The British Journal of Radiology, 79 (2006), 843–849

PICTORIAL REVIEW

Ultrasound spectrum in intraductal papillary neoplasms of breast

S GANESAN, MD, G KARTHIK, DNB, M JOSHI, MD, DNB and V DAMODARAN, MS, FRCS

Department of Radiology and Imaging, G.K.N.M Hospital and Research Centre, PN Palayam,
Coimbatore – 641037, India

ABSTRACT. Intraductal papillary neoplasms (IPNs) of breast form a wide spectrum of

pathological changes with benign intraductal papilloma occupying one end of the
spectrum and papillary carcinoma at the other end. Intraductal papillomas are known
to occur anywhere within the ductal system and are broadly classified into central and
peripheral types. Intraductal papillary carcinoma is an uncommon ductal malignancy
forming papillary structures, and these lesions characteristically lack the myoepithelial
layer present in benign papillary neoplasms. Three basic patterns of IPNs are recognized
on ultrasound – intraductal mass with or without ductal dilatation, intracystic mass and
a predominantly solid pattern with the intraductal mass totally filling the duct. Benign
papillomas are known to exhibit calcifications which tend to be extremely dense and
Received 24 November
coarse. IPNs are highly vascular tumours and have a propensity to bleed spontaneously. 2004
A distinct vascular pedicle is identified within the central core of IPNs, with branching Revised 16 May 2005
vessels arborising within the mass. In an older age group, presence of a large solid Accepted 1 June 2005
component and evidence of spontaneous intracystic bleed are more suggestive of
DOI: 10.1259/bjr/69395941
papillary carcinomas than benign papillomas. We have serially studied 42 cases of
intraductal papillary neoplasms with sonomammography and mammography from ’ 2006 The British Institute of
2001 to 2004. Radiology

Intraductal papillomas are common neoplasms with a
relative incidence of 2–3% [1]. In elderly patients,
intraductal papillomas are often asymptomatic and are
seen commonly as an incidental finding in biopsy
specimens [2]. Even though intraductal papillomas are
primarily benign, these lesions can pose problems in
view of their similarity to intraductal papillary carci-
noma clinically, on ultrasound and histologically [3].
Intraductal papillary carcinoma (IPC) is a rare ductal
carcinoma forming papillary structures, with reported
incidence of 1–4% of breast carcinomas [4]. These
neoplasms have certain characteristic imaging features
which help to differentiate these lesions from other focal
breast abnormalities.
Pathological observations
Papillomas are essentially benign proliferations of
ductal epithelium. They may occur at any age between
30 years and 77 years [4], but are commonly seen
between 30 years and 55 years [3]. They are known to
occur anywhere within the ductal system and are
broadly classified into central and peripheral types.
Central types are usually solitary, while the peripherally
located papillomas tend to be multiple within the
terminal duct lobular unit. Lesions are often confined
Address correspondence to: Dr Karthik Ganesan, Department of
CT and MRI, Jaslok Hospital and Research Centre, 15, Dr G
Deshmukh Marg, Mumbai – 400026, Maharashtra, India.
to a single breast, while bilateral lesions are reported in
up to 14% of cases [4].
Central papillomas are subareolar in location within a
major duct. On macroscopic examination, a papilloma
appears as a round to oval, small mass usually
measuring a few millimetres in size within a dilated
duct. Larger lesions dilate the duct more and extend
along the long axis of the duct presenting a spheroidal
shape. With ductal obstruction, the dilated duct with a
papillary lesion may resemble a cyst with an intracystic
solid component, this variant being termed as an
intracystic papilloma. Histologically, papillomas show
hyperplastic proliferation of ductal epithelium, having
an arborescent growth pattern with branching fibromus-
cular core of myoepithelial and epithelial cells. Lesions
may be pedunculated or broad based [3, 4].
Multiple peripheral papillomas are a rare entity in
which the lesions are located in the peripheral duct
system within the terminal ductal lobular unit. Several
adjacent ducts are involved with segmental dilatation of
the ducts, often resulting in a peripherally located mass.
The incidence of nipple discharge is lower in these
patients compared with the papillomas in larger ducts.
There is an increased risk of carcinoma in peripheral
papillomas which is directly related to the degree of
cellular atypia. Peripheral papillomas are often asso-
ciated with coexisting malignancy with a reported
incidence of 10–30% [3–6].
Intraductal papillary carcinoma (IPC) is an uncommon
ductal malignancy forming papillary structures.
Histologically papillary carcinoma shows multilayered

