Imaging Sciences Interesting Cases
Case 74
B. Keegan Markhardt, MD
Clinical Presentation: A 79-year-old woman presented with spontaneous blood-tinged right nipple discharge for several weeks.
Imaging Findings: See below.
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| Figure 1. Diagnostic mammogram of the right breast, including spot magnification craniocaudal (CC) view (standard CC and mediolateral oblique (MLO) views are not shown). There is dilation of one of the central mamillary ducts. Otherwise, there are no suspicious microcalcifications, emerging masses, architectural distortion or other signs of malignancy in the right breast. |
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| Figures 2 and 3. Diagnostic galactography (ductography). After cleansing the nipple area, the discharging duct was identified. A 30-gauge ductography cannula was introduced into the duct without difficulty. One cc of Omnipaque 300 was injected into the duct, and then taped in place. Magnification CC and true lateral views show a 1.0 cm intraductal filling defect 1.4 cm from the nipple. |
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| Figures 4 and 5. Diagnostic breast ultrasound. Targeted high frequency ultrasound of the retroareolar region of the right breast demonstrates a dilated duct containing a soft tissue mass (outlined by calipers) with Doppler flow. |
Diagnosis: Intraductal Benign Papilloma
Discussion: Nipple discharge is most commonly associated with endocrine alterations or medications. These often result in duct ectasia or fibrocystic changes in the breast. Changes are often bilateral and may lead to bilateral discharge from one or several nipple ducts. The most common cause of clinically significant discharge is intraductal growth of the ductal epithelium, resulting from hyperplasia, micropapillary proliferation, solitary papillomas, or ductal carcinoma (both in situ and invasive). Most of the intraductal changes that lead to nipple discharge are situated within 1-4 cm of the nipple.
Solitary papillomas are benign neoplasms that typically develop in larger mamillary ducts. They are the most common cause of spontaneous serous and bloody unilateral nipple discharge. In these patients, galactography (also know as ductography) is helpful in establishing the presence, number, and the location of the lesions. The ductogram typically demonstrates a central filling defect in a dilated central duct (Figs. 2 and 3).
On mammography, papillomas can be identified as solitary masses or as clusters of round and punctate calcifications with or without an associated mass. Coarse, dense, curvilinear calcifications incidentally noted within dilated ductal structures or masses are also most likely sclerosed papillomas.
Ultrasound may reveal ductal dilatation and an intraductal lesion if the lesion is close to the nipple (Figs. 4 and 5). Not all papillomas, however, are located close to the nipple or within dilated ducts. Therefore, normal ultrasound findings in a woman who has spontaneous nipple discharge do not exclude the presence of a papilloma.
Surgical excision is advised for papillomas with papillary carcinoma, atypia or nonconcordant imaging findings. Central solitary papilloma have no increased risk of malignant cancer. However, tumors starting in the terminal ducts, further from the nipple, are called peripheral papillomas and are considered a risk factor for breast cancer.
References:
- Ikeda DM. Mammographic and ultrasound analysis of breast masses. In: Breast imaging: the requisites, 1st ed. Philadelphia, PA: Elsevier Mosby, 2004:113-116.
- Cardenosa G. Cysts, cystic lesions, and papillary lesions. Ultrasound Clinics. 2006 October;1(4): 617-629.