Investing papilloma radiology imaging
A single patient with IDC was misdiagnosed with intraductal papilloma. A pair of patients with invasive ductal carcinoma were misdiagnosed with MDE and fibroadenoma. Discussion In previous years, the incidence rate of breast cancer has been increasing and there is a lack of effective preventive measures In addition, it is difficult to cure, despite its high incidence 1.
It has been demonstrated that the imaging features of MDE may be similar to those of breast cancer 2. It is therefore important to distinguish MDE from breast cancer The mean age of patients with MDE was However, the mean age of patients with breast cancer was The present study revealed that the morphology features, including aspect ratio, border, shape and microcalcification were significantly increased in breast cancer compared with MDE.
Features including unclear border, irregular, spicular sign and microcalcification, were unspecific for breast cancer, consistent with the report by Yabuuchi et al The features of MDE were of regular shape and clear border, similar to other benign tumors.
The RI and elastography score are useful in the differential diagnosis between breast cancer and MDE 9. Although the RI of benignancy and malignancy may overlap and the threshold value differs among studies, it was useful to distinguish the benign and malignant tumors 24 , Gong et al 26 reported that UE may be as useful as traditional US, with sensitivity, specificity and accuracy of Combined with UE and US, the specificity and accuracy could increase to In the present study, it was revealed that UE was important to improve the specificity and accuracy of diagnosis, consistent with previous studies 6 , Cho et al 29 also supported that UE was important in the differential diagnosis of benign and malignant tumors.
Caivano et al 30 demonstrated that the ADC value of benign and malignant were 2. In the present study, the ADC was 1. Caivano et al 30 demonstrated that for benign tumors, the mean ADC value was 3. Luo et al 31 demonstrated that the sensitivity and specificity of ADC were In the present study there was a significant difference in ADC between MDE and breast cancer groups threshold value, 1. A previous study demonstrated that the enhancement features of breast cancer were ring-like, with the rim of the lesion enhanced in the early phase, then moving to the center Enhancement patterns were distinct between breast cancer and MDE; when the lesion was enhanced in a ring-like manner, the enhancement and timing of the lesion center should be observed.
Luo et al 31 demonstrated that the EER was increased and PER was decreased in malignant tumors compared with that in benign tumors. In the present study, EER was 1. Yuan et al 33 reported that the earlier the peak time, the greater the likelihood of malignancy. Sensitivity and specificity of peak time cut-off value, sec were Peak intensity was associated with the degree of vessel formation.
It has been reported 31 that the majority of benign lesions belonged to type I TIC and malignant lesions presented type II and III, which was consistent with the results of the present study. Brookes et al 35 reported that intraductal papilloma was enhanced peripherally and then the center was enhanced. The majority of the intraductal papillomas were type II and III, similar to invasive ductal carcinoma 36 , thus it was difficult to distinguish.
Yuan et al 33 demonstrated that TIC pattern and Tpeak were the most valuable factors for differential diagnosis. Analyzing multiple parameters identified that US and MRI together may decrease the rate of misdiagnosis. US revealed a circle or oval solid echo with dotted or branched blood signals in dilated duct with a clear border and regular form Fig.
The majority of cases of MDE were located beneath the mammary areola, together with nipple retraction, sinus tract and fistula. Radiographic features Plain radiograph Plain film no longer plays a significant role in the assessment of sinonasal disease. If obtained, the most common finding is that of a nasal mass with associated opacification of the adjacent maxillary antrum 1.
CT CT features are mostly non-specific, demonstrating a soft tissue density mass with some enhancement. The location of the mass is one of the few clues toward the correct diagnosis. As the mass enlarges, bony resorption and destruction may be present, with a similar pattern to that seen in patients with squamous cell carcinoma 2. The presence of a focal, often cone-shaped, hyperostosis has been reported to correlate with the point of origin of the lesions 5.
This is useful not only in suggesting the diagnosis, but also to aid surgical planning, as the location of tumor origin determines the extent of surgery required. Angiography DSA Angiography has no significant role to play in the diagnosis or assessment of inverted papillomas. If performed, these tumors are mostly avascular 1. MRI MRI often demonstrates a distinctive appearance, referred to as convoluted cerebriform pattern , seen on both T2 and contrast-enhanced T1 weighted images.
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Imaging differential diagnosis Terminology The term inverted papilloma is also used to describe an urothelial lesion. For a discussion of that entity, please refer to inverted papilloma of the urinary tract 4. Epidemiology Inverted papillomas account for approximately 0. Clinical presentation The presentation can be similar to other sinonasal masses, with nasal obstruction, sinus pain, and epistaxis.
