Benign papillary neoplasms of the breast: mammographic findings

Nipple Discharge: When is it Worrisome?

Nipple discharge is the third most common breast related complaint seen in the breast clinics. Although the majority of cases are due to a benign etiology, 5%-12% cases of pathological nipple discharge may be harboring an underlying malignancy. A thorough radiological workup in cases of pathological nipple discharge is thus of utmost importance, with the initial imaging modality depending on the age of the patient. The imaging modalities include mammogram (MG) and ultrasound (US) with addition of breast MRI if the nipple discharge is clinically suspicious and no MG or US correlate is identified. Magnetic Resonance Imaging (MRI) also holds promise in demonstrating the exact extent of a pathology detected on US and thus aids in the planning of further management.

The diagnostic value of contrast-enhanced ultrasonography in breast ductal abnormalities

BACKGROUND

Ductal lesions are an important, often overlooked, and poorly understood issue in breast imaging, which have a risk of underlying malignancy ranging from 5 to 23%. Ultrasonography (US), which has largely replaced galactography or ductography, has become an important imaging method to assess patients with ductal lesions. However, it is difficult to distinguish benign from malignant ductal abnormalities only by ultrasonography, most of which are recommended to be at least in subcategory 4A; these require biopsy according to the ACR BI-RADS®atlas 5th Edition-breast ultrasound. Contrast-enhanced ultrasound (CEUS) has been shown to be valuable for differentiating benign from malignant tumors, but its value is unclear in breast ductal lesions. Therefore, the purposes of this study were to explore the characteristics of malignant ductal abnormalities on US and CEUS imaging and the diagnostic value of CEUS in breast ductal abnormalities.

METHODS

Overall, 82 patients with 82 suspicious ductal lesions were recruited for this prospective study. They were divided into benign and malignant groups according to the pathological results. Morphologic features and quantitative parameters of US and CEUS were analyzed by comparison and multivariate logistic regression to determine the independent risk factors. The diagnostic performance was assessed by receiver operating characteristic (ROC) curve analysis.

RESULTS

Shape, margin, inner echo, size, microcalcification and blood flow classification on US, wash-in time, enhancement intensity, enhancement mode, enhancement scope, blood perfusion defects, peripheral high enhancement and boundary on CEUS were identified as features correlated with malignant ductal lesions. However, multivariate logistic regression showed that only microcalcification (OR = 8.96, P = 0.047) and enhancement scope (enlarged, OR = 27.42, P = 0.018) were independent risk factors for predicting malignant ductal lesions. The sensitivity, specificity, positive predictive value, negative predictive value, accuracy and area under the ROC curve of microcalcifications combined with an enlarged enhancement scope were 0.895, 0.886, 0.872, 0.907, 0.890, and 0.92, respectively.

CONCLUSIONS

Microcalcification and enlarged enhancement scope are independent factors for predicting malignant ductal lesions. The combined diagnosis can greatly improve the diagnostic performance, indicating that CEUS can be useful in the differentiation of benign and malignant lesions to formulate more appropriate management for ductal lesions.

Dimorphic cells: a common feature throughout the low nuclear grade breast neoplasia spectrum

Columnar cell lesions (CCLs) are recognized precursor lesions of the low nuclear grade breast neoplasia family. CCLs are cystic enlarged terminal duct lobular units with monotonous (monoclonal) columnar-type luminal cells. CCLs without atypia are regarded as benign and CCLs with atypia as true precursor lesions with clonal molecular changes, a certain progression risk, and an association with more advanced lesions. However, reproducibility of designating atypia in CCL is not optimal, and no objective markers of atypia have been identified, although 16q loss seems to be associated with atypical CCLs. Dimorphic ("pale") cell populations have been described in low nuclear grade ductal carcinoma in situ (DCIS) but not in CCLs and atypical ductal hyperplasia (ADH). Therefore, we searched for pale cells in CCL (N = 60), ADH (N = 41), and DCIS grade 1 (N = 84). Diagnostic criteria were derived from the WHO, and atypia was designated according to the Schnitt criteria. Pale cells occurred in 0% (0/30), 73% (22/30), 56% (23/41), and 76% (64/84) of CCLs without atypia, CCLs with atypia, ADH, and DCIS grade 1, respectively. Pale cells expressed ERα, E-cadherin and p120 and variably cyclin D1, and lacked expression of CK5 and p63. In conclusion, dimorphic "pale" cells occur throughout the low nuclear grade progression spectrum, increasing in frequency with progression. Interestingly, CCL lesions without atypia do not seem to bear showed pale cells, indicating that the presence of pale cells may serve as a diagnostic morphological feature of atypia in CCLs.

ACR Appropriateness Criteria® Evaluation of Nipple Discharge: 2022 Update

The type of nipple discharge dictates the appropriate imaging study. Physiologic nipple discharge is common and does not require diagnostic imaging. Pathologic nipple discharge in women, men, and transgender patients necessitates breast imaging. Evidence-based guidelines were used to evaluate breast imaging modalities for appropriateness based on patient age and gender. For an adult female or male 40 years of age or greater, mammography or digital breast tomosynthesis (DBT) is performed initially. Breast ultrasound is usually performed at the same time with rare exception. For males or females 30 to 39 years of age, mammography/DBT or breast ultrasound is performed based on institutional preference and individual patient considerations. For young women less than 30 years of age, ultrasound is performed first with mammography/DBT added if there are suspicious findings or if the patient is at elevated lifetime risk for developing breast cancer. There is a high incidence of breast cancer in males with pathologic discharge. Men 25 years and older should be evaluated using mammography/DBT and ultrasound added when indicted. In transfeminine (male-to-female) patients, mammography/DBT and ultrasound are useful due to the increased incidence of breast cancer. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer-reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer-reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Multiple Papillomas of the Breast: A Review of Current Evidence and Challenges

