CASE 919, 920, 921, 922: BREAST PAPILLARY LESIONS: Dr PHAN THANH HẢI, Dr TRÂN THÙY TRANG, MEDIC MEDICAL CENTER, VIETNAM.

 Four cases of papillary lesions of the breast were detected by breast ultrasound.

CASE 1

32 yo multiple papillary lesions in 2 breasts,BI-RADS 4A,B.

Breast MRI

Core biopsy and IHCS

Intraductal papillary lesions

CASE 2: 47 yo L breast mass BI-RADS 4B

Intraductal Papillary Carcinoma .

CASE 3: 43 yo R papillary tumor.

Papillary lesions of the right breast.

Intraductal papillary Carcinoma. 

CASE 4: 46 yo L breast adenocarcinoma. 

Intraductal papillary Carcinoma (C50).

DISCUSSION 

• Papillomas are the most common histological type causing false positives on elastography.

Diagnostic traps:

• Fibrovascular core: Papilloma has a connective tissue and blood vessel axis > Increased central stiffness > False positive

• Stromal fibrosis: Increased collagen around the lesion → increased stiffness > False positive

• Hyalinization: Common in long-standing papillomas > increased stiffness > false positive.  

. Hemorrhage within the tumor > decreased stiffness > false negative. 

. Lesions that are too small: ROI includes surrounding tissue → Inaccurate assessment of lesion stiffness.

• Encapsulated papillary carcinoma: Minimal stromal reaction, may not be excessively firm → false negative

Papillary lesions in the breast are a heterogeneous group of lesions that may include benign tumors (such as papillomas, papillomas with atypical epithelial hyperplasia (ADH)) or cancerous tumors (DCIS, papillary carcinoma in situ or invasive, encapsulated papillary carcinoma, papillary carcinoma of the body, papillary carcinoma of the breast).

• Benign papillomas also present with diverse imaging findings: 

Mass-like form: a tumor within the duct lumen or cyst, possibly accompanied by duct dilation. 

Plaque form: a flattened tumor that spreads along the duct wall, not forming a distinct round mass;.it may thicken the duct wall or create a dense area adhering to the duct wall, forming an ill-defined plaque with increased vascularity.

Intraductal branching form: spreading along the duct lumen, developing into multiple branching papillae within the duct lumen, occupying many branches of the duct system. 

For avoiding mistakes please keep in mind:

1. Risk factors:

  Age: >55 years-old 

  Large lesions: > 1cm. Peripheral papillary lesions (> 3cm) or multiple lesions.

  History of breast cancer or high-risk lesions: ADH (Atypical ductal hyperplasia), LCIS, DCIS, history of contralateral breast cancer.

  Family history and gene mutations. 

2. High BIRADS classification lesion. 

3. Lesions with ADH pathology.