Breast
Other benign tumors
Intraductal papilloma
Editorial Board Member: Gary Tozbikian, M.D.
Editor-in-Chief: Debra L. Zynger, M.D.
Minor changes: 18 March 2021
Copyright: 2002-2021, PathologyOutlines.com, Inc.
PubMed Search: Papilloma of the breast [title]
Table of Contents
Definition / general | Essential features | Terminology | ICD coding | Epidemiology | Sites | Pathophysiology | Clinical features | Diagnosis | Radiology description | Radiology images | Prognostic factors | Case reports | Treatment | Clinical images | Gross description | Gross images | Frozen section description | Microscopic (histologic) description | Microscopic (histologic) images | Virtual slides | Cytology description | Positive stains | Videos | Sample pathology report | Differential diagnosis | Board review style question #1 | Board review style answer #1 | Board review style question #2 | Board review style answer #2 | Board review style question #3 | Board review style answer #3Cite this page: Bidot S, Li X. Intraductal papilloma. PathologyOutlines.com website. https://www.pathologyoutlines.com/topic/breastpapilloma.html. Accessed April 15th, 2021.
Definition / general
- Benign intraductal proliferation of epithelial cells with fibrovascular cores and underlying myoepithelial cells
Essential features
- Common benign breast lesion
- Distinction with malignant papillary lesions may be difficult on biopsy and immunohistochemistry may be necessary
- No consensus regarding management of papilloma without atypia
- Surgical excision of intraductal papilloma with atypical epithelial proliferation is recommended
Terminology
- Duct papilloma of the breast
- Intracystic papilloma of the breast (old terminology)
ICD coding
- ICD-10: D24 - benign neoplasm of the breast
Epidemiology
- 5% of benign breast lesions (Am J Surg Pathol 2006;30:665)
- Involves women of all ages (Arch Pathol Lab Med 2016;140:628)
- Uncommon in men
Sites
- Central intraductal papilloma: arises from large lactiferous ducts, usually solitary (Arch Pathol Lab Med 2016;140:628)
- Peripheral intraductal papilloma: involves terminal duct lobular unit, usually multiple (papillomatosis) (Arch Pathol Lab Med 2016;140:628)
Pathophysiology
- Poorly understood
- Intraductal papilloma might originate from bipotent progenitor cells that differentiate as luminal and myoepithelial cells (Am J Pathol 2018;188:1106)
Clinical features
- Solitary central intraductal papilloma may present as a retroareolar mass with serous or serosanguineous nipple discharge
- Peripheral intraductal papilloma is often discovered incidentally
Diagnosis
- Screening mammography
- Core needle biopsy, vacuum assisted biopsy, excisional biopsy (Surg Pathol Clin 2018;11:1)
Radiology description
- Nonspecific findings
- Associated calcifications identified on mammography (Diagn Interv Radiol 2013;19:471)
- Well circumscribed round or ovoid intraductal mass, associated with ductal dilation on ultrasound and MRI
- MRI may show enhancement (Diagn Interv Radiol 2013;19:471)
Radiology images
Contributed by Mark R. Wick, M.D.
Mammogram
Images hosted on other servers:
Round or ovoid mass on mammogram and ultrasound
Well circumscribed
mass with
calcifications
Ductal dilatation on mammogram
Prognostic factors
- Risk of upgrade to malignancy on surgical excision is low (~2 - 3%) for intraductal papilloma without atypia that has pathology radiology concordance (Am J Surg 2020;220:677, Breast J 2020;26:705, Cancer 2016;122:2819, Clin Imaging 2020;60:67)
- Patients with papillomatosis have a slightly increased cancer risk (Am J Surg Pathol 2006;30:665)
Case reports
- 52 year old man with intraductal papilloma that progressed to ductal carcinoma in situ (Radiol Case Rep 2018;13:602)
- 53 year old woman with a large intraductal papilloma (Int J Surg Case Rep 2019;55:1)
- 55 year old man with unilateral bloody discharge and intraductal papilloma (J Surg Case Rep 2019;2019:rjz023)
Treatment
- No consensus for intraductal papilloma without atypia
- Complete surgical excision often performed (Am J Surg 2020;220:677)
- Different management among institutions (Clin Imaging 2020;60:67)
- Complete surgical excision should be performed for intraductal papilloma with atypia
Clinical images
Images hosted on other servers:
Male with nipple discharge
Gross description
- Central intraductal papilloma: well circumscribed polypoid nodule in a cystically dilated duct (Arch Pathol Lab Med 2016;140:628)
- Peripheral intraductal papilloma: not grossly visible (Arch Pathol Lab Med 2016;140:628)
Gross images
Contributed by Mark R. Wick, M.D.
