Benign Intraductal Papilloma without Atypia on Core Needle Biopsy Has a Low Rate of Upgrading to Malignancy after Excision

Abstract

PurposeThe management of benign intraductal papilloma (IDP) without atypia diagnosed on core needle biopsy (CNB) remains controversial. This study was performed to evaluate the rate of upgrading to malignancy or high-risk lesions after excision and to identify factors associated with upgrading using a large series of benign IDP cases without atypia.MethodsWe included patients who were diagnosed as having benign IDP without atypia on CNB and underwent surgical or vacuum-assisted excision between 2010 and 2015. We analyzed the clinical, radiologic, and histopathologic features of IDPs that were upgraded to malignancy or high-risk lesions after excision.ResultsA total of 511 benign IDPs without atypia diagnosed via CNB were identified, of which 398 cases were treated with excision. After reviewing these cases, four cases of high-risk lesions in adjacent tissue on CNB, two cases which were revealed as papilloma with atypia, and nine cases of malignancy in the same breast were excluded. In the remaining 383 cases, the rate of upgrading to malignancy and high-risk lesions after excision was 0.8% and 4.4%, respectively. The presence of concurrent contralateral breast cancer, the presence of symptoms, and multifocality were factors significantly associated with upgrading to malignancy on subsequent excision. Surgical excision rather than vacuum-assisted excision was significantly associated with upgrading to high-risk lesions or malignancy.ConclusionThe rate of upgrading to malignancy for benign IDP without atypia was very low, suggesting that close clinical and radiologic observation may be sufficient for patients with benign IDP without atypia on CNB under proper settings.

Underestimation of breast cancer in intraductal papillomas treated with vacuum-assisted core needle biopsy

“…Therefore, caution is advised when recommending conservative management to that group of patients. On the other hand, we did not prove the predictive meaning of the accompanying clinical symptoms such as sanguine nipple discharge or multifocality of the lesions, which has been emphasized by Han et al [23]. Also, similarly to Rasmussen, we found no correlation between the volume of the lesions at imaging and the risk for BC underestimation, which has been suggested by Boufelli et al, and Yu et al [25,33].…”

“…At present, medical advances and significant progress in the pathology-morphology diagnosis of the breasts, especially immunohistochemistry, allow for a more precise differentiation between various papillary growths [22]. Owing to that, the current underestimation of malignant BC at CNB ranges from 0.4 to 4% [23,24]. Also, due to the development of minimally invasive techniques, e.g.…”

“…The role of atypical growths as the most important predictive factors for a malignant process was also emphasized in the meta-analysis by Wen [21], or later works by Shiino, Han, Kiran, Boufelli or Foley [12,[23][24][25]30]. Current recommendations on diagnostic-therapeutic management still advise radical surgical approach in IPs with atypia, regardless of the biopsy technique [31].…”

Benign breast papilloma: Is surgical excision necessary?

“…Conversely, there have also been several studies reporting low upgrade rates, in which conservative management has been advocated. Han et al published a study of 511 cases of IDP without atypia of which 398 were treated with surgical excision. Only 0.8% were upgraded to a diagnosis of malignancy and 4.4% to a high‐risk lesion.…”

“…Han et al found that after excluding patients with a clinically concerning palpable mass, no patients were upgraded to malignancy. The presence of a symptom, concurrent contralateral breast cancer, and multifocal lesions was all predictive of upgrade to malignancy.…”