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Spectrum of Papillary Lesions of the Breast: Clinical, Imaging, and Pathologic Correlation

Malai Muttarak1, Pailin Lerttumnongtum1, Benjaporn Chaiwun2 and Wilfred C. G. Peh3

1 Department of Radiology, Chiang Mai University, Chiang Mai, Thailand 50200.
2 Department of Pathology, Chiang Mai University, Chiang Mai, Thailand.
3 Department of Diagnostic Radiology, Alexandra Hospital, Singapore.


Figure 1
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  		Fig. 1A —Papilloma in 41-year-old woman with left-sided bloody nipple discharge. Left craniocaudal mammogram shows dense breast with no definite abnormality. Mammography is indicated in any patient with pathologic nipple discharge, but negative findings do not exclude breast lesions.

 

Figure 2
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  		Fig. 1B —Papilloma in 41-year-old woman with left-sided bloody nipple discharge. Sonogram shows dilated duct and intraductal mass (arrow). Excisional biopsy revealed papilloma. Advanced sonographic technology can depict cause of nipple discharge and also guide biopsy (fine-needle aspiration, core needle, and vacuum-assisted biopsy; preoperative localization for excisional biopsy; and percutaneous ductography). However, sonography is inferior to ductography for detecting peripheral lesions without ductal dilatation.

 

Figure 3
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  		Fig. 2A —Papilloma in 70-year-old woman with palpable mass in right breast. Right craniocaudal mammogram shows fatty breast with large oval circumscribed mass in subareolar region and groups of calcifications medially that subsequently proved to be benign.

 

Figure 4
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  		Fig. 2B —Papilloma in 70-year-old woman with palpable mass in right breast. Sonogram of left breast shows oval parallel circumscribed complex cystic mass containing intracystic mass (M) with posterior acoustic enhancement. Simple mastectomy was performed.

 

Figure 5
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  		Fig. 2C —Papilloma in 70-year-old woman with palpable mass in right breast. Gross specimen shows cystic mass (arrowheads) and intracystic nodular solid mass (arrow) corresponding to sonographic findings.

 

Figure 6
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  		Fig. 2D —Papilloma in 70-year-old woman with palpable mass in right breast. Photomicrograph shows branching papillary structures lined by benign columnar cells and fibrovascular core (arrow). (H and E, x100)

 

Figure 7
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  		Fig. 3A —Papilloma in 52-year-old woman with left-sided serosanguineous nipple discharge. Left craniocaudal mammogram shows fatty breast with dilated duct (arrowheads) connecting to circumscribed mass (arrow).

 

Figure 8
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  		Fig. 3B —Papilloma in 52-year-old woman with left-sided serosanguineous nipple discharge. Color Doppler sonogram of left breast shows dilated duct connecting to oval parallel circumscribed isoechoic mass having vascular flow. Lesion was entirely removed by vacuum-assisted core biopsy and revealed papilloma.

 

Figure 9
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  		Fig. 4A —Multiple papillomas in 53-year-old woman with palpable mass laterally in left breast. Left craniocaudal mammogram shows heterogeneously dense breast, partially circumscribed lobulated mass (M) laterally, and circumscribed lobulated mass medially (arrow).

 

Figure 10
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  		Fig. 4B —Multiple papillomas in 53-year-old woman with palpable mass laterally in left breast. Composite sonograms of left breast show irregular parallel angular hypoechoic mass in inner quadrant (arrow) and oval parallel circumscribed slightly hyperechoic mass with cystic component (C) in outer quadrant. Excisional biopsy of both masses was performed and revealed multiple papillomas.

 

Figure 11
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  		Fig. 5A —Multiple papillomas in 50-year-old woman with right-sided bloody nipple discharge. Bilateral craniocaudal mammograms show circumscribed mass laterally in right breast (arrow).

 

Figure 12
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  		Fig. 5B —Multiple papillomas in 50-year-old woman with right-sided bloody nipple discharge. Sonogram of right breast shows oval parallel circumscribed isoechoic mass (arrow) connected to dilated duct and multiple intraductal masses (arrowheads).

 

Figure 13
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  		Fig. 5C —Multiple papillomas in 50-year-old woman with right-sided bloody nipple discharge. Right craniocaudal ductogram shows cystic dilatation with filling defects (arrows) connected to mildly dilated duct. Multiple filling defects (arrowheads) are seen in central and peripheral ducts. Note that ductogram shows extent of masses in peripheral ducts better than sonogram does. Excisional biopsy revealed multiple papillomas.

 

Figure 14
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  		Fig. 6A —53-year-old woman with multiple papillomas found on screening mammography. Left mediolateral oblique mammogram shows spiculated mass (arrow) in subareolar region. Sonogram of left breast (not shown) showed irregular hypoechoic mass. Fine-needle aspiration biopsy (not shown) revealed benign epithelial cells. Because imaging findings were suggestive of malignant lesion, excisional biopsy was performed.

 

Figure 15
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  		Fig. 6B —53-year-old woman with multiple papillomas found on screening mammography. Photomicrograph of excised specimen shows a few dilated ducts (arrows) among fibrous stroma (asterisk). These ducts contain papillary proliferation of benign ductal epithelial cells and fibrovascular cores. (H and E, x100)

 

Figure 16
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  		Fig. 7A —Juvenile papillomatosis in 26-year-old woman with palpable right breast mass. Sonography is imaging technique of choice in young patient with breast mass because breast is dense and incidence of breast carcinoma is low. Sonogram of right breast shows irregular parallel spiculated heterogeneously echoic mass. Because sonographic findings were suggestive of malignancy, mammography was performed (not shown) and showed extremely dense breast with spiculated mass. No malignant cells were detected at fine-needle aspiration biopsy of mass, but imaging findings were suggestive of malignancy, and excisional biopsy was performed.