As the mass enlarges it results in bony remodeling and resorption and often extends into the maxillary antrum 1. Due to the location, impairment of normal drainage of the maxillary antrum is common, although mucocele formation is rare 1. Macroscopic appearance Macroscopically, inverted papillomas appear as irregular polypoid masses of variable consistency, pink in color, with a tendency to bleed 1. Microscopic appearance Microscopically, they appear as ribbons of respiratory epithelium enclosed by basement membrane which grow into the subjacent stroma thus with an inverted pattern with characteristic micro-mucous cysts 1,3.
Radiographic features Plain radiograph Plain film no longer plays a significant role in the assessment of sinonasal disease. If obtained, the most common finding is that of a nasal mass with associated opacification of the adjacent maxillary antrum 1. Coronal computed tomography image f shows the nasal lesions to have considerable intra-antral extensions through widened ostio-meatal units and through rarefied medial wall, as well as through widened post-meatal accessory ostia Full size image Fig.
Axial post-gadolinium-enhanced image d reveals the striations to be more conspicuous than in T2 image. Axial computed tomography e reveals rarefied and widened post-meatal accessory ostium and smooth remodeling of medial maxillary sinus wall. Coronal computed tomography image shows sino-maxillary opacification continuous through smoothly widened ostio-meatal unit with smooth sclerosis of the middle turbinate wall Full size image For the size and location preference, the lesion sizes ranged from 1.
A case of bilateral bi-nasal disease had predominant large nasal lesions with limited frontal sinus extension. Two cases had combined maxillary sinus and nasal disease. Two patients had spheno-ethmoidal sinus involvement. The affected walls are detailed in Table 2.
Only a single case had permeative destruction noted at the nasal septum with trans-sepal crossing; a case proven to have squamous cell carcinoma on top of papilloma. The same patient had defects created by remodeling only. Only one case exhibited evidence of permeative lytic destruction in a pathologically proven squamous cell carcinoma SCC on top of IP. The bony changes are revealed as irregular permeative destruction at the lamina papyracea and the nasal septum.
None of the non-SCC inverted papillomas exhibited this pattern of destruction. Table 2 Spectrum of bony changes of lesions including type of bony involvement and grading of changes Full size table Only a single case had intra-lesional calcifications. Six cases had focal sclerosis, two show linear smooth and plaque-like sclerosis of the osseous wall of the inferior turbinate IT in two nasal lesions.
A third case showed focal sclerosis at the postero-lateral wall of the maxillary sinus in direct contact with the base of the lesion. A fourth case had mild linear sclerosis along incomplete inter-sphenoid septum in a sphenoid sinus lesion, a fifth case had smooth minimal linear sclerosis at the base of the uncinate process close to a middle-meatus-epicentered lesion, nearly bisected by the uncinate process.
A sixth case show frond-like-branching focal sclerosis at the base of a recurrent inverted papilloma, quite distinguishable from diffuse sclerosis of the operated sinus, mostly representing operative-induced osteogenesis. Two patients had involvement of the frontal sinus, one is isolated, while the other is associated with OMU involvement. Regarding magnetic resonance imaging findings Table 3 , visualization of T1-weighted images revealed diffusely T1 hyper-intense signal as compared to the masticatory muscles; four of the six cases exhibited slightly hyper-intense signal.
The remaining ten cases revealed an iso-intense signal. All lesions revealed homogeneity of signal apart from a single case revealing iso-intense signal and focus of hyper-intense signal. Four out of the 16 patients revealed a cyst within the confines of the mass, adequately differentiated from retained secretions. They revealed homogenous T2 signal of fluid with thin wall. Orbital extension was seen in two cases, one of them had evidence of SCC with permeative pattern of destruction and lytic erosions at the lamina papyracea.
Two patients had obstructive sphenoiditis in two sphenoidal-located lesion. Also, frontal sinus extension was noted in two cases, creeping through the fronto-ethmoidal recess. The peak of incidence of IPs is in the fifth and sixth decades of life and still it has been reported in all age groups [ 12 , 13 ]. Obviously, men are affected more often than women with a nearly 3-to-1 male-to-female predominance ratio [ 12 , 13 ].
Our study revealed no sex preference and nearly equal proportions were reported, while age incidence was of old adults. IP most commonly arises from the lateral wall of the nose, with epicenter at the middle meatus. It can affect any sinus, the maxillary sinus being most common Fig. Bilateral IP and multifocal involvement have been reported in the literature but still are an uncommon with uncommon finding of intracranial, skull base or orbital extension in IP without SCC [ 17 , 18 ].