Objectives: To conduct a review of evidence about papillomatosis/multiple papillomas (MP), its clinical and imaging presentation, the association between MP and malignancy and the management strategies that follow. Methods: A computerized literature search using PubMed and Google Scholar was performed up to January 2021 with the following search strategy: “papilloma” OR “intraductal papilloma” OR “intraductal papillary neoplasms” OR “papillomatosis” OR “papillary lesion” AND “breast”. Two authors independently conducted a search, screening and extraction of data from the eligible studies. Results: Of the 1881 articles identified, 29 articles met the inclusion criteria. The most common breast imaging methods (mammography, ultrasound) showed few specific signs of MP, and evidence about magnetic resonance imaging were weak. Regarding the association between MP and malignancy, the risk of underestimation to biopsy methods and the frequent coexistence of MP and other high-risk lesions needs to be taken into consideration. Results about the risk of developing breast carcinoma of patients affected by MP were inconsistent. Conclusions: MP is a challenge for all breast specialists, and familiarity with its features is required to make the correct diagnosis. Further studies are needed to evaluate the factors to take into account to plan management, time of follow-up and imaging methods.

Analysis of 612 Benign Papillomas Diagnosed At Core Biopsy: Rate of Upgrade to Malignancy, Factors Associated with Upgrade, and A Proposal For Selective Surgical Excision

Background: Despite numerous published studies, management of benign papillomas without atypia remains controversial. Objective: To determine the malignancy upgrade rate of benign papillomas, identify risk factors for upgrade, and formulate criteria for selective surgery. Methods: This retrospective study included benign papillomas without atypia diagnosed on percutaneous biopsy between 12/01/2000 and 12/31/2019. Papillomas that did not undergo surgical excision or at least 2 years of imaging and/or clinical follow-up were excluded. Clinical, imaging, and histopathologic features were extracted from the electronic medical record. Features associated with upgrade to malignancy were identified. Multivariable logistic regression was performed. Results: The study included 612 benign papillomas in 543 women (mean age 54.5 ± 12.1 years); 466 papillomas were excised, and 146 underwent imaging/clinical surveillance. The upgrade rate to malignancy was 2.3% (14/612). Upgrade rate was associated (p<.05) with radiology-pathology correlation (50.0% if discordant vs 2.1% if concordant), patient age (5.6% for age ≥60 vs 0.7% for age <60), presenting symptoms (6.7% if palpable mass or pathologic nipple discharge vs 1.3% if no symptoms), and lesion size (7.3% if ≥10 mm vs 0.6% if <10 mm). Three of 14 upgraded papillomas were associated with ≥4 metachronous or concurrent peripheral papillomas. No incidental papilloma or papilloma reported as completely excised on core biopsy histopathologic analysis was upgraded. A predictive model combining radiology-pathology discordance, symptoms (palpable mass or nipple discharge), age ≥60, size ≥10 mm, and presence of ≥4 metachronous or concurrent peripheral papillomas achieved AUC 0.91, sensitivity 79%, and specificity 89% for upgrade. Selective surgery based on presence of any of these five factors, while excluding from surgery incidental papillomas and papillomas reported as completely excised on histopathology, would spare 294 of 612 lesions from routine excision, while identifying all 14 upgraded lesions. Conclusion: Benign non-atypical papillomas have a low malignancy upgrade rate; routine surgical excision may not be necessary. Selective excision is recommended for lesions satisfying any of the 5 criteria. Incidental papillomas or papillomas completely excised on histopathology may undergo imaging follow-up. Clinical Impact: The proposed criteria for selective surgery of benign papillomas on core biopsy would reduce surgeries without delaying diagnosis of malignancy.

Diagnostic accuracy of breast MRI for patients with suspicious nipple discharge and negative mammography and ultrasound: a prospective study

OBJECTIVES

To evaluate the diagnostic accuracy of breast MRI in identifying lesions requiring excision for patients with suspicious nipple discharge but normal mammograms and ultrasounds.

METHODS

Between September 2013 and May 2019, 106 female participants (mean age 57.9 years) were consecutively included in this prospective multicenter study; 102 were retained for analysis. MRI was considered negative in the absence of suspicious enhancement and positive in cases of ipsilateral abnormal enhancement (BI-RADS 3 to 5). Final diagnoses were based on histological findings of surgical or percutaneous biopsies or at 1-year follow-up. We considered all lesions requiring excision found on pathology (papilloma, atypia, nipple adenomatosis, or cancer) as positive results. We considered spontaneous resolution of the discharge at 1 year as a negative result.

RESULTS

MRI showed ipsilateral abnormal enhancement in 54 patients (53%) revealing 46 lesions requiring excision (31 benign papillomas, 5 papillomas with atypia, 2 nipple adenomatosis, and 8 cancers) and 8 benign lesions not requiring excision. No suspicious enhancement was found in the remaining 48 participants (47%). Forty-two were followed up at 1 year with spontaneous resolution of the discharge and six underwent surgery (revealing 2 benign papillomas). MRI diagnostic accuracy for the detection of a lesion requiring excision was as follows: sensitivity 96%, specificity 85%, positive predictive value 85%, and negative predictive value 96%.

