Breast papilloma: Clinical sciences

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Introduction0:00–0:33

Breast papillomas result from the abnormal growth of epithelial cells into the ductal lumen. Papillomas can be solitary and centrally located, arising in the main lactiferous ducts, or they can be multiple and peripheral, involving the terminal ductal lobular unit.
Papillomas are generally benign but can be associated with other high-risk lesions, and rarely, malignant pathologies. When assessing a patient with a chief concern suggestive of breast papilloma, first obtain a focused history and physical exam.

History and Physical Exam0:33–1:44

Patients might report spontaneous unilateral nipple discharge, ranging in consistency from clear to bloody. They may have noticed a breast lump or had an abnormal screening mammogram.
On physical exam, you might palpate a breast mass, but this is less common. An important thing to do is to attempt and elicit nipple discharge.
Apply gentle pressure around the areola in a clockwise fashion, and if nipple discharge occurs note the location of the duct and the exact site of your applied pressure when it was expressed.
Also take note if the discharge appears to be serous to serosanguinous, or frankly bloody.Here’s a clinical pearl! If the nipple discharge does not appear to be bloody, it can be tested with a Guaiac test kit to assess for the presence of any occult blood.

Imaging1:44–3:45

Now, if you see these findings in history and physical, you should suspect breast papilloma and order some imaging. The first step is to obtain a breast ultrasound and a diagnostic mammogram.
On ultrasound, you might see a solid nodule or mass within a dilated breast duct, as well as its associated fibrovascular pedicle.
On a diagnostic mammogram, findings are oftentimes normal or unremarkable. However, a round or mass may be seen, and occasionally even a cluster of central or peripheral microcalcifications.
If you see any of these findings, you’ll want to proceed to a core needle biopsy for further investigation. Here’s a clinical pearl!
If your patient with unilateral spontaneous nipple discharge has negative ultrasound and mammogram findings, it does not mean that you should discontinue your workup!
Several advanced imaging options can be used in your clinical investigation. The first step is to obtain a breast MRI.
If this is negative, two additional invasive imaging studies are available: galactography and ductoscopy. Galactography utilizes the injection of contrast material into a cannulated breast duct combined with mammography.
A filling defect seen on imaging confirms the diagnosis of an intraductal papilloma and helps to identify its location. When it comes to ductoscopy, this utilizes a very small camera that can visually explore breast ducts.
This can be therapeutic as well as diagnostic when combined with surgery. Dye, such as methylene blue, can be injected into the duct after locating a papillary lesion with ductoscopy, and then the same duct can be identified and removed through a small periareolar incision.

Core Needle Biopsy3:45–3:56

Okay, once imaging is complete, and you still think the patient might have breast papilloma, the next step is to confirm the diagnosis by obtaining a tissue sample using a core needle biopsy.
First, let’s see what it would look like on core needle biopsy. So, papillomas appear as intraductal proliferations of branching fibrovascular stalks that are lined with orderly layers of ductal epithelial cells and myoepithelial cells.

Intraductal papilloma/Papillomatosis3:56–5:59

Less frequently, papillomas can also present with focal necrosis, so do not misinterpret the presence of necrosis as a sign of atypia or malignancy!
In fact, the biopsy will also reveal the absence of any atypical or malignant cells. If this is the case, you are dealing with an intraductal papilloma or papillomatosis.
The difference is that intraductal papilloma means that there is a solitary central papilloma, while in papillomatosis there are multiple peripheral papillomas.
More specifically, patients with papillomatosis have five or more papillomas within a local segment of breast tissue. Additionally, patients with papillomatosis might have a higher chance of bilateral lesions, so when this is the case always double-check to make sure that both breasts were examined and imaged.
Moving on to management, for patients with a solitary intraductal papilloma, you should start by calling for a surgical consultation for possible excision.
The surgeon and patient can continue discussions about the excision of the papilloma versus close observation and routine surveillance, such as continued age-based breast cancer screening.
Most patients will typically have the duct surgically removed.When it comes to papillomatosis, there’s an important thing to keep in mind.
Papillomatosis carries a higher risk of developing a malignant lesion in the future. Because of this, surgical excision is always recommended for papillomatosis.
After surgery, the patient should undergo post-treatment surveillance and continue age and risk factor-based breast cancer screening.

Papilloma with atypia5:59–7:03

Alright, going back to the core needle biopsy results, let’s discuss another possibility. You might see areas of atypical ductal hyperplasia, or ADH for short.
Now, ADH means that there is additional cellular proliferation and noticeably fewer myoepithelial cells. These areas are less than 3 millimeters in size and do not have malignant features.
If this is the case you can make the diagnosis of papilloma with atypia. Keep in mind that this is not a malignant lesion, but these patients are considered to be at higher risk for developing a future malignancy.
Once the diagnosis is made, go ahead and consult a surgeon for excision of the lesion, and even consideration of prescribing a SERM, such as tamoxifen, for risk reduction.
Once again, after surgery, the patient should undergo post-treatment surveillance and continue age and risk factor-based breast cancer screening.

Papilloma with Malignancy7:03–9:25

Ok, finishing up, let’s go over one last category of potential core needle biopsy results. Sometimes you will encounter biopsy results consistent with a papillary lesion that contains regions of malignant cells that may or may not be confined by a basement membrane.
If this is what you see, go ahead and diagnose papilloma with malignancy. This includes papillary lesions associated with an immediately adjacent growth of ductal carcinoma in situ, or DCIS, as well as various malignant lesions with distinctive papillary morphology, such as papillary DCIS or invasive papillary carcinoma, which is a rare subtype of invasive breast cancer.
Patients with a papillary malignancy that is found to have any form of DCIS are treated similarly to other patients diagnosed with DCIS.
Start with a surgical consultation for excision. This can take the form of breast-conserving therapy, which includes a partial mastectomy and post-surgical radiation therapy; or, in certain cases, a complete mastectomy with or without breast reconstruction.
Depending on the results of hormone receptor testing, patients with ER-positive lesions can start a SERM, such as tamoxifen for chemoprevention and risk reduction.
Make sure to take a complete history of the patient’s individual and familial risk factors, in order to see if they qualify for additional genetic counseling and testing.
Finally, after surgery, continue post-treatment surveillance. Similarly, when patients are diagnosed with invasive papillary carcinoma or any papilloma with associated invasive malignancy, it is worked up as an invasive breast cancer.
Begin by performing appropriate TNM staging, including evaluating for axillary adenopathy and ultrasound-guided FNA of any suspicious nodes.
Establish the hormone receptor and HER2/Neu status of the tumor, and consider thorough history-taking to assess if the patient is a candidate for genetic counseling and testing.
Then, obtain a surgical consultation for further management based on TNM staging. Alright, as a quick recap… Breast papillomas result from the abnormal growth of epithelial cells into the ductal lumen.

Review9:25–10:26

To diagnose a papilloma, begin with a history and physical examination. Then, obtain an ultrasound and mammogram, followed by a core needle biopsy.
On biopsy, if you find a papilloma with no atypical or malignant features, get surgical consultation for further management and possible excision; while if papillomatosis is found, surgical excision is always advised, since it carries a higher risk of developing a malignant lesion in the future.
Patients whose papillomas have areas of atypical growth, such as atypical ductal hyperplasia, should undergo surgical excision and even consideration of chemoprevention, such as tamoxifen.
Lastly, patients with papillary malignancy, which can range from DCIS to various forms of invasive malignancy, should be treated in the same fashion as other forms of in-situ and invasive breast malignancies.
Breast papilloma: Video, Causes, and Symptoms | Osmosis