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Clinical Observations |
1 Department of Radiology, St. Marianna University School of Medicine, 2-16-1
Sugao, Miyamae-ku, Kawasaki City, Kanagawa, 216-8511 Japan.
2 Department of Surgery, St. Marianna University School of Medicine, Kanagawa,
Japan.
3 Department of Pathology, St. Marianna University School of Medicine, Kanagawa,
Japan.
Received October 13, 2004;
accepted after revision December 16, 2004.
Address correspondence to N. Bhattarai.
Abstract
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CONCLUSION. Intraductal papilloma appeared in most cases as a well-circumscribed mass with early enhancement and delayed washout associated with a dilated duct, predominantly showing signal hyperintensity on T1- and T2-weighted imaging.
Keywords: breast • MR imaging
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MRI was performed with the patient in a prone position using a 1.5-T Intera Master (Philips Medical Systems) and a 4.7-cm diameter Microscopy Coil (Philips Medical Systems) as a surface coil to evaluate fine signal data from the ductal system. Use of this coil allows local signal acquisition with very high signal-to-noise ratio, which was used to increase spatial resolution by acquiring a 512 x 256 matrix for a 7-cm field of view, resulting in a 0.137-mm in-plane resolution, much higher than that of existing coils (0.3-0.7 mm). An inherent property of these small coils, which display very high local sensitivity, is that signal yield at a greater distance from the coil is low. This problem was overcome using a postprocessing technique that provides perfect correction, resulting in a uniform signal level. The technique, known as Constant Level Appearance (CLEAR, Philips Medical Systems), was performed by acquiring auxiliary signals from the small coil itself and also a body coil. These supplementary signals were used to produce auxiliary values, which were then used to correct image data from the small coil.
Axial T2-weighted (TR/TE, 1500/120) turbo spin-echo and axial T1-weighted (43/8.7; flip angle, 50°) 3D fast-field echo images were obtained using a fat-saturation technique and the CLEAR algorithm with a slice thickness of 1.6 mm (0.8-mm overlap). Gadodiamide hydrate (Omniscan, Daiichi Pharmaceuticals) was administered IV as bolus injection at a dose of 0.1 mmol/kg body weight over 10 sec. Immediately after injection of the contrast agent, early-phase T1-weighted axial imaging was performed (acquisition time, 60 sec). Delayed-phase axial imaging (acquisition time, 5 min 48 sec) was taken after the early phase, and delayed-phase coronal imaging was subsequently performed. During the dynamic phase, three postcontrast images were taken: early axial, delayed axial, and delayed coronal in series, one after another.
All MR images were interpreted retrospectively by two radiologists experienced in breast imaging with a knowledge of clinical and histopathologic findings. Masses and dilated ducts were interpreted (Table 1) as showing signal hyper-, iso-, or hypointensity compared with signal intensity in the normal breast gland. The dilated duct was interpreted as distal (from the lesion toward the nipple) or proximal. Maximum diameters of the dilated duct and lesion were measured. Patterns of enhancement were interpreted in the early and delayed phases as homogeneously enhanced or not and washed out or not, respectively.
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On MR ductography, all 18 cases (100%) of intraductal papilloma were associated with a dilated duct displaying distal dilation (n = 11, 61%), distal and proximal dilation (n = 6, 33%), or proximal dilation (n = 1, 6%). The minimum detected diameter of a dilated duct was 2 mm (range, 2-10 mm). Signal intensity of the dilated ducts on T1-weighted fat-saturation imaging was high in 15 cases (83%), isointense in two cases (11.1%), and low in one case (5.5%). Signal hyperintensity of the dilated ducts was seen in 14 cases (78%) on T2-weighted imaging, and 14 cases (78%) revealed signal hyperintensity of the dilated ducts on T1- and T2-weighted imaging. Of the 18 cases of intraductal papilloma, 11 had a history of bloody nipple discharge and 10 showed signal hyperintensity on T1-weighted imaging. Despite a history of bloody nipple discharge, one case of intraductal papilloma showed signal isointensity of the dilated duct on T1-weighted imaging.