CONCLUSION

In patients with suspicious nipple discharge and normal mammogram and ultrasound, MRI demonstrates excellent performance to identify lesions for which excision is required. Normal MRI indicates it is safe to propose follow-up only management, thus avoiding unnecessary duct excision.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02819362 KEY POINTS: • Breast MRI can be useful for the management of patients with suspicious nipple discharge and negative mammogram and ultrasound. • MRI detected a lesion requiring excision in 46 participants (45%) with unexplained discharge. • If breast MRI is negative, follow-up is a safe alternative for these patients.

Magnetic resonance imaging in the evaluation of pathologic nipple discharge: indications and imaging findings

Pathologic nipple discharge (PND) is typically unilateral, spontaneous, involves a single duct, and is serous or bloody in appearance. In patients with PND, breast MRI can be helpful as an additional diagnostic tool when conventional imaging with mammogram and ultrasound are negative. MRI is able to detect the etiology of nipple discharge in 56-61% of cases when initial imaging with mammogram and ultrasound are negative. Advantages to using MRI in evaluation of PND include good visualization of the retroareolar breast and better evaluation of posterior lesions which may not be well evaluated on mammograms and galactograms. It is also less invasive compared to central duct excision. Papillomas and nipple adenomas are benign breast masses that can cause PND and are well visualized on MRI. Ductal ectasia, and infectious etiologies such as mastitis, abscess, and fistulas are additional benign causes of PND that are well evaluated with MRI. MRI is also excellent for evaluation of malignant causes of PND including Paget's disease, ductal carcinoma in-situ and invasive carcinoma. MRI's high negative predictive value of 87-98.2% is helpful in excluding malignant etiologies of PND.

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.

Nipple Discharge: Current Clinical and Imaging Evaluation

OBJECTIVE. Nipple discharge is a common complaint that is first evaluated with clinical assessment. Physiologic discharge does not require imaging other than routine screening mammography. Initial evaluation of pathologic nipple discharge involves mammography and ultrasound. evaluation of pathologic nipple discharge involves mammography and ultrasound. Because of its high sensitivity in detecting breast malignancy and its biopsy capability, MRI is increasingly used in lieu of ductography. CONCLUSION. The problem-solving algorithm for evaluating suspicious nipple discharge is evolving. When diagnostic imaging for evaluation of pathologic nipple discharge is negative, management is based on clinical suspicion. If additional imaging is warranted, MRI is preferred because of its increased sensitivity, specificity, and patient comfort. Although central duct excision is the current standard for evaluation of malignancy in patients with pathologic nipple discharge, studies suggest that, given the high negative predictive value of MRI, surveillance may be a reasonable alternative to surgery.

The nipple-areolar complex: comprehensive imaging review

The nipple-areolar complex can be affected by a variety of benign and malignant entities that can present with non-specific symptoms. Benign pathologies commonly affecting the nipple-areolar complex include nipple calcifications, nipple adenoma, abscess of Montgomery tubercles, ductal ectasia, periductal mastitis, and papilloma. Malignant pathologies that affect the nipple-areolar complex include Paget's disease of the breast, ductal carcinoma in-situ, and invasive ductal carcinoma. Clinical history and examination, imaging, and tissue sampling when appropriate are co-dependent factors that guide the assessment of nipple-areolar pathologies. This article provides a review of the normal anatomy, common anatomical variants, benign and malignant pathologies, and imaging techniques to guide the diagnostic assessment of the nipple-areolar complex.

Core needle biopsy of benign, borderline and in-situ problematic lesions of the breast: Diagnosis, differential diagnosis and immunohistochemistry

Core needle biopsy (CNB) is the most common sampling technique for the histologic evaluation of breast abnormalities. Diagnosing benign proliferative, borderline and some in-situ lesions in CNB is challenging and subject to a significant degree of interobserver variability. In addition, due to the inherent limitations of CNB, "upgrading" to a more significant pathology at excision is an important consideration for some lesions. Pathologists carry a major responsibility in patient diagnosis, risk stratification and management. Familiarity with the histologic features and the clinical significance of these common and problematic lesions encountered in CNB is necessary for adequate treatment and patient follow-up. This review will focus on benign, atypical and in-situ epithelial proliferations, papillary lesions, radial sclerosing lesions, adenosis and cellular fibroepithelial lesions. Highlights of histologic features, useful strategies for accurate diagnosis, basic immunohistochemistry and management will be presented.

Heterogeneous risk profiles among B3 breast lesions of uncertain malignant potential

Background:

Most cases of breast lesions of uncertain malignant potential (B3) undergo surgical intervention. We aimed to analyze the outcome of B3 lesion subtypes in a large series of screen-detected cases.

Methods:

We screened 2,986 core needle biopsies to classify B3 lesions. Positive predictive values (PPVs) for malignancy were calculated for a comprehensive risk characterization according to clinicopathologic and morphologic variables.

Results:

B3 lesions comprised 35% atypical ductal hyperplasia (PPV = 20%), 16.7% flat epithelial atypia (PPV = 12%), 22.7% lobular neoplasia (PPV = 16.2%), 9% papillary lesion (PPV = 18.5%), 8.6% phyllodes tumor (PPV = 3.8%), and 8% radial scars (PPV = 4.1%) based on histopathologic diagnosis. Upgrade rates were 15.9% for calcifications, 13.7% for mass lesions, and 16.7% for architectural deformities, with 8.3% of malignant lesions classified as ductal carcinoma in situ and 6.7% as invasive cancers (PPV = 15%).