Intracystic mass
Images hosted on other servers
Intraductal polypoid mass
Frozen section description
- Frozen section not performed on lesions suspected to be intraductal papilloma
Microscopic (histologic) description
- Circumscribed intraductal proliferation comprised of arborizing fibrovascular cores lined by outer layer of luminal cells and an inner layer of myoepithelial cells (Histopathology 2016;68:22)
- Myoepithelial cells might be inconspicuous in sclerotic areas
- Myoepithelial cells also present at the periphery of the involved duct
- Frequently associated with usual type ductal hyperplasia and apocrine metaplasia, less frequently squamous, osseous or chondroid metaplasia may be seen
- May undergo ischemic or hemorrhagic changes, either spontaneously or secondary to biopsy / trauma
- May show prominent fibrosis / sclerosis which may contained entrapped glands (sclerosing papilloma)
- May be involved by:
Microscopic (histologic) images
Contributed by Xiaoxian (Bill) Li, M.D., Ph.D.
Minute intraductal papillomas
Papillary cores
Involved by usual ductal hyperplasia
Involved by apocrine metaplasia
Involved by ductal carcinoma in situ
Contributed by Jijgee Munkhdelger, M.D., Ph.D. and Andrey Bychkov, M.D., Ph.D.
Intraductal papilloma with DCIS immunoprofile
Intraductal papilloma with DCIS, CK5/6
Intraductal papilloma with DCIS, p63
Virtual slides
Images hosted on other servers:
Sclerosing intraductal papilloma
Cytology description
- Large stellate tissue fragments of benign ductal cells in a proteinaceous background (Diagn Cytopathol 2007;35:386)
Positive stains
- Myoepithelial cell markers (CK5, p63, p40, calponin, alpha smooth muscle actin, smooth muscle myosin heavy chain / SMMHC) show myoepithelial cells in fibrovascular cores and at the periphery of the involved duct (Arch Pathol Lab Med 2016;140:628)
- In intraductal papilloma involved by usual ductal hyperplasia
- ER is patchy positive (Pathol Int 2012;62:381)
- CK5 is patchy positive in a mosaic pattern (Pathol Int 2012;62:381)
Videos
Intraductal papilloma
Sample pathology report
- Right breast, 9 o'clock, 1 cm from the nipple, ultrasound guided core biopsy:
- Intraductal papilloma with apocrine metaplasia
- Comment: Patchy positivity for CK5 and ER supports the above diagnosis.
Differential diagnosis
- Atypical ductal hyperplasia involving an intraductal papilloma (atypical papilloma) (Histopathology 2016;68:22):
- Monotonous low grade cellular proliferation
- Atypical proliferation is small (≤ 3 mm) (Cancer 1996;78:258, Am J Surg Pathol 2006;30:665)
- Decreased myoepithelial cells
- CK5/6 negative, ER diffusely positive
- Monotonous low grade cellular proliferation
- Intraductal papillary carcinoma (papillary DCIS) (Histopathology 2016;68:22):
- Encapsulated papillary carcinoma (Histopathology 2016;68:22):
- Invasive papillary carcinoma
- Tall cell carcinoma with reverse polarity
- Adenomyoepithelioma (Mod Pathol 2020;33:1764):
- Thought to be a variant of intraductal papilloma
- Rare biphasic tumor often with papillary morphology
- Benign adenomyoepithelioma is generally a well circumscribed nodule with epithelial and myoepithelial cell proliferation and most often prominent myoepithelial proliferation
Board review style question #1
Regarding this breast specimen, what is the correct diagnosis?
- Intraductal papillary carcinoma
- Intraductal papilloma with apocrine metaplasia
- Intraductal papilloma with DCIS
- Intraductal papilloma with LCIS
- Invasive papillary carcinoma
Board review style answer #1
B. This intraductal papilloma shows typical features of apocrine metaplasia.
Comment Here
Reference: Intraductal papilloma
Comment Here
Reference: Intraductal papilloma
Board review style question #2
What is the staining pattern of p63 for intraductal papilloma of the breast without atypia?
- At the periphery of involved duct only
- In the fibrovascular cores only
- Intraductal papillomas do not stain for p63
- At the periphery and in the fibrovascular cores
Board review style answer #2
D. p63 stain for myoepithelial cells is positive throughout the lesion, including in the fibrovascular cores and at the periphery of the involved duct.
Comment Here
Reference: Intraductal papilloma
Comment Here
Reference: Intraductal papilloma
Board review style question #3
What is the typical staining pattern of atypical epithelial proliferation involving an intraductal papilloma of the breast?
- Diffusely positive for ER and patchy positive for CK5/6, negative for p63
- Diffusely positive for ER, negative for p63 and CK5/6
- Diffusely positive for ER, p63 and CK5/6
- Negative for ER, p63 and CK5/6
- Patchy positive for ER, negative for p63 and CK5/6
Board review style answer #3
B. The atypical low grade epithelial proliferation is diffusely positive for ER, negative for CK5/6 and negative for p63.
Comment Here
Reference: Intraductal papilloma
Comment Here
Reference: Intraductal papilloma
