Breast intraductal papillomas without atypia in radiologic‐pathologic concordant core‐needle biopsies: Rate of upgrade to carcinoma at excision

Abstract

Background The surgical management of breast intraductal papilloma without atypia (IDP) identified at core needle biopsy (CNB) is controversial. We assessed the rate of upgrade to carcinoma at surgical excision, and identified parameters predictive of upgrade. Methods We identified women with CNB diagnosis of intraductal papilloma without atypia or carcinoma at our center between 2003 and 2013. Radiologic-pathologic concordance was assessed for all cases, and discordant cases were excluded. We correlated the radiologic and clinicopathologic features of patients with CNB diagnosis of IDP with upgrade to carcinoma at surgical excision. Results Our study population consists of 189 women with 196 IDPs; 166 women (171 IDPs) underwent excision. The upgrade rate was 2.3% (4/171). The upgrade lesions were 2 invasive lobular carcinomas and 2 cases of ductal carcinoma in situ (DCIS). One case of DCIS involved the residual IDP, whereas the other 3 carcinomas were ≥8 mm away. Twenty-four women (25 IDPs) did not undergo excision, and had stable imaging at follow-up (median of 23.5 months). Conclusions The upgrade rate at excision of IDP diagnosed at CNB with radiologic-pathologic concordance is 2.3%. Our findings suggest that observation is appropriate for patients with radiologic-pathologic concordant CNB yielding IDP, regardless of its size.

Intraductal Papilloma Without Atypia on Image- Guided Breast Biopsy: Upgrade Rates to Carcinoma at Surgical Excision

“…In previous studies, the upgrade rate was substantially lower in cases with pathologic-radiologic concordance [6,7]. In the present study, 2 patients with IDP and subsequent upgrade after excision showed initial BI-RADS 5, indicating pathologic-radiologic discordance after initial biopsy.…”

“…Many investigators suggested that areas of atypia or carcinoma may be missed in the limited tissue material gained with needle biopsy, thus requiring excisional biopsy for IDPs. Meanwhile, others suggested that IDPs with concordant benign imaging characteristics do not require excision [6,17,18]. To our knowledge, almost all previous studies investigated IDP based on only a single imaging modality with a focus on US [19], while our study evaluated both CNB and VAB guided by MG, US, and MRI.…”

“…Therefore excision of IDP found on image-guided biopsy is frequently recommended in interdisciplinary post-biopsy conferences. In contrast, other studies found low upgrade rates at surgical excision and concluded that imaging surveillance might be sufficient [6,12,13]. …”

“…In a recent study, Pareja et al [6 ]found a malignant upgrade rate of 2.3% in 171 radiologic-pathologic concordant lesions. In a study cohort of 77 patients, no malignant upgrades were reported, and 100 patients were stable according to imaging over the course of 36 months [20].…”

“…Surgical excision is generally recommended for atypical papilloma diagnosed with image-guided breast biopsy, due to its high upgrade rates to breast cancer [2,3,4,5]. However, the management of intraductal papilloma without atypia (IDP) on image-guided breast biopsy remains controversial due to divergent results in previous studies reporting upgrade rates to malignancy after excision ranging from 0 to 25% [6,7,8,9,10,11]. It has been suggested that image-guided biopsy is limited by tissue fragmentation and small specimen size and therefore might miss areas with atypia and breast cancer.…”