Conclusion:

B3 lesions entail a heterogeneous risk of malignancy, and careful radiologic–pathologic correlation is required for optimal treatment.

Benign Breast Tumours - Diagnosis and Management

With improvements in breast imaging, mammography, ultrasound and minimally invasive interventions, the detection of early breast cancer, non-invasive cancers, lesions of uncertain malignant potential, and benign lesions has increased. However, with the improved diagnostic capabilities comes a substantial risk of false-positive benign lesions and vice versa false-negative malignant lesions. A statement is provided on the manifestation, imaging, and diagnostic verification of isolated benign breast tumours that have a frequent manifestation, in addition to general therapy management recommendations. Histological evaluation of benign breast tumours is the most reliable diagnostic method. According to the S3 guideline and information gained from analysis of the literature, preference is to be given to core biopsy for each type of tumour as the preferred diagnostic method. An indication for open biopsy is also to be established should the tumour increase in size in the follow-up interval, after recurring discrepancies in the vacuum biopsy results, or at the request of the patient. As an alternative, minimally invasive procedures such as therapeutic vacuum biopsy, cryoablation or high-intensity focused ultrasound are also becoming possible alternatives in definitive surgical management. The newer minimally invasive methods show an adequate degree of accuracy and hardly any restrictions in terms of post-interventional cosmetics so that current requirements of extensive breast imaging can be thoroughly met.

ACR Appropriateness Criteria® Evaluation of Nipple Discharge

Appropriate imaging evaluation of nipple discharge depends the nature of the discharge. Imaging is not indicated for women with physiologic nipple discharge. For evaluation of pathologic nipple discharge, multiple breast imaging modalities are rated for evidence-based appropriateness under various scenarios. For women age 40 or older, mammography or digital breast tomosynthesis (DBT) should be the initial examination. Ultrasound is usually added as a complementary examination, with some exceptions. For women age 30 to 39, either mammogram or ultrasound may be used as the initial examination on the basis of institutional preference. For women age 30 or younger, ultrasound should be the initial examination, with mammography/DBT added when ultrasound shows suspicious findings or if the patient is predisposed to developing breast cancer. For men age 25 or older, mammography/DBT should be performed initially, with ultrasound added as indicated, given the high incidence of breast cancer in men with pathologic nipple discharge. Although MRI and ductography are not usually appropriate as initial examinations, each may be useful when the initial standard imaging evaluation is negative. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Papillary lesions of the breast: To excise or observe?

Papillary lesions of the breast range from benign to atypical to malignant. Although papillomas without frank cancer are benign, their management remains controversial. When a core needle biopsy of a lesion yields a diagnosis of intraductal papilloma with atypia, excision is generally recommended to rule out a concurrent malignant neoplasm. For intraductal papillomas without atypia, however, recommendations for excision versus observation are variable. The aims of this study are to evaluate the rate of concurrent malignancies for intraductal papilloma diagnosed on core needle biopsy and to assess the long-term risk of developing cancer after the diagnosis of a papillary lesion. This single institution retrospective study analyzed 259 patients that were diagnosed with intraductal papilloma (IDP) by core needle biopsy from 1995 to 2010. Patients were grouped by initial diagnosis into three groups (papilloma without atypia, papilloma with atypia, and papilloma with atypical duct hyperplasia or atypical lobular hyperplasia (ADH/ALH) and followed up for long-term outcomes. After a core needle biopsy showing IDP with atypia or IDP + ADH/ALH, surgical excision yielded a diagnosis of concomitant invasive or ductal in situ cancer in greater that 30% of cases. For intraductal papilloma without atypia, the likelihood of cancer was much lower. Moreover, even with excision, the finding of intraductal papilloma with atypia carries a significant risk of developing cancer long-term, and such patients should be followed carefully and perhaps should be considered for chemoprevention.

Atypical papillary lesions after core needle biopsy and subsequent breast carcinoma

Background: Papillary lesions of the breast cause diagnostic problem because papillary structures are found in benign and malignant processes. Core needle biopsy is important to make an initial diagnosis, but it still has potential pitfalls. Comparison between core needle biopsy and excisional biopsy can predict the possibility of malignant change in atypical papillary lesions.

Objective: Evaluate the concordance between core needle biopsy and excisional results in atypical papillary lesions of the breast.

Materials and methods: The pathology database of University of Texas Medical Branch at Galveston, USA was searched for patients with atypical papillary lesions at core needle biopsy who subsequently underwent surgical excision. Pathology reports from the excisional biopsies was also examined to assign each case to one of three categories, downgrade to benign papilloma, no change (remained atypical papillary lesion), and upgrade to carcinoma. The mammograms and ultrasounds were reviewed for each case. They characterized the lesions according to multiple imaging criteria.

Results: Twenty-four patients with atypical papillomas at core biopsy subsequently underwent surgical excision. The lesions were downgraded to benign papilloma in 25%, remained atypical papillary lesion in 33%, and upgraded to carcinoma in 42%. On mammographic presentations (n = 23), masses were in 61%, architectural distortion in 4.3%, mass with calcifications in 9%, mass with architectural distortion and calcifications in 4.3%, calcifications alone in 17.4%, and architectural distortion and calcifications in 4.3%. On ultrasound findings (n = 21), solid masses were in 90%, intracystic masses in 10%, peripheral in locations in 81%, and subareolar in location in 19%.

