Breast papillomas: current management with a focus on a new diagnostic and therapeutic modality

Abstract

Breast papilloma is a term that describes an intraductal papillary configuration of the mammary epithelium on macroscopic or microscopic examination. It includes solitary intraductal papillomas, multiple papillomas, papillomatosis, and juvenile papillomatosis (JP).Recent advances in mammary ductoscopy (MD) have raised new possibilities in the diagnosis and treatment of breast papillomas. This technique represents an important diagnostic adjunct in patients with pathological nipple discharge (PND) by allowing direct visualisation and biopsy of intraductal lesions and guiding duct excision surgery. Treatment of breast papillomas often entails surgical duct excision for symptomatic relief and histopathological examination. Recently, more conservative approach has been adapted. MD-assisted microdochectomy should be considered the procedure of choice for a papilloma-related single duct discharge. Furthermore, there is increasing evidence that MD has the potential to reduce the number of duct excision procedures and minimise the extent of surgical resection. Imaging-guided vacuum-assisted core biopsy can be diagnostic and therapeutic for papillomas seen on mammography and/or ultrasound. Patients with multiple papillomas do have an increased risk of developing cancer and should be kept under annual review with regular mammography (preferably digital mammography) if treated conservatively. Magnetic resonance (MR) can be also used in surveillance in view of its high sensitivity. Because the risk is small, long term and affects both breasts, long-term follow-up is more appropriate than prophylactic mastectomy. Patients who prove to have solitary duct papilloma have insufficient increase in the risk of subsequent malignancy to justify routine follow-up.

Figure 1

Mammary ductoscopy image showing intraductal papilloma.

Figure 2

PND is identified, duct is dilated using appropriate lacrimal dilators, and MD is gently advanced into the ductal system until papilloma is identified. Blue dye is injected into the affected duct.

Figure 3

The duct is exposed by a skin incision inside the edge of the nipple-areola complex. The nipple is reflected away from the breast tissue in the area covered by the areola. The "blue dye" – involved duct is identified and divided as it enters the undersurface of the nipple

Figure 4

The dissection is carefully carried out caudally around the involved duct using the bovie cautery. During dissection, many dilated major ducts containing fluid can be identified. The nipple is gently everted, the subcuticular tissue approximated with an interrupted layer of 5-0 Vicryl suture. The skin is closed with a fine layer of 6-0-monocryl suture, and the wound is dressed with sterile strips.

Figure 5

US-guided vacuum-assisted core biopsy of a mass lesion in the left breast (left). The lesion has resolved at the end of procedure (right).

Figure 6

A proposed algorithm for the management of PND. PND: pathological nipple discharge. MCC: Micro calcifications. MD: Mammary Ductoscopy. BCS: Breast conserving surgery