Audit on Intraductal Papilloma of the Breast: Upgrade Rate, Management Pitfalls, and Updated Guidelines in a Tertiary Health Care Center

Abstract

BackgroundIntraductal papillomas (IDPs) are typically classified as B3 lesions in histology as they may show intralesional heterogeneity with a potential upgrade to malignancy. On core needle biopsy (CNB), a distinction between papilloma versus papillary ductal carcinoma in situ (DCIS) may be difficult. It is well known that otherwise benign papillomas may harbor foci of atypical ductal hyperplasia or DCIS. In this study, we aimed to calculate the radiological (mammogram and ultrasound) accuracy of IDP and to analyze the accuracy of CNB to diagnose IDP. Furthermore, we calculated the percentage of upgrade to malignancy after surgical excision. Any case that had a co-existing in-situ or invasive carcinoma during surgical excision was considered as an "upgrade" to malignancy. Finally, we analyzed the current management protocol for IDP in the institution and suggested changes, if needed. MethodologyThis is a retrospective cross-sectional study. A total of 112 cases diagnosed as IDP radiologically and/or by histopathology over a one-year time frame were included. A retrospective analysis of the accuracy of the radiological diagnosis was done by comparing it with CNB and/or surgical excision biopsy reports. The number of cases diagnosed with a co-existing in-situ or invasive carcinoma was calculated. This was considered as an "upgrade" from a B3 lesion in CNB to carcinoma in surgical excision. Current institutional management protocols were evaluated and compared with international benchmarks. ResultsOut of the 112 cases, 91 were suspected to be papilloma by imaging. The remaining 21 cases who were positive for papilloma on biopsy but were not diagnosed radiologically were also studied separately. Among the biopsied patients, eight were positive for IDP with atypia in CNB. Five out of these eight cases had an insitu or invasive component during the surgical excision, with one invasive lobular carcinoma, three lobular carcinomas in situ, and one DCIS on surgical excision histopathology. The upgrade percentage was calculated to be 22.72%. ConclusionsDue to the large upgrade potential of IDP, it is recommended to biopsy every radiologically suspected lesion and excise pathology-proved lesions. If the biopsy shows papilloma without atypia, vacuum excision is sufficient; otherwise, surgical excision with a clearance of margins is advocated. Annual mammograms/surveillance is recommended for biopsy-proven cases. IDP has a high upgrade potential, and, hence, care should be taken to biopsy suspicious lesions. An excision of biopsy-proven lesions must be done.

Malignant upgrade rate and associated clinicopathologic predictors for concordant intraductal papilloma without atypia: A systematic review and meta‐analysis

“…IDP is a relatively common diagnosis at breast biopsy, encountered on approximately 3%−6% of all CNB specimens. 22 Despite an array of publications to date seeking to establish the optimal management, the decision whether to proceed with surgical excision or imaging F I G U R E 2 Forest plot of study specific upgrade rate to carcinoma at surgical excision of benign, concordant IDP diagnosed at percutaneous biopsy, and pooled estimate. CI, confidence interval; IDP, intraductal papilloma; RE, random effects.…”

Puzzling Papillomas: A Case of an Intraductal Papilloma Mimicking an Abscess

“…Intraductal breast papillomas are benign tumors that fall within the spectrum of papillary breast lesions [ 1 ]. Despite constituting less than 2% of breast lesions [ 2 ], they are important as they are high-risk malignancy precursor lesions [ 3 ]. Most patients with papillomas are asymptomatic but they can occasionally present with a palpable abnormality and bloody or clear nipple discharge [ 1 ].…”

“…Most patients with papillomas are asymptomatic but they can occasionally present with a palpable abnormality and bloody or clear nipple discharge [ 1 ]. Timely diagnosis is essential, as upgrade rates to malignant and pre-malignant lesions range from 1.6-20% [ 3 - 6 ]. Our case presents a challenging dilemma of an intraductal papilloma (IDP) initially misdiagnosed as an abscess.…”

Breast cancer risk in papilloma patients: Osteopontin splice variants indicate prognosis

“…The fibrovascular cores are, in turn, lined by layers of epithelial cells, with or without a complete layer of intervening myoepithelial cells [ 3 ]. Although criteria to distinguish papillomas from papillary carcinomas have long been described in the literature [ 4 ], on core needle biopsy, a differentiation between papilloma and papillary ductal carcinoma in situ may be difficult [ 2 ].…”

“…Among benign breast biopsies, papillomas account for about 5% of the cases [ 1 , 2 ]. Morphologically, these papillary lesions of the breast are characterized by the presence of arborizing fibrovascular cores derived from the wall of the ducts, which are often distended by the lesions.…”