Conclusion: Due to the high upgrade rate of atypical papillary lesions to carcinoma (42%), excision of all atypical papillary lesions with wide excision margin is recommended for cases with pathologic diagnosis of atypical papillary lesion on core-needle biopsy.

A Case of Intraductal Papilloma of the Breast With High 18F-FDG Uptake on PET/CT

We present a case of intraductal papilloma in the right breast of a 51-year-old woman with high F-FDG uptake. Its maximum standardized uptake value increased from 10.2 on early (1 h) PET/CT scan to 12.2 on delayed (2 h) PET/CT scan suggesting a primary breast cancer. However, histopathology proved it to be an intraductal papilloma. Immunohistochemically, strong expression of glucose transporter-1 and weak expression of hexokinase-II were noted in the papilloma. With the detection of a subareolar intracystic mass with high F-FDG uptake, intraductal papilloma should be included in the differential diagnosis.

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.

Breast MRI in patients with unilateral bloody and serous-bloody nipple discharge: a comparison with galactography

Purpose. Assessing the role of breast MRI compared to galactography in patients with unilateral bloody or serous-bloody nipple discharge. Materials and Methods. Retrospective study including 53 unilateral discharge patients who performed galactography and MRI. We evaluated the capability of both techniques in identifying pathology and distinguishing between nonmalignant and malignant lesions. Lesions BIRADS 1/2 underwent follow-up, while the histological examination after surgery has been the gold standard to assess pathology in lesions BIRADS 3/4/5. The ROC analysis was used to test diagnostic MRI and galactography ability. Results. After surgery and follow-up, 8 patients had no disease (15%), 23 papilloma (43%), 11 papillomatosis (21%), 5 ductal cancer in situ (10%), and 6 papillary carcinoma (11%) diagnoses. Both techniques presented 100% specificity; MRI sensitivity was 98% versus 49% of galactography. Considering MRI, we found a statistical association between mass enhancement and papilloma (P < 0.001; AUC 0.957; CI 0.888–1.025), ductal enhancement and papillomatosis (P < 0.001; AUC 0.790; CI 0.623–0.958), segmental enhancement and ductal cancer in situ (P = 0.007; AUC 0.750; CI 0.429–1.071), and linear enhancement and papillary cancer (P = 0.011). Conclusions. MRI is a valid tool to detect ductal pathologies in patients with suspicious bloody or serous-bloody discharge showing higher sensitivity and specificity compared to galactography.

Role of galactography in the early diagnosis of breast cancer

BACKGROUND

The purpose of this study was to evaluate the usefulness of galactography (GL) in the early diagnosis of breast cancer in patients with pathologic nipple discharge (PND).

PATIENTS AND METHODS

We retrospectively studied all galactograms obtained in 117 women with PND, who subsequently had a biopsy. The findings detected in the galactograms of the patients in this study were assigned to different categories of the Galactogram Image Classification System (GICS): GICS 2, benign; GICS 3, probably benign; GICS 4, suspicious for malignancy; and GICS 5, highly suspicious for malignancy.

RESULTS

The galactograms were classified into GICS 2 (29 cases; 24.7%), GICS 3 (42 cases; 35.8%), GICS 4 (30 cases; 25.6%), and GICS 5 (16 cases; 13.6%). A good correlation was observed between histological diagnosis and GICS categories (p < 0.05). All cases diagnosed with carcinoma (n = 18) were classified in GICS categories 4-5: ductal carcinoma in situ in 14 cases (11.9%) and invasive carcinoma in 4 cases (3.4%).

CONCLUSION

GL is a useful procedure in the early diagnosis of breast cancer in patients with PND.

Selective ductectomy for the diagnosis and treatment of intraductal papillary lesions presenting with single duct discharge

Solitary ductal papilloma of the breast, although considered a benign disorder has a potential association with carcinomas. We studied and analyzed the role of selective ductectomy (SD) for the diagnosis and treatment of intraductal lesions presenting with single duct discharge and ductography suggestive of intraductal (papillary) lesions. During a ten-year-period, files of patients presenting with single (or rarely dual) duct discharge were retrospectively reviewed. The examinations included mammography, ductography and ultrasonography and cytology of the fluid discharged from the duct in all patients. Patients treated with SD were considered further and their histological diagnosis and treatment were analyzed. The series included 100 patients. In 6 cases malignancy was found in the specimen consisting of four in situ and two invasive ductal carcinomas. These 6 patients had a second operation and this was followed by adjuvant treatment. Nine further patients had atypical ductal hyperplasia in or around papillomas and one patient had lobular neoplasia around her papilloma. In the present series, the incidence of carcinoma associated with the clinical suspicion of papillary lesions was 6%, and further 10% had low grade neoplastic proliferations resulting in the diagnosis of atypical papillomas or atypical ductal hyperplasia or lobular neoplasia around the papilloma, indicating that single duct discharge may be a symptom a malignancy, and that ductal papillomas have malignant potential. For such a low risk and grade of malignancy simple follow-up could be one option, but in some cases SD could be applied to relieve the patients from symptoms and establish a diagnosis.

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.

[Evaluation of suspicious nipple discharge with MRI: review of 50 cases]

PURPOSE

To determine the role of MRI in the evaluation and management of patients with suspicious nipple discharge and normal mammographic and US evaluation.

PATIENTS AND METHODS

A total of 50 patients with suspicious nipple discharge and normal mammographic and US evaluation prospectively underwent MRI. The first 16 patients underwent routine breast MRI, while MR-ductography with image fusion at the console was added for the last 34 patients.

