Papilloma and Papillomatosis
A papilloma is a benign growth that occurs in the breast ducts. A papilloma has ‘finger-like’ fronds and often completely blocks the duct.
‘Mammary epithelium’ make up a papilloma, these are the cells that comprise the duct-wall linings of the breast.
Papillomas are a solid lump of new cells, Indeed papillomas resemble a wart-like growth, rather than a breast cyst. Therefore, a breast papilloma, at first, can be a symptom that is suspicious for breast cancer until doctors properly analyze it.
Do not worry, a papilloma itself is benign. However, if papillomas appear in multiples this may be a risk for the development of breast cancer. Papillomas tend to develop in women in the 35 to 55 age range.
Is a breast Papilloma the same as the Human Papilloma Virus (HPV)?
Intraductal (breast) papillomas are not at all related to the Human Papillomavirus Virus (HPV). In addition Papillomas are not related to genital warts. Genital warts are small, fleshy growths that occur after exposure to the Human Papilloma Virus (HPV). Breast papillomas simply share the same name because they have similar features.
Breast intraductal papilloma symptoms
A papilloma can present as a small ‘outwardly curved’ bump. Papillomas can either grow on the surface of the breast or within the breast ducts themselves. In the latter case, papillomas are only visible on mammography or by a microscope.
A papilloma will generally form right around or below the nipple. A woman may discover a small lump herself by doing breast self-exams or often a health care provider may find a small lump just beneath the surface through delicate palpation (feeling and pressure).
Papillomas can also be painful.
Nipple Discharge and Breast Papilloma
A papilloma will usually involve a nipple discharge, sometimes of serous fluid but sometimes with blood as well. ( About half of the time the nipple discharge contains blood).
Sometimes nipple discharge is called ‘pathological nipple discharge’ or ‘PND’, and this symptom accounts for about 5% of all women who attend breast cancer screening clinics.
So, between 40% to 70% of women who present with this symptom (PND) end up with a diagnosis of papilloma. Sometimes, however, pathological nipple discharge is associated with either carcinoma ‘in situ‘ or invasive breast cancer, so it is a serious symptoms that has to be fully investigated.
The rate of PND associated with breast cancer, and even other types like cervical cancer, is hard to know for sure. Some studies place it at over 20 %, but a large, comprehensive study would probably place the rate considerably lower.
Types of papillomas of the breast
There are two basic ‘categories‘ of breast papilloma development:-
- Solitary Papilloma: A single growth
- Multiple Papillomas
The solitary papillomas are more prone to nipple discharge and tend to involve a papillary neoplasm which has ‘punctured’ a major breast duct just below the nipple.
Generally speaking, solitary papillomas are benign and not worrisome. The doctor might drain the tumor by excision or by needle aspiration. If this is the case, a histological evaluation of the fluid will follow, just to rule out any cancer. However, most of the time papillomas do not require routine follow-ups. Many physicians don’t even consider a solitary papilloma as a ‘true disease’ process.
Multiple Papillomas and Papillomatosis
Multiple breast papillomas present a greater risk and more difficult management problem. Here the tumors occur deeper within the breast and probably will not cause nipple discharges.
Multiple papillomas form a subset of about 10 % of all intraductal papillomas, and also tend to occur more frequently in younger women.
Papillomatosis areas are quite often ‘bilateral’ (occurring in both breasts). Sometimes the physical ‘placement’ of one of a multiple of papillomas will be given a particular name. “Central” papillomas grow deeper within the breast, whilst “peripheral’ papillomas occur toward the outer edges of the breast.
Some physicians argue that there needs to be at least five clearly separate papillomas within a given segment of breast tissue in order for the tumor to be termed ‘papillomatosis’. Multiple papillomas are more suspicious for subsequent breast cancer development than solitary papillomas.
Breast Papilloma may present with or without ‘atypia’
When a papilloma tissue sample is sent for microscopic evaluation, the pathologist may be looking for signs of ‘atypia‘. Sometimes, within the context of the presentation of ‘multiple’ papillomas, cellular atypica may already be present or may develop over time.
