in a 51-year-old woman who had noted bloody discharge from her right nipple. She was referred for breast sonography a few days later.The sonographic examination revealed a dilated duct enclosing a mass, which was surgically removed. Histological examination revealed that the lesion was benign (intraductal papilloma).This case illustrates the role of imaging in confirming clinical diagnoses of papillomatous lesions. Histological confirmation is always necessary, however, to rule out the presence of intraductal papillary carcinoma.

Imaging approaches to diagnosis and management of common ductal abnormalities

Ductal disease is an important, often overlooked, and poorly understood issue in breast imaging that results in delays in diagnosis and patient care. The differential diagnosis for an intraductal mass is broad and includes inspissated secretions, infection, hemorrhage, solitary or multiple papillomas, and malignancy. Each breast is composed of eight or more ductal systems, with most disease arising in the terminal ductal-lobular unit. Imaging evaluation of the ductal system usually entails a combination of mammography, galactography, ultrasonography (US), and in some cases magnetic resonance (MR) imaging. The most common finding with all modalities is ductal dilatation with a focal or diffuse abnormality. Benign diseases of the ducts include duct ectasia, blocked ducts, inflammatory infiltrates, periductal mastitis, apocrine metaplasia, intraductal papillomas, and papillomatosis. Malignant diseases of the ducts include ductal carcinoma in situ, invasive ductal carcinoma, and Paget disease. Most commonly performed with US or MR imaging guidance, percutaneous biopsy methods are helpful in diagnosis and management of ductal findings. Because most findings are smaller than 1 cm, located within a duct, and thus sometimes not visible after a single pass, vacuum-assisted devices help improve the accuracy of sampling.

Benign papilloma diagnosed on image-guided 14 G core biopsy of the breast: effect of lesion type on likelihood of malignancy at excision

AIM

To ascertain the negative predictive value (NPV) for atypia and malignancy of 14 G core biopsy of papillomas and to determine whether lesion type influences the likelihood of malignancy at lesion excision.

MATERIALS AND METHODS

Ninety-six lesions with a 14 G core biopsy diagnosis of benign papilloma without atypia in 95 women were included. The imaging features (mass or microcalcification), biopsy mode, and number of core samples taken were documented. All patients subsequently underwent lesion excision with either extensive vacuum-assisted biopsy (VAB; 72 lesions) or surgery (24 lesions). Mammographic follow-up of at least 2 years was available for 32 lesions that were benign at VAB.

RESULTS

Atypia or malignancy was found more commonly in association with microcalcification (six of 29 lesions: 21%; median number of nine 14 G cores) than a mass (five of 67 lesions: 7%; median number of three 14 G cores), although the difference does not reach statistical significance (p = 0.088). The NPV of a 14 G core biopsy diagnosis of papilloma for atypia or malignancy is 89% (85/96). Disease underestimation may be more common in microcalcification lesions despite the greater number of cores obtained.

CONCLUSION

Excision (using VAB or surgically) of all papillomas diagnosed as benign on 14 G needle core biopsy is recommended. Surgery may be more appropriate than VAB for some microcalcification lesions unless they are small and can be confidently removed in their entirety using VAB.

Solitary intraductal papillomas of the breast: MRI features and differentiation from small invasive ductal carcinomas

OBJECTIVE

Intraductal papilloma of the breast can resemble invasive ductal carcinoma (IDC). The purpose of this study was to characterize MRI features of solitary intraductal papillomas and identify features that differentiate intraductal papillomas from small IDCs.

MATERIALS AND METHODS

Forty-four intraductal papillomas and 49 small (diameter≤2.0 cm) IDCs confirmed by histopathology were included. Analysis of MR findings included morphology, signal intensity preenhancement, time-signal intensity curve (TIC), enhancement degree, and evolution of enhancement pattern on dynamic contrast-enhanced MRI (DCE-MRI), and diffusion-weighted imaging. The chi-square test and independent-samples Student t test were performed.