RESULTS

In 22 of 25 high-risk and malignant lesions, MRI showed enhancement whereas it was normal in three cases. In 25 benign cases (resolution of discharge/benign non-proliferative breast disease), MRI was negative in 22 cases and falsely positive in three cases.

CONCLUSION

In this clinical setting, MRI shows excellent sensitivity, PPV and NPV. A negative result on MRI would support clinical follow-up as opposed to surgery.

MRI features of intraductal papilloma of the breast: sheep in wolf's clothing?

BACKGROUND

Intraductal papillomas often present as small, smooth masses, dilated ducts or microcalcifications at mammography and as smooth, hypoechoic masses at sonography. At magnetic resonance imaging (MRI), intraductal papillomas often present as small smooth masses, however, often with strong enhancement with type 2 or 3 time intensity curves. The result of the MR analysis is therefore not infrequently inconclusive in order to characterize the mass as benign or malignant.

PURPOSE

To characterize the appearance of intraductal papillomas of the breast at MRI, and determine whether the application of diagnostic rules described in literature could contribute to correctly classifying the lesions as benign.

MATERIAL AND METHODS

Twenty patients with histologically proven intraductal papillomas were included. Two radiologists independently reviewed the MR images of the breast. The BI-RADS(®) nomenclature was used to describe morphology and contrast-enhancement kinetics. Interobserver agreement in the interpretation of the MR images by the two investigators was performed. Kappa coefficient was calculated as index for the level of agreement. Subsequently, three sets of diagnostic rules, including the Göttinger score described by Fischer and the interpretation flowcharts according to Kinkel and to Tozaki were applied to characterize whether a biopsy should be recommended or not.

RESULTS

All papillomas presented as masses on dynamic contrast-enhanced MRI. Only five papillomas showed a round, oval, or lobulated shape combined with smooth margins and continuous rise of the time intensity curve. Using the Göttingen score, biopsy would be recommended in 16 patients. Based on the interpretation flowcharts of Kinkel and of Tozaki, an additional 13 and 10 papillomas, respectively, were correctly classified as benign. Dilated ducts were visible in 10 patients. The interobserver agreement was good or excellent for all included variables.

CONCLUSION

Including systematic analysis of breast MRI to the diagnostic protocol and interpreting the images according to predetermined diagnostic rules, most solitary intraductal papillomas of the breast may be correctly characterized as benign.

Multiple Papillomatosis of Breast and Patient's Choice of Treatment

Papillary lesions of breast represent a range of lesions. Intraductal papilloma and its association with nipple discharge are well known. However, multiple papillomatosis has quite distinct characteristics and decision making can be somewhat challenging. We report a case of multiple papillomatosis in association with ductal carcinoma in situ (DCIS). Patient opted for ipsilateral mastectomy and prophylactic mastectomy of contralateral breast. Her decision of having prophylactic mastectomy was vindicated by presence of incidental DCIS in the contralateral breast. To our knowledge, this is the first reported case of multiple papillomatosis with DCIS of breast, along with incidental synchronous papillomatosis of contralateral breast with DCIS. The case illustrates few distinct features of multiple papillomatosis of breast and exemplifies how a patient's choice is so paramount in decision making process. Patients should be fully informed of the treatment options of the condition, and their wishes should be fully taken into account while making the final decision.

Are we overtreating papillomas diagnosed on core needle biopsy?

BACKGROUND

Breast papillomas often are diagnosed with core needle biopsy (CNB). Most studies support excision for atypical papillomas, because as many as one half will be upgraded to malignancy on final pathology. The literature is less clear on the management of papillomas without atypia on CNB. Our goal was to determine factors associated with pathology upgrade on excision.

METHODS

Our pathology database was searched for breast papillomas diagnosed by CNB during the past 10 years. We identified 277 charts and excluded lesions associated with atypia or malignancy on CNB. Two groups were identified: papillomas that were surgically excised (group 1) and those that were not (group 2). Charts were reviewed for the subsequent diagnosis of cancer or high-risk lesions. Appropriate statistical tests were used to analyze the data.

RESULTS

A total of 193 papillomas were identified. Eighty-two lesions were excised (42%). Caucasian women were more likely to undergo excision (p = 0.03). Twelve percent of excised lesions were upgraded to malignancy. Increasing age was a predictor of upgrading, but this was not significant. Clinical presentation, lesion location, biopsy technique, and breast cancer history were not associated with pathology upgrade. Two lesions in group 2 ultimately required excision due to enlargement, and both were upgraded to malignancy.

CONCLUSIONS

Twenty-four percent of papillomas diagnosed on CNB have upgraded pathology on excision--half to malignancy. All of the cancers diagnosed were stage 0 or I. For patients in whom excision was not performed, 2 of 111 papillomas were later excised and upgraded to malignancy.

Ensuring excision of intraductal lesions: marker placement at time of ductography

RATIONALE AND OBJECTIVES

To propose grid coordinate marker placement for patients with suspicious ductogram findings occult on routine workup. To compare the success of marker placement and wire localization (WL) with ductogram-guided WL.

MATERIALS AND METHODS

A retrospective search of radiology records identified all patients referred for ductography between January 2001 and May 2008. Results for 16 patients referred for ductogram-guided WL and 5 patients with grid coordinate marker placement at the time of ductography and subsequent WL were reviewed. Surgical pathology results and clinical follow-up were reviewed for concordance.

