Breast nonmalignant
Benign tumors
Intraductal papilloma


Topic Completed: 1 April 2010

Revised: 30 May 2019

Copyright: 2002-2019, PathologyOutlines.com, Inc.

PubMed Search: Papilloma of the breast [title]

Hind Warzecha, M.D.
Belinda Lategan, M.D.
Page views in 2018: 17,548
Page views in 2019 to date: 14,009
Cite this page: Nassar H, Lategan B. Intraductal papilloma. PathologyOutlines.com website. http://www.pathologyoutlines.com/topic/breastpapilloma.html. Accessed August 25th, 2019.
Definition / general
  • Intraductal proliferation of epithelial and myoepithelial cells overlying fibrovascular stalks
Terminology
  • "Papillomatosis" is a confusing term because it may refer to hyperplasia or multiple papillomas
  • Central papilloma: occupies large lactiferous ducts, usually solitary
  • Peripheral papillomas: barring certain circumstances, proportionately less common in men
  • Sclerosing papilloma: stroma is densely collagnized and may be most prominent part of lesion, may entrap epithelial component and raise suspicion of malignancy
  • Papilloma with atypia (atypical intraductal papilloma): papilloma with ADH
  • Papilloma with DCIS: intraductal papilloma with DCIS (component of regular intraductal papilloma is still recognizable in the lesion)
Sites
Epidemiology
  • Common; mean age 48 years
Sites
  • Large lactiferous ducts: central papilloma (more common in male breast)
  • Smaller peripheral ducts: peripheral papilloma
Etiology
  • Arises from large or small ducts (arising from terminal duct lobular unit)
  • May be related to ductal adenoma
Clinical features
  • May present as bloody nipple discharge (thought to be due to tortion / infarction) or palpable mass
  • Any age (range 3 - 80 years based on case reports)
  • Central or peripheral
  • Central (large duct): close to nipple within principal lactiferous ducts, 90% solitary, 70% associated with nipple discharge; usually ages 30 - 49 years but any age
  • Peripheral: often clinically occult, discovered by mammographic calcifications
  • Single papillomas: no increased risk of subsequent malignancy with or without associated ADH / ALH (Am J Surg Pathol 2006;30:665) although in one study, 16% contained carcinoma (Eur J Surg Oncol 2010;36:384)
  • Multiple papillomas: increased risk of subsequent malignancy, particularly if ADH / ALH is present (Am J Surg Pathol 2006;30:665)
    • 5 or more papillomas are associated with coexisting atypical (ALH / LCIS, ADH) or malignant breast lesions, also recurrence and contralateral disease (Hum Pathol 2003;34:234)
  • Atypical papillomas: distinction from papillary DCIS is based on size of atypical area or % of papilloma
    • 4x increased risk of invasive carcinoma compared to papillomas without atypia, usually near site of original papilloma (Cancer 1996;78:258)
  • Male papilloma: morphologically and pathologically no different from papillomas in women; incidence difficult to determine due to relatively few case reports, but deemed by most to be less common than in women due to structure and anatomy of male breast
Diagnosis
  • Core needle biopsy, excision
  • Radiology description
  • Mass occupying a cystic space on imaging
  • Best recognized on Ultrasound
  • Radiology images

    Contributed by Dr. Mark R. Wick

    Mammogram

    Case reports
    Treatment
    Gross description
    • Well circumscribed, polypoid intraductal mass, usually < 3 cm, soft, hemorrhagic
    • Often infarcted
    Gross images

    Contributed by Dr. Mark R. Wick:

    Intracystic



    Images hosted on other servers:

    Polypoid intraductal mass

    Hemorrhagic cyst with tan tumor

    Microscopic (histologic) description
    • Multiple papillae in complex arborizing pattern with well developed vascular connective tissue core surrounded by epithelial and myoepithelial cells
    • Benign nuclei, frequent apocrine metaplasia, inflammation
    • May arise within a large cystic duct, have comedo type necrosis without DCIS (Ann Diagn Pathol 2004;8:276), rarely sebaceous metaplasia (Virchows Arch 2001;438:505)
    • Infracted cases may have squamous metaplasia or appear pseudoinfiltrative due to fibrosis (Hum Pathol 1984;15:764)
    • Fibrosis at edge of papillomas may entraps glands and resemble invasion (Semin Diagn Pathol 2010;27:13)
    • Glandular proliferation within stalks may resemble cribriform DCIS
    • Needle biopsies can deposit clusters of benign cells in a distribution that resembles invasive carcinoma
    Microscopic (histologic) images

    Scroll to see all images:

    Apocrine intraductal papilloma with large nuclei and prominent nucleoli

    Fusion of adjacent papillae, gland-like spaces

    Resembles sclerosing adenosis

    Infarcted papilloma


    With fibroblasts

    Small ducts surrounded by hyalinized fibrous tissue

    Squamous metaplasia


    With spindle cells

    Vessels but not spindle cells are actin+

    With LCIS spreading in a pagetoid manner beneath ductal epithelium (plaque-like pattern)



    Images hosted on other servers:

    Arising in a small duct

    Fibrocystic changes

    Palpable subareolar mass

    Intricate branching fronds


    Irregular glandular spaces

    Two cell pattern

    Multiple nodules and stromal fibrosis

    Epithelial and myoepithelial cells

    Stromal fibrosis resembles invasion


    Central papilloma

    Papilloma with florid ductal hyperplasia

    Encysted papilloma with hyperplasia

    Peripheral papilloma


    Within lymph node

    Solid type

    Apocrine intra-
    ductal papilloma
    with large nuclei /
    prominent nucleoli

    Papilloma with atypia


    Papilloma with separate focus of ADH

    Papilloma with severe atypia

    With micropapillary DCIS

    In a dilated duct, H&E


    Within ectatic duct, H&E

    Inner layer of columnar cells

    Various images

    p63

    Smooth muscle actin

    Cytology description
    • High positive predictive value (Diagn Cytopathol 2006;34:818)
    • Infarcted papillomas: early stages show numerous degenerated cells with smudged nuclei, ghost cells and necrotic debris; late stages show clusters of fibroblasts, ductal cells and necrotic debris (Diagn Cytopathol 2006;34:373)
    Cytology images

    Images hosted on other servers:

    Leishman-Giemsa

    FNA

    Polygonal cells

    Columnar and polygonal cells

    Electron microscopy description
  • Demonstrates epithelial vs myoepithelial differentiation of bilayered lining of fibrovascular cores
  • Molecular / cytogenetics description
    • Clonal
    Videos


    Histopathology breast - intraductal papilloma
    Differential diagnosis
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