Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 


 
 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 34  |  Issue : 3  |  Page : 1195-1198

Radiological evaluation of small-size solitary intraductal papilloma


Department of Diagnostic Radiology, University of Toledo Medical Center, Toledo, Ohio, USA; Department of Radiology, Jazan University, Jazan, Saudi Arabia

Date of Submission01-May-2021
Date of Decision10-May-2021
Date of Acceptance17-May-2021
Date of Web Publication18-Oct-2021

Correspondence Address:
Dhayihi Turki
Beach Street, Jazan

Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_50_21

Rights and Permissions
  Abstract 


Detection of intraductal papilloma can be difficult; however, conventional ductography, MRI, ultrasound, and ductoscopy play important roles in the diagnostic process. Intraductal papilloma is usually benign in nature, with a small parentage being malignant. When evaluating the average size of a papilloma, which is between 1 and 3 cm, both conventional ductography and MRI have high sensitivity in detection. However, MRI has slightly better sensitivity and less invasiveness in comparison with conventional ductography and is considered the state of art in evaluation of normal-size intraductal papilloma. A 40-year-old female patient presented with a history of clear nipple discharge from the left breast. Left breast had no palpable mass, and there were no skin changes. From the center part of the nipple, there was watery clear discharge (serous) from a single duct. No bloody nipple discharge was expressed from either nipple. Mammography was negative for masses or nipple retraction. Ultrasound demonstrated dilated duct with no intraductal mass. Conventional ductogram demonstrated dilated duct with abrupt cutoff and no filling defect. MRI did not demonstrate any mass except dilated duct. Owing to concavity seen in the ductogram, mammography-guided wire placement was done for the dilated duct and then surgically removed. Pathology revealed 2-mm intraductal papilloma, with no atypia or carcinoma in situ. Neither the conventional ductogram nor the MRI ductography proves to be a better method of diagnosing miniscule intraductal papilloma. Individually, both methods have the potential to emphasize various aspects of the ducts in a way that would be valuable to the reader.

Keywords: case report, conventional ductography, intraductal papilloma, MRI ductography, small intraductal papilloma, solitary intraductal papilloma


How to cite this article:
Turki D. Radiological evaluation of small-size solitary intraductal papilloma. Menoufia Med J 2021;34:1195-8

How to cite this URL:
Turki D. Radiological evaluation of small-size solitary intraductal papilloma. Menoufia Med J [serial online] 2021 [cited 2024 Mar 29];34:1195-8. Available from: http://www.mmj.eg.net/text.asp?2021/34/3/1195/328341




  Introduction Top


Solitary intraductal papilloma is usually a benign lesion located centrally or in retroareolar area. The most common presentation of intraductal papilloma is nipple discharge, which can be serous or bloody in nature [1],[2]. On mammography, a small solitary intraductal papilloma can be occult secondary to dense breast in the retroareolar region; however, a large papilloma can be seen as round circumscribed lesion. On conventional ductography, it can appear as filling defect with smooth or lobulated margins; however, it is an invasive procedure and can be done only when discharge is present during canulation of the duct [3],[4]. On ultrasound, it can appear as a nodule within dilated duct, which may demonstrate flow on color Doppler. On MRI, it may appear as enhancing nodule with or without intraductal component and variable washout curve. Differentiating benign from malignant intraductal papilloma can be difficult on imaging and usually requires biopsy to differentiate between them [3],[5]. Miniscule solitary intraductal papilloma is hard to diagnose, and no specific radiological test is known to be superior for detection of less than 10-mm nodules. In general, the management of intraductal papilloma is local excision with rim of uninvolved breast tissue if appeared localized. However, for indistinct appearing papilloma or presence of microcalcification, core biopsy should be done first, and then follow-up with mammography and ultrasound can be done if the core biopsy result shows papilloma without atypia [6].


