Multiple Papillomas of the Breast: A Review of Current Evidence and Challenges

Abstract

Objectives: To conduct a review of evidence about papillomatosis/multiple papillomas (MP), its clinical and imaging presentation, the association between MP and malignancy and the management strategies that follow.

Methods: A computerized literature search using PubMed and Google Scholar was performed up to January 2021 with the following search strategy: "papilloma" OR "intraductal papilloma" OR "intraductal papillary neoplasms" OR "papillomatosis" OR "papillary lesion" AND "breast". Two authors independently conducted a search, screening and extraction of data from the eligible studies.

Results: Of the 1881 articles identified, 29 articles met the inclusion criteria. The most common breast imaging methods (mammography, ultrasound) showed few specific signs of MP, and evidence about magnetic resonance imaging were weak. Regarding the association between MP and malignancy, the risk of underestimation to biopsy methods and the frequent coexistence of MP and other high-risk lesions needs to be taken into consideration. Results about the risk of developing breast carcinoma of patients affected by MP were inconsistent.

Conclusions: MP is a challenge for all breast specialists, and familiarity with its features is required to make the correct diagnosis. Further studies are needed to evaluate the factors to take into account to plan management, time of follow-up and imaging methods.

Keywords: diagnosis; intraductal papilloma; management; papillary lesions; papillomatosis; underestimation.

Figure 1

Flowchart of the selection of studies.

Figure 2

A 55-year-old asymptomatic woman. (a) Medio-lateral view and (b) cranio-caudal view of screening mammography demonstrated small round or oval opacities in the lower-outer quadrant of the left breast (arrows); (c) Ultrasound examination showed multiple intracystic masses.

Figure 3

A 56-year-old woman with breast implants presenting with unilateral bloody nipple discharge. (a) Tomosynthesis slices in medio-lateral and cranio-caudal view with implant displaced showed multiple dilated ducts in the retroareolar region (arrows). (b) MRI showed ductal contrast enhancement (arrow).

Figure 4

A 55-year-old woman presenting with unilateral bloody nipple discharge. (a) Mammography in medio-lateral view and cranio-caudal view showed multiple scattered calcifications (arrows). (b) Tomosynthesis slice in the CC view showed multiple dilated ducts from the retroareolar region to the outer quadrants (arrows). (c) Ultrasound demonstrated multiple dilated ducts partially filled with intraluminal content (arrows).

Figure 5

A 36-year-old woman with left bloody nipple discharge. (a) Ultrasound demonstrated bilateral multiple hypoechoic masses with circumscribed margins with ductal relation (arrows). (b) MRI showed dilated ducts with high T1 signal on pre-contrast sequences (circle) and multiple enhancing masses related with ductal contrast enhancement on post-contrast images (arrows).

Figure 6

A 43-year-old woman presenting with unilateral bloody nipple discharge. (a) Mammography in cranio-caudal and medio-lateral views did not show any mass or asymmetric density, but only a millimetric cluster on calcification in the upper-outer quadrant of the left breast (circle). (b) Ultrasound demonstrated multiple small masses with ductal relation (arrows). (c) MRI showed multiple enhancing masses associated to ductal contrast enhancement with a “string of pearls” appearance.

Figure 7

Histologic section showing multiple papillomas composed of a fibrovascular core covered with ductal epithelial and myoepithelial cells (dotted arrow) combined with foci of intraductal carcinoma (solid arrow).