Intraductal breast papilloma: aetiology, clinical presentation, diagnosis and treatment

Intraductal papilloma is a benign mass located in the mammary ducts, which develops as a result of abnormal overgrowth of epithelial cells.

Intraductal papillomas may be solitary or multiple and located in any quadrant of the breast but are most commonly localised centrally behind the nipple, affecting the central duct.

Risk factors for developing intraductal papilloma:

• Hormonal imbalance;
• Associated endocrine diseases (obesity, diabetes mellitus, thyroid disorders);
• Taking oral contraceptives;
• Hormone replacement therapy with oestrogen-containing agents;
• Hereditary predisposition.

Aetiology and pathogenesis of intraductal papilloma

The development of intraductal papilloma is based on hormonal imbalance, namely the increased sensitivity of breast tissue to oestrogen and its hyperproduction.

Hyperoestrogenaemia triggers proliferation of breast ductal epithelial cells, leading to hyperplasia of breast tissue and ductal dilation. As a result of these processes, papillary outgrowths are formed in the lumen of the duct, which are intraductal papilloma.

Morphological presentation

Intraductal papilloma can be central (usually solitary and large in size) and peripheral (small in size, may be multiple). Histologically, they are characterised by the presence of a fibrovascular rod covered with epithelial and myoepithelial cells (true papillae).

Intraductal papilloma may erode and sclerotise, but atypical proliferation, squamous cell or apocrine metaplasia with subsequent malignisation and development of ductal breast cancer is also possible.

Clinical Manifestations

Clinical manifestations of intraductal papilloma depend on its size and localisation.

Peripheral intraductal papillomas are usually asymptomatic and detected by screening ultrasound.

Central intraductal papillomas are characterised by the following symptoms:

• A yellowish-transparent to red-brown (bloody) nipple discharge is the most common symptom;
• Presence of a palpable mass in the areolar region behind the nipple.

Diagnosis of intraductal papilloma

1. Medical history, examination and palpation of breasts.
2. Breast ultrasound and peripheral lymph nodes: a mass protruding into the lumen of the duct or cystic cavity is visualised.
3. Mammography in most cases is uninformative and is used as a method of clarifying diagnosis when ductal breast cancer is suspected. Radiologically, an intraductal papilloma may be defined as a rounded mass with clear, even contours, similar to a cyst, but of higher density.
4. Ductography is used to clarify the diagnosis. On radiographs, after contrast agent injection, duct dilation and deformity, irregularities of contours with the presence of contrasted formations and filling defect (disruption in the contrast enhancement pattern) are determined.
5. MRI is used for clarifying diagnosis. Intraductal papillomas are characterised by the presence of a well-defined rounded mass on MRI, isointense or slightly hypointense in T1-mode, and well accumulating contrast in T2-mode.
6. Cytological examination of nipple discharge.
7. Fine-needle aspiration biopsy of the tumour.
8. Core needle biopsy of the tumour.

You can see radiographs and MRI images illustrating an intraductal papilloma below. Authors: Mohammad Taghi Niknejad, Bahman Rasuli. Source: Radiopaedia [11]:

Ductography of the right breast: a filling defect typical of an intraductal papilloma is detected on the radiograph. Author: Mohammad Taghi Niknejad

MRI picture of intraductal papilloma in T2-weighted, fat-suppressed mode. Author: Bahman Rasuli

MRI picture of intraductal papilloma in T1-weighted mode. MRI for intraductal papilloma. Author: Bahman Rasuli

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Treatment of intraductal papilloma

Intraductal papilloma should be treated surgically due to the high risk of malignisation. A sectoral resection of the breast (lumpectomy) with subsequent histological examination of the removed material is indicated.