  Case report Top


A 40-year-old female presented with a history of clear nipple discharge from the left breast. The patient initially noted nipple discharge from the same breast a year ago, which then appeared intermittently as pink discharge. The patient denied any breast mass or skin changes. No discharge from the right breast was reported. The patient's physical examination revealed a normal right breast, no mass was appreciated, nor any skin change or nipple discharge. Left breast had no palpable mass, and there were no skin changes. From the center part of the nipple, there was watery clear discharge (serous) from a single duct. No bloody nipple discharge was expressed from either nipple. She has no family history of breast or ovarian cancer or HNPCC-related cancer. The patient does have a past history of lupus nephritis. Her medications include plaquenil, omeprazole, lunesta, cozaar, and Claritin.


  Discussion Top


The patient was initially evaluated with mammography to see if there is any sort of solid, cystic masses, or architecture distortion; however, it was unremarkable. Ultrasound imaging was recommended to see if there is any mass that is not visible on the mammography or dilated duct, and it was able to demonstrate a dilated subareolar duct with abrupt termination distally [Figure 1], corresponding with the finding in conventional ductography [Figure 2]. Internal debris was also visualized in obstructed duct, but no intraductal papilloma was appreciated. Axillary lymphadenopathy was noted along with the nipple discharge.
Figure 1: Ultrasound-dilated duct with debris.

Click here to view
Figure 2: Conventional ductogram dilated duct 2 cm from nipple.

Click here to view


MRI was done on the left breast which is the best radiological method to evaluate masses, abnormal ducts, or abnormal mass-like enhancement. The MR demonstrated a dilated duct with no visible papilloma [Figure 3]. Lymph nodes demonstrated benign morphology. However, some were enlarged as much as a 1.3 cm on short axis. It was classified as BI-RADS 4 (suspicious), and tissue sampling along with surgical consultation was recommended at the time.
Figure 3: MRI-duct dilatation.

Click here to view


The patient later presented for evaluation using conventional ductogram after the MRI, which is usually preserved for intraductal lesion evaluation because it more invasive. In the conventional ductography, abrupt dilated duct was demonstrated [Figure 2]; however, the papilloma could not be visualized, just as it was not visible on the MR ductogram, which may be owing to intraductal mass, suspicious for intraductal papilloma.

Owing to the concave seen in the duct once contrast was administered, it was believed that there was a 2-mm papilloma present in the retroareolar region of a breast, meaning if the duct were to be removed, then the papilloma would also be removed. The patient says she went home and she squeezed the breast until blood came out and something solid appeared to come out. The solid was assumed to be a blood clot released and most likely formed owing to the papilloma.

The patient returned 3 weeks later for conventional ductography before surgery, which appeared to be an obstructed in a prior study. However, injection of contrast into the duct confirmed no ductal dilatation or obstruction [Figure 4], as noted in the prior study, which was referred to the blood clot removed by the patient when she previously squeezed her breast.
Figure 4: 2017-no more obstruction or dilation.

Click here to view


After discussing the findings with the attending surgeon, mammography-guided wire localization was done, which was 3 cm posterior to the nipple. Breast tissue adjacent to the tip of the wire was resected and confirmed with specimen radiograph. Surgery was then performed on the breast, and the duct was removed.

The fine-needle aspirations of the lymph nodes were verified, as benign, and cellular fluid from the central duct appeared to be a benign finding. The patient was then notified that it was most likely benign but could show malignancy on a small chance. The patient then requested that it be removed and was done so accordingly. Although the papilloma could not be seen, the duct was removed. Pathology report showed intraductal papilloma ∼2 mm in size with negative margins without atypia or carcinoma.

Typically, the use of MRI is considered to be a much more powerful method of imaging. Ideally, once the breast was imaged using the MRI, it should have been easy to see the papilloma [1],[7]. Moreover, MRI can be helpful in differentating between intraductal papilloma and invasive ductal carcinoma by the pattern of early-phase enhancement [8]. On an MRI, the shape of a papilloma is much more visible, but in this patient, it was not visible. Even though it would be more easily seen, this does not take away from the fact that the papilloma should have been visible on the conventional ductogram as well. MR ductogram also allows for three-dimensional modeling, which can help improve seeing any abnormalities. This is owing to the dilation being potentially easier to see once a three-dimensional model has been rendered. It also allows the model to be combined with the findings from the conventional ductogram [9].