The British Journal of Radiology, October 2006 843

 S Ganesan, G Karthik, M Joshi and V Damodaran

papillary projections with microscopic frond formations

extending from the vascularized stalks. These lesions
characteristically lack the myoepithelial layer present in
benign lesions. IPCs are reported in patients from 25 years
to 89 years of age with a peak incidence between 40 years
and 75 years [4]. IPCs have a wide spectrum of presenta-
tions varying from a focally invasive lesion with micro-
scopic frond formation to a large mass located within a
cystically dilated duct. Multiple lesions tend to occur
within the same duct with papillary configurations.

Ultrasound features
Ultrasound features of intraductal papillary neo-
plasms (IPN) primarily depend on the gross macroscopic
appearance of the lesion. Three basic patterns of IPNs are
recognized on ultrasound – intraductal mass with or
without ductal dilatation, intracystic mass and a pre-
dominantly solid pattern with the intraductal mass
totally filling the duct [3, 7]. If the tumour is small, a
focally dilated duct may be the only observation. A
solitary dilated duct, even in the absence of a demon-
strable intraductal mass, is highly suggestive of an
intraductal papilloma, especially, if the patient is Figure 2. Papillary carcinoma. A moderately large mass is
presenting with a serosanguinous nipple discharge [3]. seen to almost totally fill the entire dilated duct. Relatively
Dilated duct with an intraductal mass or a cyst with an hypoechoic debris is seen to fill the peripheral duct adjacent
intracystic solid mass is the hallmark of intraductal to the mass. A short segment of proximal duct is noted at 10–
papillomas (Figure 1). The ductal component may vary 11 o’clock position.
in size from a minimally dilated duct to a large cystically
dilated, obstructed duct. Similarly the intraductal soft
relationship between the mass and the duct on ultra-
tissue component may range in size from a very small
sound and classified the masses into four categories: type
lesion which may be impossible to image to a large mass
I – intraluminal mass; type II – extraductal mass; type III
completely filling the dilated duct or the cyst obscuring
– purely solid mass; type IV – mixed variety [9]. Benign
the ductal or cystic component simulating other
papillomas are known to exhibit calcifications. These
solid masses (Figure 2) [3, 8]. Han et al analysed the
calcifications tend to be dense and coarse (Figures 3–5).

Figure 3. Benign intraductal papilloma with calcification.

Figure 1. A focal mass arising from the ductal wall with Focal dilatation of a solitary duct with intraluminal echo-
relatively narrow base of attachment is present. Note the genic debris. Note small focal mass with dense, coarse
branching pattern and peripheral fronding typical of calcifications in the proximal duct, with ductal obstruction
intraductal papilloma/papillary carcinoma (D-Duct). (small arrows).

844 The British Journal of Radiology, October 2006

Pictorial review: Intraductal papillary neoplasms of breast

(a) (b)

Figure 4. Benign calcified intraductal papilloma with adjacent oil cyst. (a) Small focal mass with coarse, irregular and dense
calcifications (small arrows) adjacent to a cystic mass (C). Echogenic floating debris within the cyst with floating fat-fluid level
(long arrows). (b) Colour flow studies – focal increase in flow within the mass.

Small IPNs are often mammographically negative. A
minimal to moderate duct dilatation may be observed on
mammography as a progressively tapering band-like
density extending from the nipple-subareolar region
towards the breast parenchyma for a variable distance
(Figure 6). Larger lesions in a dilated duct may resemble
any other focal well-circumscribed dense mass on
mammography (Figure 7). Calcified IPNs exhibit dense,
central, peripheral or combined form of coarse calcifica-
tion similar to those seen in cases of calcified fibro-
adenomas (Figure 8). Boonjuwetat et al described the
mammographic appearances of papillary neoplasms in a
series of 15 cases. They reported that most lesions
presented as solitary dense masses with no evidence of

(a) (b)

Figure 5. Calcified giant intraductal papilloma. (a) Ultrasound and (b) mammography demonstrate a large, bilobed, densely
calcified mass with distal shadowing (arrows).