Our study revealed nasal involvement to have the highest prevalence. Axial computed tomography a reveals non-specific maxillary sinus opacification with focal hyperostosis at its postero-lateral wall. Axial T2-weighted image b shows linear striations divergent from the site of focal hyperostosis. T2 image also nicely differentiates obstructed secretions from solid mass reflecting moderate diffusivity with black-out effect of focal sclerosis at diffusion image c and apparent diffusion co-efficient value of 1.
Axial fat suppressed post-gadolinium image e reveals linear striations may be less or equal to visibility in T2-weighted image. Coronal computed tomography image f shows smooth widening of the ostio-meatal unit with nasal extension of the maxillary mass Full size image Fig.
Axial post-operative computed tomography a reveals thick sclerotic septa that could be post-operative neo-osteogenesis rather than neoplastic induced. Axial T2-weighted reveals b the solid recurrent lesion as frond-like tissue on left side of the sphenoid cavity, with linear striations. Axial diffusion in c shows low spatial resolution reflected by too much bone-air interfaces, still apparent diffusion co-efficient map d nicely shows restricted tissue of only 0.
Post-gadolinium image e shows enhanced solid component with too much less visibility of striations. Coronal computed tomography f reveals extension through the posterior nasal recess and endoscopic defect. Focal linear sclerosis of intra-sinus septum is seen blue arrow which may suggest surgery versus neoplasm induced Full size image Fig. Axial T2-weighted a shows the solid tissue filling the sinus, with faintly depicted curved striations in multiple opposed direction, more resolved in axial non-FAT saturation T2-weighted image b.
Apparent diffusion co-efficient map c reflects the compact cellularity with a small apparent diffusion co-efficient value of 0. Axial post-gadolinium-enhanced image d reveals solid enhancing mass with very ill-defined striations. Axial computed tomography image e reveals non-specific opacity. Coronal computed tomography image f reveals lobulated sphenoid sinus opacity pedunculated through spheno-ethmoidal recess showing smooth widening Full size image CT is usually the initial investigation and shows red flag signs of sino-nasal mass.
It is an excellent method for visualization of associated bony changes unlike a malignant tumor; IP causes bone remodeling thinning and bowing and resorption rather than osseous destruction [ 19 ]. Bone remodeling is reported to be most commonly at the medial wall of the maxillary sinus, followed by the lamina papyracea. The nasal septum is preserved until late in the disease course [ 20 ]. All patients had resorption pattern created by remodeling, and permeative erosion was seen in the single case with IP plus SCC Table 5.
Six cases had focal hyperostosis: Only two had the cone-shaped appearance and both involved a maxillary sinus wall, one of them was post-operative recurrence. The underlying histopathology was suggested to be some form of chronic osteitis and hyper-vascularity, which may induce neo-osteogenesis or in other words, new bone formation.
Still, our study did not correlate with post-operative specimens between sclerosis and origin of the tumor. Also, intra-lesional calcification is rare and non-specific; only one case presented with spotty calcified focus [ 21 , 22 , 23 , 24 , 25 ]. For MR imaging, multiple distinctive imaging features have been illustrated through literature.
The lesion shows non-specific T1 iso-to-hyper-intense signal and T2 signal, nearly hypo-to-iso-intense to brain parenchyma or skeletal muscles with fat suppression techniques. Following gadolinium, it shows evidence of contrast enhancement with adequate delineation of the tumors form the obstructive secretions with ruling out multiple pathologies as antro-choanal polyp, sinusitis, mucocele, and invasive fungal infections, as well as mapping the tumor extent.
The diffusion pattern is non-specific and could not separate the IP from malignant lesions. Our study showed just similar general MRI features. Still this retrospective review selected the lesions with striated pattern on T2 and post-contrast T1 images [ 26 , 27 , 28 , 29 ]. Though Yousem et al. By histopathological examination, the IP is made of a compact cellular metaplastic epithelium and a sub-epithelial loose connective tissue.
This pattern contributes to the striated pattern in the MRI: the compact epithelium contributes to linear hypo-intense signal and less enhanced line in enhanced images, while the sub-epithelial loose connective tissue contributes to more T2 hyper-intense signal line and accumulation of gadolinium in variable concentrations according to its architecture. Barnes et al. A study made by Maroldi et al. The study by Jeon et al. Further, the direction of the striated pattern was described in a certain pattern.
Since the pathologic architecture follows a certain pattern of growth made by in-folding epithelium, a certain smooth direction of striations is expected. This would not be expected in lesions with disorganized matrix. Furthermore, we considered that presence of intra-lesional cyst would not interrupt this sign. These cysts represent retention sub-epithelial cyst lined by glands and contains secretion.
This would reveal smooth imperceptible line and T2 fluid signal, while enhancement could be only marginal or central and smooth, reflecting either retained secretions or lining epithelial glands, respectively. The literature included reported cases of multiple bony attachments with higher post-operative recurrences.
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