In other studies, it has been noted that using a coil can help increase visibility of the area of concern on the MR scans. It has allowed for more information to be gathered on the ductal systems. A microscopy coil has shown to be helpful in seeing and identifying masses near the tumor on a finer level [9],[10]. This method was not used because the papilloma was not identifiable. It was 2 mm in size, not allowing it to appear on any MR ductogram scans or conventional ductogram scan, meaning there was no way of noting the papilloma and placing the coil at the point of concern.

Conventional ductogram is the most common method of evaluating breasts and nipple discharge. Aside from being a cheaper option, the use of contrast helps to identify abnormalities in the ducts much easier. It is easier to be seen, as the contrast allows any obstructions in the duct to become more visible. Despite being able to see contrast and how it acts in the duct, the second scan made it appear as though the duct was normal. The second conventional ductogram scan yielded false-negative results. In an MR ductography, ducts usually appear as a curve, which makes it harder to note the abnormalities [9],[10]. However, the radiation caused by conventional ductography as well as the potential pain in the patient makes the MR ductography more appealing, as the MR ductography does not cause either of the two issues [2],[9].


  Conclusion Top


Neither the conventional ductogram nor the MRI proves to be a better method of diagnosing miniscule papilloma on a more detailed level. Individually both methods have the potential to emphasize various aspects of the ducts in a way that would be valuable to the reader.

Financial support and sponsorship

Nil.

Conflicts of interest

None declared.



 
  References Top

1.
Yılmaz R, Bender Ö, Çelik Yabul F, Dursun M, Tunacı M, Acunas G. Diagnosis of nipple discharge: value of magnetic resonance imaging and ultrasonography in comparison with ductoscopy. Balkan Med J 2017; 34:119–126.  Back to cited text no. 1
    
2.
Woods ER, Helvie MA, Ikeda DM, Mandell SH, Chapel KL, Adler DD. Solitary breast papilloma: comparison of mammographic, galactographic, and pathologic findings. Am J Roentgenol 1992; 159:487–491.  Back to cited text no. 2
    
3.
Panzironi G, Pediconi F, Sardanelli F. Nipple discharge: the state of the art. BJR Open 2019; 1:20180016.  Back to cited text no. 3
    
4.
Cardenosa G, Doudna C, Eklund GW. Ductography of the breast: technique and findings. Am J Roentgenol 1994; 162:1081–1087.  Back to cited text no. 4
    
5.
Eiada R, Chong J, Kulkarni S, Goldberg F, Muradali D. Papillary lesions of the breast: Mri, ultrasound, and mammographic appearances. Am J Roentgenol 2012; 198:264–271.  Back to cited text no. 5
    
6.
Richter-Ehrenstein C, Tombokan F, Fallenberg EM, Schneider A, Denkert C. Intraductal papillomas of the breast: Diagnosis and management of 151 patients. Breast 2011; 20:501–504.  Back to cited text no. 6
    
7.
Bhattarai N, Kanemaki Y, Kurihara Y, Nakajima Y, Fukuda M, Maeda I. Intraductal papilloma: Features on MR ductography using a microscopic coil. Am J Roentgenol 2006; 186:44–47.  Back to cited text no. 7
    
8.
Zhu Y, Zhang S, Liu P, Lu H, Xu Y, Yang WT. Solitary intraductal papillomas of the breast: MRI features and differentiation from small invasive ductal carcinomas. Am J Roentgenol 2012; 199:936–942.  Back to cited text no. 8
    
9.
Hirose M, Nobusawa H, Gokan T. MR ductography: Comparison with conventional ductography as a diagnostic method in patients with nipple discharge. Radiographics 2007; 27 (suppl_1):S183–S196.  Back to cited text no. 9
    
10.
Kanemaki Y, Kurihara Y, Itoh D, Kamijo K, Nakajima Y, Fukuda M, et al. MR mammary ductography using a microscopy coil for assessment of intraductal lesions. Am J Roentgenol 2004; 182:1340–1342.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

Top
 
 
  Search
 
Similar in PUBMED
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Case report
Discussion
Conclusion
References
Article Figures

 Article Access Statistics
    Viewed804    
    Printed20    
    Emailed0    
    PDF Downloaded65    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]