These atypical cellular features may include:-
- Hyperchromatic nuclei
- Marked nuclear atypia
- Cribriform patterns
- A monotonous cell population
- Absent supporting stroma
When enough atypical features are present, the phyicians may begin to classify the papilloma as ‘atypical ductal hyperplasia‘ or ADH. This is a more serious, higher-risk diagnosis. In this case regular screening and treatment are necessary.
Juvenile Papillomatosis (JP)
Papillomatosis or ‘multiple papillomas’ tends to affect a slightly younger age group then solitary papillomas, but sometimes the condition can affect very young women, even as young as 10 years old.
The mean age of diagnosis of JP tends to be around the early 20’s. This ‘juvenile papillomatosis’ often includes a painless mass that may be thought to be a fibroadenoma.
Juvenile papillomatosis tends to have many features of atypical hyperplasia and also some cyst development.
Although juvenile papillomatosis is not breast cancer, there is an increase in the risk for breast cancer development, especially if it is bilateral.
Family history also tends to play a role in an increase for risk or tendency of papillomatosis to develop into breast cancer. There is even some evidence to suggest that a young patients female relatives might be more susceptible to breast cancer development than the average population, though no one knows exactly why this is.
Do Women with breast papilloma have an increase in risk for breast cancer?
Any kind of proliferative cell growth in the breast raises concerns of breast cancer or an increase in the risk for future breast cancer development.
Fibrocystic changes of any sort are thought to confer a slightly increased risk of breast cancer development over the long term, but only slightly higher than for the general population.
Specialists consider a solitary papilloma to be benign. Indeed, the risk for breast cancer only slightly increases for women who show any benign fibro-cystic changes. Multiple papillomas, however, are associated with an increase in the risk for breast cancer development, but this is still very low.
If any of the papillomas show ‘atypical’ cells or cell formations, the risk is significantly higher and we may in fact be speaking about a different diagnosis altogether, i.e. atypical ductal hyperplasia.
Papilloma can sometimes ‘conceal’ a breast cancer
However, recent studies point to a diagnostic and assessment inaccuracy associated with papillomas and breast cancer risk. Indeed, medics now suspect that most instances of papilloma and papillomatosis thought to have ‘evolved’ or ‘developed’ into breast cancer, were actually breast carcinoma to begin with and simply under-diagnosed.
Where there is a strong correlation between mammographic studies and microscopic studies that convincingly point to a benign tumor, there is a very low risk of subsquent breast cancer appearance. In any event, annual follow-up for multiple papillomas is a prudent course of action.
Imaging and diagnostic features of breast papilloma
Mammograms and ultrasounds are not necessarily that useful in diagnosing an inverted papilloma. A mammogram will generally be performed regardless as a precaution for any lesion involving bloody discharges, but intraductal papillomas do not tend to show up well on a mammogram.
Papillomas tend to be small and unless doctors suspect a large ‘fat’ element, or a somewhat larger lump, the breast mammogram will probably look normal.
Ultrasound also does not reliably diagnose a papilloma. Ultrasound is generally useful in getting a reading on the relative amounts of fluid, solid, and fat elements in a lesion, and can readily determine if a lesion is a benign cyst (fluid filled). Papillomas are generally non-liquid but do occasionally appear as solid nodules within a fluid-filled duct and some papillomas may present with cystic elements.
Breast MRI can reveal ‘hidden’ views, but cannot reliably distinguish benign from malignant cells within a papilloma
MRI is an extremely sensitive diagnostic imaging tool and can sometimes reveal features of a papilloma ‘hidden’ to other views, but there is quite a range in possible appearances of a papilloma. MRI might reveal some ‘atypical’ or irregular enhancements that cannot reliably be distinguished from malignant cell growth, so biospy will be needed anyway.
But, if the MRI shows nothing it is still a helpful, but expensive, reassurance. MRI might show the total absence of atypical features surrounding the papilloma. If this is the case, it can be very reassuring for a patient. However, given the high cost and sub-optimal specificity, MRI is unlikely to be used for most suspected breast papillomas.