RESULTS

Nine of 16 patients (56.3%) underwent successful ductogram-guided WL. Eight of nine patients had papillomas, one of which also had atypical ductal hyperplasia (ADH). One of nine patients had ectatic ducts with inspisated debris. Seven patients who failed ductogram-guided WL eventually underwent open surgical biopsy. Four of seven patients had papillomas, one of which also had lobular carcinoma in situ. Remaining patients had ADH (1/7) and fibrocystic changes with chronic inflammation (3/7). All five (100%) patients with grid coordinate marker placement underwent successful WL and marker excision. Pathology results included three papillomas, papillary intraductal hyperplasia, and fibrocystic change.

CONCLUSION

Grid coordinate marker placement at the time of abnormal ductogram provided an accurate method of localizing ductal abnormalities that are occult on routine workup, thus facilitating future WL. Marker placement obviated the need for repeat ductogram on the day of surgery and ensured surgical removal of the ductogram abnormality.

Risk factors for malignancy in benign papillomas of the breast on core needle biopsy

BACKGROUND

This study was designed to evaluate the clinical and pathologic parameters of benign papillomas diagnosed on core needle biopsy (CNB) and predict malignancy risk after surgical excision.

METHODS

We retrospectively reviewed clinicopathologic findings for 160 CNB-diagnosed benign papillomas followed by surgical excision from 154 patients.

RESULTS

Ten (6.3%) of the excised lesions were diagnosed as malignant. Univariate analysis showed that those that were palpable on physical examination, detected as a mass on mammography, or >1 cm on sonography were significantly associated with malignancy. In multivariate analysis, lesions that were palpable (odds ratio (OR), 29.2; 95% confidence interval (CI), 4.06-209.58; P = 0.001) or detected as a mass (OR, 5.68; 95% CI 1.08-29.87; P = 0.04) remained significantly associated with malignancy. In a CART analysis, including all variables, lesions that were palpable and associated with a mass on mammogram were confirmed as malignant.

CONCLUSIONS

Breast lesions diagnosed as benign papillomas on CNB had a 6.3% risk of being malignant. The risk was highest for lesions that were palpable and detectable as a mass on a mammogram. In addition, the low-risk patients avoid immediate surgical excision, although they should be followed carefully.

Diagnostic value of 3D fast low-angle shot dynamic MRI of breast papillomas

PURPOSE

To evaluate the value of breast MRI in analysis of papillomas of the breast.

MATERIALS AND METHODS

From 1996 to 2004, 94 patients underwent surgery due to papillomas of the breast. Among them, 21 patients underwent 3D fast low angle shot (FLASH) dynamic breast MRI. Eight masses were palpable and 11 of 21 patients had nipple discharge. Two radiologists indifferently analyzed the location, size of the lesions and shape, margin of the masses, multiplicity and ductal relation. The MRI findings were categorized according to breast imaging reporting and data system (BI-RADS) lexicon. The amount and pattern of enhancement and associated findings were also evaluated according to BI-RADS. We then compared the MRI findings with galactography, mammography and breast ultrasonography (US) and examined histopathologic correlation.

RESULTS

On breast MRI, the lesion size was 0.4-1.59 cm, and 18 patients showed subareolar location. On 4.25 cm (mean 1.54) dynamic enhanced images, imaging findings showed mass (n = 10), intracystic mass (n = 3), focus (n = 5), ductal enhancement (n = 2), and segmental enhancement (n = 1). In cases of the masses, the shapes of the masses were round (n = 4), lobulated (n = 3), and irregular (n = 6), and margins were circumscribed (n = 6), microlobulated (n = 5), and indistinct (n = 2). The enhancement patterns were homogeneous enhancement (n = 7), heterogeneous (n = 3) or rim enhancement (n = 3).

CONCLUSION

The contrast enhanced dynamic breast MRI was highly sensitive for diagnosis of breast papillomas. MRI could play a key role in the pre-operative work-up for multiple papillomas and papillomatosis.

Papillary neoplasms of the breast: a review

CONTEXT

Interpretation of papillary lesions of the breast remains a challenging task because of the wide morphologic spectrum encountered in the benign, atypical, and malignant subtypes. Data on clinical significance and outcome of papillary lesions, with superimposed atypia or areas similar to ductal carcinoma in situ partially replacing the benign elements, are sparse. Furthermore, complete excision of even a fully developed papillary carcinoma confined to a dilated or cystic duct is associated with an excellent prognosis, whereas a complex papilloma extending into multiple branches of a duct may ultimately recur as a carcinoma because of incomplete excision of microscopic foci. This makes an outcome-based classification difficult.

OBJECTIVE

An arbitrary yet practical approach to classification is outlined, with discussion of methods to circumvent the various diagnostic difficulties. The limitations in precise diagnosis of papillary lesions in aspirates are addressed, and the implications of finding papillary lesions in core biopsies are discussed. Although the focus is on intraductal lesions, associated invasive carcinomas and invasive micropapillary carcinoma are also presented.

DATA SOURCES

The literature on papillary lesions and invasive micropapillary carcinoma is reviewed.

CONCLUSIONS

It would be prudent to completely excise any papillary lesion that has not been entirely removed by the initial core biopsy. The optimal management of localized papillary lesions is complete excision with a small rim of uninvolved breast tissue without any prior needle instrumentation if and when the papillary nature can be determined by imaging. Thus managed, most of these lesions behave indolently, and outcome is usually excellent.

