Intraductal papilloma

Breast nonmalignant
Benign tumors
Intraductal papilloma

Authors: Hind Warzecha, M.D., Belinda Lategan, M.D.

Topic Completed: 1 April 2010

Minor changes: 22 May 2020

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

PubMed Search: Papilloma of the breast [title]

Page views in 2019: 22,298

Page views in 2020 to date: 8,693

Table of Contents

Cite this page: Nassar H, Lategan B. Intraductal papilloma. PathologyOutlines.com website. https://www.pathologyoutlines.com/topic/breastpapilloma.html. Accessed May 30th, 2020.

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)

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

14 year old boy with enlarging unilateral breast mass (J Pediatr Surg 2011;46:e33)
44 year old man with benign intracystic papilloma of the breast (J Ultrasound Med 2008;27:1397)
47 year old woman with coincidence of mammary and sentinel lymph node papilloma (Am J Surg Pathol 2008;32:784)
57 year old man with intracystic papilloma in the breast (Breast Cancer 2006;13:84)
Intraductal breast papillomas in patients with Costello syndrome (Cir Esp 2007;81:345)

Treatment

Local excision or microdochectomy (removal of breast duct)
Core biopsy diagnosis of papilloma even without ADH probably requires excision (Ann Surg Oncol 2008;15:2272, Am J Surg Pathol 2002;26:1095, Eur J Surg Oncol 2008;34:1304, AJR Am J Roentgenol 2006;186:1328, Cancer 2009;115:2837; but see Am J Clin Path 2004;122:440, Am J Clin Path 2004;122:217, no need for excision if no atypia)
In men, as there is a relatively high incidence of carcinoma with papillary architecture, it is reasonable to excise all papillary lesions to rule out malignancy

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:

AFIP 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

Positive stains

Epithelium: CK5 / 6, CK14, 34betaE12 (Virchows Arch 2007;450:539); also CD44s (J Clin Pathol 1999;52:862)
Myoepithelium: actin, S100, p63 (Am J Surg Pathol 2001;25:1054), calponin, smooth muscle myosin heavy chain (Am J Clin Path 2005;123:36), CD10 (Mod Pathol 2002;15:397)

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

Invasive papillary carcinoma: invasion into stroma, no myoepithelial layer
Micropapillary DCIS
Papillary DCIS: delicate or absent fibrovascular core, often atypical nuclei or atypical mitotic figures, pseudostratification, usually no apocrine metaplasia; other DCIS may be present, 71% have no / incomplete myoepithelal layer, 76% are 34betaE12 negative, 67% are positive for neuroendocrine markers (Virchows Arch 2007;450:539)