The British Journal of Radiology, October 2006 845

 S Ganesan, G Karthik, M Joshi and V Damodaran

(a) (b)

(c)

Figure 6. Benign intraductal papilloma. (a) Mammography – oblique band like density along inferolateral quadrant of the left
breast. (b) Ultrasound – focal dilatation of a solitary duct with an intraluminal mass arising from the ductal wall. (c) Doppler
studies – distinct vascular pedicle within the central core with branching vessels arborising within the mass.

calcification in any of these lesions. A few lesions were
mammographically negative either due to the size of the
lesion or due to the dense parenchymal pattern [10].
IPNs are highly vascular and have a propensity to bleed
spontaneously. Spontaneous haemorrhage into a dilated
duct characteristically produces a fluid–debris level due to
the denser cellular components settling down to the
dependant position. The supernatant serum is anechoic
while the dependant cellular debris is echogenic. Presence
of fluid–debris level in a cyst, representing spontaneous
bleed into the cyst, is virtually suggestive of a mural
proliferative lesion (Figures 9 and 10) [11]. IPNs have a
characteristic flow pattern on colour flow studies. A
distinct vascular pedicle is identified in IPNs within the
central core with branching vessels arborising within the
mass. Colour flow studies are sensitive in identifying even
very small IPNs, in view of its characteristic vascularity
(Figure 11). Intraductal papillomas and papillary carcino-
mas have considerable overlap in imaging features and it
may not be possible to differentiate them on ultrasound. In

846 The British Journal of Radiology, October 2006

Pictorial review: Intraductal papillary neoplasms of breast
(a)
Figure 7. (a) Mammography – focal well circumscribed dense mass along the retroareolar region of the left breast.
(b) Ultrasound – large cystic mass with echogenic debris totally filling the cyst.
an older age group presence of a larger solid component
and evidence of spontaneous intracystic bleed are more
suggestive of papillary carcinomas than benign papillo-
mas (Figure 12) [9].
The differential diagnosis of IPNs depends upon the
basic imaging appearances. Presence of sectoral dilata-
tion of ducts with no demonstrable intraductal mass has
to be differentiated from mammary duct ectasia, which is
a chronic inflammatory condition. Bleeding into a duct,
inspissated material in mammary duct ectasia and ductal
carcinoma in situ may produce dilated ducts with
intraductal filling defects resembling IPNs. Mammary
ductectasia is often bilateral and tends to affect multiple
ducts. In intraductal carcinoma, ductal dilatation is
unilateral, sectoral and irregular with ductal wall
thickening. Colour flow studies reveal lack of flow in
inspissated intraductal debris. Increased or variable
periductal flow may be present in intraductal carcinomas
while the IPNs reveal the characteristic arborescent
The British Journal of Radiology, October 2006
(b)
vascularity. A cystically dilated duct may resemble a
simple cyst when the intracystic component is very
small. This has to be differentiated from other cystic
masses like a simple cyst, complex cyst, haematoma,
abscess and fat necrosis. A dilated duct with an
intraductal solid component consisting of a central core
and peripheral fronds, with characteristic flow on colour
flow studies, is virtually diagnostic of IPNs. When the
mass is large enough to fill the dilated duct or the cyst, it
may not be possible to delineate the peripheral ductal or
cystic component. These lesions have to be differentiated
from other solid masses [3].
Fine needle aspiration cytology (FNAC) or core biopsy is
required in all cases to arrive at a definitive diagnosis even
though the imaging findings are suggestive of IPNs.
FNAC from non-palpable small masses and from the solid
component in large cystic lesions can be performed under
ultrasound control. At our institution, small papillary
lesions within a minimally dilated duct, observed as
847

