37 year-old female with bloody nipple discharge arising from a
single duct in her right breast.
Solitary intraductal papilloma.
Grey-scale ultrasound imaging demonstrates a solid and cystic mass
in the right breast. Power Doppler shows vascularity within the
solid component of the lesion. On galactography, this mass appears
as a filling defect in the ductal system of the right breast.
Nipple discharge is worrisome when bloody or serous, unilateral,
from one duct, and spontaneous. The most common cause of serous or
bloody nipple discharge (90%) is a solitary intraductal papilloma,
with less common differential considerations including ductal
carcinoma in situ (DCIS), ductal ectasia, fibrocystic change, or
intraductal debris. Solitary intraductal papilloma is a benign
neoplasm that arises from the ductal epithelium of the breast and
should be distinguished from papillomatosis (multiple papilloma,
often in multiple ducts), which carries a much higher risk of
subsequent cancer development and may represent a premalignant
lesion. With a solitary papilloma, mammography may be normal or may
show a well-circumscribed equal density mass or clustered
microcalcifications. Likewise, ultrasound may be normal or may
demonstrate a solid and/or cystic lesion, representing the
papilloma within a dilated duct. The solid component often
demonstrates flow on Doppler studies, differentiating this lesion
from intraluminal debris. Note that the differential for a cystic
breast mass does include invasive breast cancer. Galactography is
the imaging study of choice for the evaluation of suspicious nipple
discharge, often demonstrating the abnormality in patients with
normal mammograms and ultrasounds. As in this case, a papilloma
will show up as a filling in the opacified ductal system. DCIS and
papillary carcinoma can have a similar appearance. Diagnosis can be
made by percutaneous (core-needle) or surgical biopsy. Patients
that receive the diagnosis of papilloma on a percutaneous
core-needle biopsy should be referred to a breast surgeon for
Pisano ED, Braeuning MP, Burke E. Diagnosis please. Case 8:
solitary intraductal papilloma. Radiology. 1999 Mar;210(3):795-8.
Dinkel HP, Gassel AM, Muller T, Lourens S, Rominger M, Tschammler
A. Galactography and exfoliative cytology in women with abnormal
nipple discharge. Obstetrics & Gynecology.2001; 97:625-9.