From the Guidelines
Intraductal papillomas should be managed with surgical excision, preferably through a microdochectomy or central duct excision, to provide definitive diagnosis and remove the potential for future growth or malignant transformation, as supported by the most recent evidence from 2022 1. The management process typically begins with diagnostic imaging, such as mammogram and ultrasound, followed by a core needle biopsy, which is preferred over fine-needle aspiration due to its ability to provide larger tissue samples for histological examination 1. Key considerations in the management of intraductal papillomas include:
- The potential for malignancy, with reported rates of upgrade to malignancy between 3% and 14% 1
- The importance of complete removal of the lesion to prevent future growth or malignant transformation
- The role of imaging modalities, such as mammography, ultrasound, and MRI, in guiding the biopsy and surgical excision
- The need for patient education and discussion of potential complications, such as changes in nipple sensation or appearance, and the small risk of recurrence While close observation with regular follow-up imaging may be considered for small, asymptomatic papillomas without atypical features, this approach carries a small risk of underdiagnosing a malignancy and should be discussed thoroughly with the patient 1. Post-surgical follow-up should include regular breast examinations and imaging as recommended for the patient's age and risk factors, with consideration of the patient's individual risk profile and medical history 1.
From the Research
Management of Intraductal Papilloma
The management of intraductal papilloma involves several approaches, including:
- Surgical excision: This is generally recommended as a precaution due to the risk of subsequent carcinoma 2, 3, 4, 5
- Selected ductolobular segmentectomy: This operative method has been described as a treatment option for both solitary and multiple intraductal papilloma, with favorable results including a fine cosmetic appearance and no recurrence of papilloma during follow-up 3
- Close follow-up with ultrasound: This may be recommended for patients with small solitary intraductal papilloma, as the upgrade rate to cancer is low 6
- MRI-guided excision: This has been shown to be accurate in the detection, localization, and resection of intraductal papilloma lesions, and may be applicable to patients with and without nipple discharge 2
Factors Associated with Malignancy
Several factors have been associated with an increased risk of malignancy in intraductal papilloma, including:
- Size of the papilloma: Larger papillomas have been shown to be associated with an increased risk of cancer upgrade 6
- Multiplicity of papillomas: Multiple papillomas have been shown to be associated with an increased risk of atypia or malignancy 4
- Presence of atypia: Papillomas with atypia have been shown to be associated with an increased risk of malignancy 5
Diagnostic Approaches
Several diagnostic approaches have been used to evaluate intraductal papilloma, including:
- Core needle biopsy: This has been shown to be a useful diagnostic tool, but may not always provide a definitive diagnosis 6, 4, 5
- Ultrasound: This has been shown to be useful in detecting mass-like lesions, but may not be as accurate as MRI in detecting non-mass like lesions 2
- MRI: This has been shown to be accurate in the detection, localization, and resection of intraductal papilloma lesions, and may be useful in guiding excision 2