Applied Radiology

Diagnosis

Solitary intraductal papilloma.

Findings

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.

Discussion

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 excisional biopsy.

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.