Papillary lesions of the breast: imaging findings and diagnostic challenges

Abstract

Papillary breast lesions encompass a wide spectrum of pathologies ranging from benign lesions, such as solitary intraductal papilloma, to the uncommon papillary carcinoma. These lesions have various clinical presentations and diverse radiological features. Differentiating benign and malignant papillary lesions based on imaging features may often be difficult. Other benign and malignant pathologies can also mimic papillary lesions on imaging, and tissue diagnosis is essential. Imaging plays an important role in lesion identification, assessment of extent, tissue sampling, and follow-up. Surgical excision has been recommended for all papillary lesions due to an increased incidence of high-risk lesions and neoplasia even with percutaneous, biopsy-proven benign papillomas. This review looks at papillary breast lesions from the radiologists' standpoint and discusses the clinical, imaging, and pathological features of these lesions, as well as the role of imaging in their evaluation. P apillary lesions in the breast are uncommon but arise from a wide range of pathologies and have diverse clinical and imaging features. A papillary lesion is characterized by an arborescent structure composed of fibrovascular stalks covered by a layer of epithelial cells with or without an intervening myoepithelial cell layer (1). Overlapping features make differentiation of benign and malignant papillary lesions difficult on imaging, and a tissue diagnosis is essential. Definitive histopathologic diagnosis on core biopsy can occasionally be difficult. Additionally, even those lesions shown by percutaneous biopsy to be benign papillomas are associated with an increased likelihood of high-risk lesions and neoplasia. Due to nonspecific findings on imaging and histopathology, as well as varying malignant potential, papillary lesions present significant diagnostic and management challenges for the radiologists, pathologists, and surgeons. We briefly review the types of papillary lesions, multimodality imaging findings, and the radiologist's role in their evaluation. The types and clinical features of papillary lesionsPapillary lesions can be broadly categorized as benign or malignant. Benign papillary lesions include a solitary intraductal papilloma, multiple intraductal papillomas, and atypical ductal hyperplasia (ADH) within a papilloma. Malignant papillary lesions include ductal carcinoma in situ (DCIS) arising in a papilloma, papillary DCIS, intracystic or encapsulated papillary carcinoma, solid papillary carcinoma, invasive papillary carcinoma arising in an intracystic papillary carcinoma, and invasive papillary carcinoma (1). Intraductal papillomaSolitary papillomas arise from a large central duct, are more common in perimenopausal women, and present with nipple discharge. Multiple papillomas are peripheral lesions arising from the terminal duct lobular unit. These are less common, usually affect a younger age group, and present as a palpable mass. Both can be associated with proliferative and high-risk lesions, such as radial ...

Ultrasound in the diagnosis of papillary breast lesions

“…On ultrasound, the lesions can be solid, round or lobulated, or can present as complex masses (fig 13a) [1,5,11]. The diagnosis is made on the basis of core or excisional biopsy; the lesions have no specific features, on neither Doppler ultrasound or elastography and they are often mistaken with other benign or malignant lesions [12] (fig 13b,c).…”

“…On ultrasound, the lesion presents as a hypoechoic mass or multiple small lesions, but is usually not detected sonographically [15]. In young patients, when ultrasound is performed as a first step examination, it can detect the associated microcalcifications, especially when the underlying breast tissue is diffuse hipoechoic [11]. In these situations, no matter what the patient's age is, mammography should be indicated in order to analyze their morphology.…”

“…Mammography can show a small, circumscribed subareolar mass, rarerly with associated calcifications or a solitary dilated retroareolar duct but, in most cases, the lesion is occult on mammography. On ultrasound, a solitary papilloma appears as a dilated duct with a hipoechoic content, as a parenchimal profliferation inside a dilated duct [10] or as a solid mass with well defined borders [1,7,9,11] (fig 6). Doppler ultrasound and elastography, by showing the presence of blood vessels inside the intraductal content (fig 7) or the stifness vs BGR sign specific for fluid filled lesions, can differentiate intraductal lesions by apocrine metaplasia or dilated ducts with viscous content (fig 8-10).…”

“…Lesions may be occult or patients can present with palpable masses or, rarely, with nipple discharge [3]. Because these patients have a higher risk of developing breast cancer (3 to 7 times) patients with multiple papillomas should be carefully followed [3,11].…”

ecancermedicalscience

“…Radiological findings suggestive of papillary breast lesions are rare and of low specificity for the diagnosis of malignancy, since they cannot categorically distinguish benign lesions from those that are potentially malignant [5, 6]. …”