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Breast Imaging

E3006. The Family Tree of Papillary Breast Lesions

Tyminski M,  Heath A,  Vijayaraghavan G. University of Massachusetts Medical Center, Worcester, MA

Address correspondence to M. Tyminski (moniquemarie1313@yahoo.com)

Background Information: A papillary lesion of the breast is characterized by a fibrovascular stalk with an overlying layer of epithelial cells with or without a myoepithelial layer. They are often described as arborescent or treelike in appearance. The wide range of papillary lesions of the breast can often be a diagnostic challenge due to overlapping features between benign and malignant conditions. The chance of upgrade on excision further adds to the diagnostic and treatment dilemma. Knowledge of the types and imaging appearances among the spectrum of papillary breast lesions is essential to precise diagnosis and accurate radiology-pathology correlation. Breast lesions in this exhibit include solitary intraductal papilloma, multiple intraductal papillomas, papilloma with atypia (atypical ductal hyperplasia), ductal carcinoma in situ (DCIS) arising in a papilloma, papillary DCIS, and papillary carcinomas.

Educational Goals/Teaching Points: The goal of this exhibit is to identify the common presentations of benign and malignant papillary breast lesions on various imaging modalities. Pathologic correlation will highlight their morphologic characteristics. Examples will be presented with clinical history, imaging findings on mammography, ductography, ultrasound, and MRI. Case examples of benign papillary lesions on core biopsy that were upgraded on excision will also be illustrated.

Key Anatomic/Physiologic Issues and Imaging Findings/Techniques: On mammography, benign and high-risk papillary lesions can present as a round or oval mass that may be associated with ductal dilatation. These lesions can also be occult on mammography depending on multiple factors including the size of the lesion and breast density. Malignant papillary lesions tend to present as a mass with associated pleomorphic calcifications on mammography. There is overlap in the imaging appearances of benign and high-risk papillary breast lesions on ultrasound. The typical imaging presentation is a mural-based solid nodule within a dilated duct. There may be flow from a vascular feeding pedicle. The ultrasound appearance of malignant papillary breast lesions is often of a complex cystic mass, ill-defined hypoechoic mass, or mural-based nodular solid mass. Associated calcifications are common. There is limited information on the MRI appearance of papillary breast lesions. Small intraductal papillomas may be occult or present as an enhancing mass. Kinetics are variable, making differentiation from high-risk and malignant papillary lesions difficult. Papillary DCIS often presents as nonmasslike enhancement on MRI.

Conclusion: Papillary breast lesions have a wide spectrum of imaging appearances. Understanding the differences on imaging is a key component to the proper workup and diagnosis. Tissue sampling with radiology-pathology correlation aids in accurate diagnosis as there is a chance of upgrade on excision in these lesions. Prompt recognition is the key to optimizing patient care.