 

Figure 17
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  		Fig. 7B —Juvenile papillomatosis in 26-year-old woman with palpable right breast mass. Sonography is imaging technique of choice in young patient with breast mass because breast is dense and incidence of breast carcinoma is low. Photomicrograph shows a few dilated ducts (arrows) containing papillary proliferation of benign ductal epithelial cells, fibrovascular cores, and multiple cysts (C) interspersed with dense stroma. (H and E, x40)

 

Figure 18
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  		Fig. 8A —55-year-old woman with micropapillary ductal carcinoma in situ (DCIS) found on screening mammography. Magnified craniocaudal mammogram shows clustered amorphous microcalcifications (arrow). Excisional biopsy was performed by preoperative needle localization.

 

Figure 19
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  		Fig. 8B —55-year-old woman with micropapillary ductal carcinoma in situ (DCIS) found on screening mammography. Photomicrograph shows dilated ducts containing proliferation of neoplastic ductal epithelial cells arranged in micropapillary pattern (arrows). Note absence of fibrovascular core in DCIS. (H and E, x200)

 

Figure 20
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  		Fig. 9A —Invasive papillary carcinoma in 69-year-old woman with mass in left breast. Note that mammography and sonography of this patient are difficult to differentiate from those of papilloma in Figure 2A, 2B, 2C, 2D. However, presence of complex solid–cystic mass with spontaneous intracystic bleeding in older age woman is suggestive of papillary carcinoma rather than papillomas. Left craniocaudal mammogram shows fatty breast with large lobulated circumscribed mass (arrow) laterally.

 

Figure 21
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  		Fig. 9B —Invasive papillary carcinoma in 69-year-old woman with mass in left breast. Note that mammography and sonography of this patient are difficult to differentiate from those of papilloma in Figure 2A, 2B, 2C, 2D. However, presence of complex solid–cystic mass with spontaneous intracystic bleeding in older age woman is suggestive of papillary carcinoma rather than papillomas. Sonogram shows oval parallel circumscribed complex cystic mass containing solid nodular projection (M) and highly echogenic fluid–fluid level (arrow) of blood. Excisional biopsy was performed and revealed papillary carcinoma. Modified radical mastectomy was subsequently performed.

 

Figure 22
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  		Fig. 9C —Invasive papillary carcinoma in 69-year-old woman with mass in left breast. Note that mammography and sonography of this patient are difficult to differentiate from those of papilloma in Figure 2A, 2B, 2C, 2D. However, presence of complex solid–cystic mass with spontaneous intracystic bleeding in older age woman is suggestive of papillary carcinoma rather than papillomas. Photomicrograph shows dilated duct with papillary fronds and lined by malignant columnar cells (short arrows). Note invasive focus (long arrow). (H and E, x200)

 

Figure 23
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  		Fig. 10A —Noninvasive papillary carcinoma, solid type, in 44-year-old woman with left-sided bloody nipple discharge. Magnified mediolateral oblique mammogram shows extremely dense breast with group of pleomorphic calcifications.

 

Figure 24
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  		Fig. 10B —Noninvasive papillary carcinoma, solid type, in 44-year-old woman with left-sided bloody nipple discharge. Sonogram shows dilated duct (arrowhead) filled with echogenic contents and multiple calcifications (arrow). Fine-needle aspiration biopsy was performed under sonographic guidance.

 

Figure 25
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  		Fig. 10C —Noninvasive papillary carcinoma, solid type, in 44-year-old woman with left-sided bloody nipple discharge. Fine-needle aspiration smear shows fragments of atypical columnar cells suggestive of papillary tumor with necrotic material in background. Microcalcification (arrow) is noted among tumor fragments. (Papanicolaou stain, x200)

 

Figure 26
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  		Fig. 10D —Noninvasive papillary carcinoma, solid type, in 44-year-old woman with left-sided bloody nipple discharge. Because at cytology differentiating benign from malignant papillary tumors is difficult, excisional biopsy was performed with aid of marker on skin. Photomicrograph of excised specimen shows distended duct (arrowheads) occupied by spindle-shaped cells with necrosis and calcifications in center (arrow). (H and E, x100)

 

Figure 27
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  		Fig. 11A —Invasive micropapillary carcinoma in 38-year-old woman with palpable mass in right breast. Right mediolateral oblique mammogram shows dense breast with ill-defined mass (short arrow), multiple pleomorphic calcifications superiorly, and enlarged increased density right axillary nodes (long arrow). Fine-needle aspiration biopsy (not shown) revealed ductal carcinoma. Modified right mastectomy was performed and revealed invasive micropapillary carcinoma with axillary node metastases in three of 19 nodes.

 

Figure 28
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  		Fig. 11B —Invasive micropapillary carcinoma in 38-year-old woman with palpable mass in right breast. Photomicrograph shows clusters of tumor cells with intervening clear spaces that are characteristic of invasive micropapillary carcinoma. (H and E, x100)

 

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