Figure 8. Mammography. Well circumscribed peripherally
calcified lesion within a progressively tapering band-like
density extending from the nipple-subareolar region
towards the breast parenchyma.
incidental findings in an asymptomatic patient on sono-
mammography are not subjected to FNAC or core biopsy.
These patients are advised serial follow up with sono-
mammography. Larger lesions, lesions with atypical
characteristics and lesions in symptomatic patients are
subjected to FNAC and core biopsy. The criteria for calling
Figure 9. Intracystic papillary carcinoma. A moderately large
cystic mass in the central breast region with large intracystic
solid component is present. The mass is attached to the wall
by a broad base and shows irregular branching pattern with
peripheral fronding. (D – Cystically dilated duct).
848
S Ganesan, G Karthik, M Joshi and V Damodaran
Figure 10. Colour flow studies in intraductal papillary
neoplasms (IPNs). Distinct vascular pedicle within the central
core with branching vessels arborising within the mass.
a core B3 are the following: papillary lesion, atypical
intraductal epithelial proliferations, radial scar, lobular
neoplasia and fibroepithelial lesions. Lee et al reported that
the B3 core group is a more heterogeneous group and has a
lower rate of malignancy on further biopsy. However, they
concluded that the majority of lesions categorised as B3
required excision [12]. Agoff et al evaluated the need for
surgical excision in intraductal papillary neoplasms and
suggested that all such lesions with atypical ductal
hyperplasia required excision owing to the high rate of
associated neoplasia [13]. Although some lesions cate-
gorised as B3 lesions on core biopsy may be re-categorised
Figure 11. Benign intraductal papilloma in a cystically
dilated duct. Cystically dilated duct with a small focal mass
attached to the ductal wall with a narrow base between 10
and 11 o’clock position. A short segment of dilated proximal
duct is identified with dependant echogenic debris with
layering effect forming a fluid-debris level.
The British Journal of Radiology, October 2006
Pictorial review: Intraductal papillary neoplasms of breast
on excision biopsy as B2 lesions, all lesions categorised as
B3 and above are subjected to excision biopsy at our
institution.
References
1. Cilotti A, Bagnolesi P, Napoli V, et al. Solitary intraductal
papilloma of breast. An echographic study of 12 cases.
Radiol Med (Torino) 1991;82:617–20.
2. Kramer WM, Rush BF. Mammary duct proliferation in the
elderly: a histopathologic study. Cancer 1973;31:130–7.
3. Tohno E, Cosgrove DO, Sloane JP. Benign processes-
tumors. In: Tohno E, Cosgrove DO, Sloane JP, editors.
Ultrasound diagnosis of breast diseases. Edinburgh:
Churchill Livingstone, 1994:94–7.
4. Dahnert W. Breast disorders. In: Dahnert W. Radiology
review manual, 4th edn. Philadelphia, PA: Williams and
Wilkins, 1999:458–74.
5. Haegenson CD. Diseases of the breast, 3rd edn.
Philadelphia, PA: W.B. Saunders, 1986:136–75.
6. Murad TM, Contesso G, Mouriesse H. Papillary tumors of
large lactiferous ducts. Cancer 1981;48:122–33.
7. Kasumi F. Ultrasound of breast diseases. Shinohara –
shuppan Co., Tokyo, 1983. Cited in Benign processes –
Tumors, Intraductal Papilloma, In: Tohno E, Cosgrove DO,
The British Journal of Radiology, October 2006
Sloane JP, editors. Ultrasound diagnosis of breast diseases.
Edinburgh: Churchill Livingstone, 1994:94.
8. Yang WT, Suen M, Metrewell C. Sonographic features of
benign papillary neoplasms of the breast: review of 22
patients. J Ultrasound Med 1997;16:161–8.
9. Han BK, Choe YH, Ko YH, Yang JH, Nam SJ. Benign
papillary lesions of the breast: sonographic-pathologic
correlation. J Ultrasound Med 1999;18:217–23.
10. Boonjunwetwat D, Prathombutr A. Imaging of benign
papillary neoplasm of the breast: mammographic, galacto-
graphic and sonographic findings. J Med Assoc Thai
2000;83:832–8.
11. Tohno E, Cosgrove DO, Sloane JP. Diagnostic features on
ultrasound. In: Tohno E, Cosgrove DO, Sloane JP, editors.
Ultrasound diagnosis of breast diseases. Edinburgh:
Churchill Livingstone, 1994:58–9.
12. Lee AH, Denley HE, Pinder SE, Ellis IO, Elston CW, Vujovic
P, et al. Excision biopsy findings of patients with breast
needle core biopsies reported as suspicious of malignancy
(B4) or lesion of uncertain malignant potential (B3).
Histopathology 2003;42:331–6.
13. Agoff SN, Lawton TJ. Papillary lesions of the breast with
and without atypical ductal hyperplasia: can we accurately
predict benign behaviour from core needle biopsy? Am J
Clin Pathol 2004;122:440–3.
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