Spectrum of papillary lesions of the breast: clinical, imaging, and pathologic correlation

OBJECTIVE

Papillary lesions of the breast are a heterogeneous group of lesions that are difficult to diagnose as benign or malignant. The purpose of this article is to review clinical presentation, imaging features, and pathologic correlation of papillary lesions of the breast and to discuss the prognosis and management of these lesions.

CONCLUSION

Recognition of the variety of benign and malignant papillary lesions of the breast will facilitate diagnosis and proper management.

[Core needle biopsy of papillary breast lesions: impact on patient management]

OBJECTIVES

To evaluate the clinical and radiological presentations of papillary breast lesions and to evaluate the performance of core needle breast biopsy in papillary lesions.

MATERIAL AND METHODS

We retrospectively studied 55 papillary breast lesions in 46 patients aged 28 to 87 years diagnosed using core needle biopsy in the period 1994-2005. We reviewed the clinical and radiological presentations of the lesions, the findings at histological study after percutaneous biopsy, and the correlation of these findings with those of the surgical biopsy (44 cases) and/or radiological follow-up (42 cases).

RESULTS

The most common mammographic presentation was circumscribed or ill-defined, single or multiple nodules. Ill-defined lesions were significantly associated with malignancy (p < 0.05). The results of the percutaneous biopsy were: benign papillary lesion (n = 32), papillary lesion with atypia (n = 9), and malignant papillary lesion (n = 14). The diagnostic accuracy of core needle biopsy calculated from the 44 cases with surgical confirmation was: sensitivity 63%, specificity 100%, predictive positive value 100%, predictive negative value 73%, and rate of underestimation 25%. During follow-up, increased lesion size or the appearance of new lesions was seen in four patients.

CONCLUSIONS

The diagnosis can be suspected in cases of postmenopausal patients with multiple circumscribed or ill-defined, solid or mixed lesions at ultrasound study. Although the finding of an invasive malignant papillary lesion after percutaneous biopsy enables treatment to be planned, in the remaining situations (benign papillary lesion, with atypia, or carcinoma in situ) underestimation is common and the lesion should be surgically excised. Vacuum-assisted biopsy systems might improve these results.

Breast Papillomas in the Era of Percutaneous Needle Biopsy

BACKGROUND

The significance of breast papillomas detected on core needle biopsy (CNB) remains unclear. While those associated with malignancy or atypia are excised, no clear solution exists for benign papillomas. We sought to determine the indication for surgical excision, incidence of malignancy, significance, and natural history.

METHODS

In this retrospective review, patients were divided into benign, atypical, or malignant cohorts based on initial results. While patients with malignant or atypical features were encouraged to undergo surgical excision, no standard recommendation was given for benign papillomas. Mammographic features, method of initial diagnosis, pathology results, and follow-up data were analyzed.

RESULTS

Between January 1994 to December 2005, 5,257 CNBs were performed at our tertiary level medical center. 206 patients were diagnosed with 215 breast papillomas. 174 (81%) papillomas were benign, 26 (12%) were associated with atypia, and 15 (7%) were associated with malignancy. Two benign papillomas (1.1%) developed into cancer over an average of 53 months. Average follow-up of those patients not undergoing excision for benign papilloma was 41 months; we had 92 patients with greater than two year follow-up and 57 patients with greater than four year follow-up. Of patients with atypia or malignancy associated with papilloma, there was a 26% and 87% associated rate of malignancy, respectively.

CONCLUSIONS

Benign breast papillomas diagnosed by CNB have a low risk of malignancy and do not need excision. However, they should be considered high risk lesions which require serial radiographic monitoring. Papillomas associated with atypia or malignancy should continue to be excised.

Papillary lesions of the breast: a review

Papillary lesions comprise a wide spectrum of lesions in terms of their clinical presentation, morphologic appearance, malignant potential, and clinical behavior. Their defining feature is that of a fibrovascular stromal core lined by epithelial and myoepithelial cells, attached to the wall of the duct and extending into the duct lumen. Papillary lesions are often diagnostically challenging both on core biopsy and in excision specimens. Much of the difficulty arises from the many different terminologies that are used to describe the various entities that are included under the umbrella term of papillary lesions. Separation of papillary lesions into categories with a meaningful clinical outcome is most appropriate; however, there is a relative paucity of well-designed outcome studies with substantial cohort numbers to provide information in this regard. We use a pragmatic approach to the classification of papillary lesions in our practice, as we will outline in this review. We will also discuss controversies surrounding papillary lesions and focus on management of these lesions on core biopsy and in excision specimens.

Papilläre Tumoren der Mamma

The term papilloma applies to benign proliferative epithelial breast lesions with a papillary architecture. The papillae in such lesions contain an arborizing fibrovascular core, glandular surface epithelium and a basal myoepithelial layer. A basement membrane encloses these structures. Papilloma may occur at any site in the ductal lobular system and according to its localization is subdivided into two types: solitary (central) papilloma which are located in the major nipple/subareolar ducts or large segmental ducts and multiple (peripheral) papillomas in cystically dilated terminal ductal lobular units (TDLU). Stromal changes, epithelial metaplasia and/or proliferations and neoplasia may alter the prototypical architecture. In a significant number of papillomas atypia can be identified which have to be classified as atypical proliferates of the ductal type. These lesions must be distinguished from the papillary type of ductal carcinoma in situ. Some 17% of all papilloma are associated with (synchronous) intraductal or invasive carcinoma, but these also act as an indicator for subsequent (metachronous) carcinoma. As a consequence, in minimally invasive biopsy papilloma has to be classified as B3 and usually has to be followed by surgical excision.