What are the diagnosis and treatment options for intraductal papilloma?

Diagnosis and Treatment of Intraductal Papilloma

For intraductal papillomas, surgical excision remains the standard management approach due to the risk of malignancy upgrade (3-14%), with vacuum-assisted core biopsy serving as both diagnostic and potentially therapeutic in select cases. 1

Diagnostic Approach

Clinical Presentation

• Intraductal papilloma typically presents with spontaneous, unilateral, and often bloody discharge from a single duct orifice (35-48% of pathologic nipple discharge cases) 2
• Distinguished from duct ectasia, which presents with non-bloody discharge (often green or yellow) from multiple duct orifices, usually bilateral 2

Imaging Evaluation

• Mammography is the first-line imaging modality for evaluation of pathologic nipple discharge in patients ≥40 years 1
• Ultrasonography is more sensitive than mammography and should be performed in all patients with pathologic nipple discharge 1
• MRI shows three patterns for intraductal papillomas: small luminal mass papillomas, tumor-like papillomas, and MRI-occult papillomas 3
• Ductography may demonstrate small lesions and localize the duct responsible for nipple discharge but is technically challenging with 10-15% inadequate or incomplete results 1

Tissue Diagnosis

• Core needle biopsy (CNB) is preferred over fine needle aspiration (FNA) due to improved sampling and better diagnostic accuracy 1
• Biopsy procedures may be guided by stereotactic mammography, ultrasound, ductography, or MRI, depending on which imaging modality best depicts the lesion 1
• Placement of a tissue marker at the end of the biopsy allows for needle localization and excision if needed 1

Treatment Options

Surgical Management

• Complete surgical excision is the standard management for intraductal papillomas diagnosed at biopsy 2
• Surgical approaches include microdochectomy (for single duct papillomas) or major duct excision (for multiple papillomas) 2, 4
• Major duct excision remains the reference standard to exclude malignancy in patients with unremarkable imaging 1

Minimally Invasive Approaches

• Vacuum-assisted core needle biopsy can be both diagnostic and therapeutic, with cessation of nipple discharge in 90-97.2% of patients 1, 2
• However, vacuum-assisted biopsy should not replace surgical duct excision due to high underestimation rate (50%) for high-risk lesions and DCIS, false-negative rate (7%), and detection of lesion remnants 1

Conservative Management

• Recent evidence suggests that patients with non-bloody pathologic nipple discharge, benign CNB, or normal imaging (cancer risk <2%) may be considered for non-operative management if they don't have risk factors such as prior ipsilateral breast cancer, BRCA mutation, or atypia on CNB 1
• For small solitary intraductal papillomas (<1cm) without atypia, close follow-up with ultrasound may be considered instead of excision (upgrade rate to cancer only 0.9%) 5, 6

Risk Stratification

High-Risk Features Requiring Surgical Excision

• Atypical features on biopsy (33% upgrade rate to malignancy) 6
• Papillomas >1cm in size (significantly associated with cancer upgrade) 5
• Bloody nipple discharge 2
• Discordant imaging and pathology findings 1, 2
• Male patients (57% risk of malignancy vs 16% in females) 2
• Older age (32% risk of malignancy in patients >60 years vs 10% in patients 40-60 years) 2

Follow-up Recommendations

• Patients with multiple papillomas have an increased risk of developing cancer and should be kept under annual review with regular mammography 4
• Patients with solitary duct papilloma without atypia have insufficient increase in risk of subsequent malignancy to justify routine follow-up beyond standard breast cancer screening 4

Important Considerations

• Papillomas are historically considered high-risk lesions, with reported rates of upgrade to malignancy between 3-14% 1, 7
• The management of papillomas diagnosed on CNB is controversial and varies by institution 1
• Ultrasound does not reliably distinguish between benign and malignant small intraductal lesions 1
• The decision between percutaneous biopsy versus major duct excision should involve shared decision-making with the patient 1