RESULTS

Of 44 intraductal papillomas, 27 (61.4%) were round or oval and 17 (38.6%) were irregular in shape, whereas 38 of 49 (77.6%) IDCs showed irregular or lobular shape (p<0.001). Smooth margins were seen in 43.2% (19/44) of the intraductal papillomas and 8.2% (4/49) of the IDCs. Most intraductal papillomas and IDCs showed slightly higher signal intensity on T2-weighted images. On DCE-MRI, 68.2% (30/44) of intraductal papillomas and 12.2% (6/49) of IDCs showed an early homogeneous or heterogeneous to delayed rimlike enhancement pattern (p=0.000). The difference in early-phase enhancement rates between intraductal papillomas (155.41%±19.15%) and IDCs (176.40%±35.61%) was significant (p=0.001). Differences in TIC and apparent diffusion coefficient values between the two groups were not significant.

CONCLUSION

A low early-phase enhancement rate and evolution of the DCE-MRI enhancement pattern from homogeneous or heterogeneous enhancement to rim enhancement is more likely to suggest intraductal papilloma than IDC.

Vacuum-assisted core biopsy in diagnosis and treatment of intraductal papillomas

BACKGROUND

The aim of this study was to assess the value of mammographically-guided and ultrasonographically-guided vacuum-assisted core biopsy (VACB) in the diagnosis and treatment of intraductal papillomas of breast and to answer the question of whether biopsy with the Mammotome (Mammotome; Cincinnati, OH) allows the avoidance of surgery in these patients.

PATIENTS AND METHODS

In the period 2000 to 2010, a total of 1896 vacuum-assisted core biopsies were performed, of which 1183 were ultrasonographically guided and 713 were mammographically guided (stereotaxic).

RESULTS

In 62 patients (3.2%) histopathologic examination confirmed intraductal papilloma, and in 12 patients (19.4%) atypical lesions were also found. Open surgical biopsy specimens revealed invasive cancer in 2 women these 12 women (false-negative rate, 16.7%; negative predictive value, 83.3%). Biopsy specimens from the remaining 50 patients (80.6%) revealed papilloma without atypia, and further clinical observation and imaging examinations did not show recurrence or malignant transformation of lesions. Hematoma developed in 3 (4.8%) patients as a complication of biopsy; surgical intervention was not required in any of the patients.

CONCLUSION

VACB is a minimally invasive and efficient method for diagnosing intraductal papilloma of the breast. If histopathologic examination confirms a benign lesion and corresponds to the clinical presentation, surgery may be avoided. However in all cases, histopathologic diagnosis of papilloma with atypical hyperplasia or a suspected malignant lesion in imaging examinations, despite negative biopsy results, should always be an indication for surgical excision.

Papillary lesions of the breast: MRI, ultrasound, and mammographic appearances

OBJECTIVE

The purpose of this article is to describe the different imaging appearances of benign and malignant papillary lesions of the breast as well as to point out potential errors of interpretation that can lead to misdiagnosis.

CONCLUSION

There is a wide spectrum of appearances of papillary lesions of the breast on MRI, ultrasound, and mammography. This variable appearance of papillary lesions makes differentiation of benign from malignant pathologies difficult on imaging, and tissue sampling is usually warranted.

Intracystic papillary carcinoma of the breast: report of three cases and literature review

Intracystic papillary carcinoma is a rare malignant tumor of the breast. It occurs communally in postmenopausal women. Clinically it can be asymptomatic or manifested by a breast mass or a nipple discharge. On imaging intracystic papillary carcinoma has usually benign features. Pathologic diagnosis can be difficult at classical histological examination and identification of myoepithelial cells layer by immunohistochemical study can be useful. In the majority of cases of pure intracystic papillary carcinoma, conservative management is possible. Adjuvant therapy is still controversial and prognosis is excellent. We report three cases of intracystic papillary carcinoma diagnosed on immunohistochemical examination and managed with conservative surgery.