Breast ductography is an established diagnostic technique that is sometimes useful for women who present with nipple discharges. Ductography (also called galactography or ductogalactography) basically involves injecting a ‘contrast enhancing’ die or substance directly into the breast ducts and then performing an X-Ray. This allows the physician to follow the course of fluids through the ducts and determine if and where there is any blockage (or cell block).
A simple, solitary papilloma may quite easily appear as a ‘blocked duct’.
Multiple papillomas can also be observed as absent or sub-segmental distribution of fluid in the branching ducts. There will be a typical and identifiable pattern.
Ductography might also detect the presence of malignant processes, through distortions, narrowing, and obstruction of various ducts. However, ductography has considerable limitations at arriving at a definitive diagnosis, so it is no longer a widely practised procedure.
Microscopic features of breast papilloma
Breast papillomas will typically have a characteristic ‘arboriform’ (tree like, or frond like) structure with a central fibrovascular core (combination of fibrous tissues and blood supply elements). The lesion may also have an inner myoeptihelial and outer luminal epithelial layer. The epithelial elements might show generic-type hyperplasia, apocrine metaplasia, and rarely squamous papilloma or squamous cell carcinoma.
Sclerosis, or hardening of the fibrovascular core is common, as well as complete or partial obliteration of the duct lumen (total blockage). When the hardening and blockage aspects seem to be the dominant features of the tumor, it might be classified as ductal adenoma. Microscopic analysis of a suspected papilloma or follow-up evalution of a confirmed papilloma might also reveal atypical hyperplasia features, or even in situ carcinoma, (DCIS) and will be classified and treated accordingly.
Is there any relationship between papilloma and the micropapillary form of DCIS?
When ‘papilloma-like’ symptoms present to a pathologist he/she needs to make a differential diagnosis between benign papilloma on the one hand, and malignant micropapillary DCIS on the other. Both diseases have similar frond-like features. The ‘Transitional epithelium’ in some less-typical papillomas can resemble micropapillary DCIS cells.
However, there does not appear to be any relationship between papilloma and micropapillary Ductal carcinoma in situ (DCIS). One can be as misdiagnosed as the other, and sometimes carcinoma of the breast can arise ‘de novo’ (on its own, from the beginning) from the same area as a papilloma. However, there appears to be no ‘disease-related’ connection between them. A papilloma is not part of a micropapillary DCIS scenerio and does not ‘evolve into’ micropapillary DCIS or papillary breast carcinoma.
Treatment and management of breast papilloma
Solitary papillomas; if there are no functional complications or atypical features, will often just be left alone. If there is a nipple discharge, the doctor will first drain the lesion and quite likely perform a surgical excision.
Often the surgeon makes a small incision at the edge of the areola and the resulting scar tissue is virtually unnoticeable.
If there are no atypical features, there is no need to rush into surgical removal of breast papillomas
Treatment of multiple papillomas can be a bit of a grey area and judgement call. Since the only real treatment for papillomatosis ( multiple papillomas) will be mastectomy, this is a decision that medics tend to delay as much as possible. Papillomatosis will require careful follow-ups by annual checkups. If there is no evidence of atypical or malignant processes there really is no clear reason to do anything.
Where there is also a bloody nipple discharge with papillomatosis, this tends to indicate a more suspicious situation and if it is an ongoing thing, doctors may consider a mastectomy. However, there are new treatment techniques such as the “microdochectomy”, which is the surgical excision of the major affected breast duct and not the entire breast. This may be a prudent treatment option for localized, suspicious papillomas with discharges.
- Dzodic R, Stanojevic B, Saenko V, Nakashima M, Markovic I. Pupic G, Buta M, Inic M, Rogounovitch T, Yamashita S. (2010) Intraductal papilloma of ectopic breast tissue in axillary lymph node of a patient with a previous intraductal papilloma of ipsilateral breast: a case report and review of the literature. Diagnostic Pathology 2010, 5:17 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2841131/
- Lewis JT, Hartmann LC, Vierkant RA, Maloney SD, Shane Pankratz V, Allers TM, Frost MH, Visscher DW. (2006) An analysis of breast cancer risk in women with single, multiple, and atypical papilloma. Am J Surg Pathol. 2006 Jun;30(6):665-72.