All papillomas were located in the subareolar region (100%) and represented single lesions. The average distance of the lesion from the nipple was 18 mm (range, 9-49 mm). All 18 papillomas (100%) were isointense on T2-weighted imaging. The minimum diameter of the detected lesion was 3 mm (range, 3-13 mm). Most lesions (n = 16) had smooth margins (well circumscribed) and two had irregular margins. Homogeneous early enhancement was apparent in 17 lesions (94%), with one lesion (6%) showing poor enhancement in the early phase. Lesions appeared homogeneously washed out in 13 cases (72%), two (11%) were heterogeneously washed out, two (11%) showed a plateau, and one (6%) showed central washout; the peripheral aspect of the one specific lesion did not show washout in the delay phase (Figs. 1A, 1B, 1C, 1D, and 1E).
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Detection of intraductal papilloma is also possible using MRI. However, MRI using a conventional coil cannot detect small lesions. In a study by Rovno et al. [8], most papillomas (16/23) were occult on MRI, a finding explained by the small size of papillomas that were undetected on MRI. In that same study and one by Orel et al. [9], slice thickness was 2-3 mm and resolution was 300-700 µm. However, in our study using a microscopic coil, slice thickness was 1.6 mm, providing a high spatial resolution of 0.137 mm suitable for the detection of small lesions. All papillomas were detected by MR ductography using a microscopic coil. The minimum diameter of ducts detected was 2 mm, and the minimum papilloma diameter was 3 mm. MR ductography using a microscopic coil can detect ducts measuring 0.8 mm and intraductal lesions as small as 1.0 mm [1]. This ultrahigh resolution allows very fine images.
Ductal dilatation was identified in all cases of intraductal papilloma, with or without the history of nipple discharge. Ductal dilatation thus represents one of the important findings in cases of intraductal papilloma. Most cases (12/18) showed distal duct dilatation.
Signal hyperintensity of the duct on T1-weighted fat-saturation imaging and clinical correlations were explained by hemorrhagic content of the duct. A possible explanation for signal hyperintensity of the duct on T2-weighted imaging includes age of the hemorrhage. Different ages of hemorrhage result in different signal intensities of the duct on T2-weighted imaging.
In almost all cases, the papilloma appeared as a well-circumscribed mass (16/18), with most homogeneously enhanced in the early phase (17/18) and washed out in the delayed phase (13/18). Early enhancement and delayed washout may be attributable to a papilloma rich in fibrovascular stroma. Similarly, intraductal papilloma has been described without using a microscopic coil as a well-circumscribed enhancing mass associated with duct dilation on MRI [8-11]; these procedures have not provided sufficient information regarding patterns of enhancement. Our study revealed a similar enhancing pattern for even the smallest papilloma (3 mm). This enhancing pattern is thus a fundamental characteristic of papilloma.
Our study has a few limitations. We only investigated a surgically confirmed population. Although smaller (2-3 mm) papillomas are common, papillomas less than 3 mm in diameter could not be investigated, as no papillomas in the study population were that size. Although no specific criteria exist for the selection of patients for surgery in cases of intraductal papilloma at our hospital, surgeons usually do not perform operations on smallsize suspected intraductal papillomas; they recommend that these patients undergo follow-up examinations. Because of this, we failed to include the more common smallsized papillomas in our study. Our study did not provide information about discrimination between benign and malignant lesions regarding their pattern of enhancement because of the limited number in the study group. Further study is necessary to clarify the difference between them.
In conclusion, MR ductography using a microscopic coil offers a better technique for detection of intraductal papilloma than conventional breast MRI. The majority of intraductal papillomas in our study on MR ductography using a microscopic coil appeared as well-circumscribed masses homogeneously enhanced in the early phase and washed out in the delay phase. The papillomas were associated with dilated ducts showing signal hyperintensity on T1- and T2-weighted imaging.
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