Papillary lesions of the breast: To excise or observe?

Abstract

Papillary lesions of the breast range from benign to atypical to malignant. Although papillomas without frank cancer are benign, their management remains controversial. When a core needle biopsy of a lesion yields a diagnosis of intraductal papilloma with atypia, excision is generally recommended to rule out a concurrent malignant neoplasm. For intraductal papillomas without atypia, however, recommendations for excision versus observation are variable. The aims of this study are to evaluate the rate of concurrent malignancies for intraductal papilloma diagnosed on core needle biopsy and to assess the long-term risk of developing cancer after the diagnosis of a papillary lesion. This single institution retrospective study analyzed 259 patients that were diagnosed with intraductal papilloma (IDP) by core needle biopsy from 1995 to 2010. Patients were grouped by initial diagnosis into three groups (papilloma without atypia, papilloma with atypia, and papilloma with atypical duct hyperplasia or atypical lobular hyperplasia (ADH/ALH) and followed up for long-term outcomes. After a core needle biopsy showing IDP with atypia or IDP + ADH/ALH, surgical excision yielded a diagnosis of concomitant invasive or ductal in situ cancer in greater that 30% of cases. For intraductal papilloma without atypia, the likelihood of cancer was much lower. Moreover, even with excision, the finding of intraductal papilloma with atypia carries a significant risk of developing cancer long-term, and such patients should be followed carefully and perhaps should be considered for chemoprevention.

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

“…It is undisputed that surgical excision is required when an atypical papilloma is found in breast biopsy material, due to the high risk for synchronous or metachronous carcinoma [15]. At the same time, the management of IDPs, which are regarded as benign proliferative disease, remains controversial, and patient numbers in previous studies are limited.…”

Intraductal papilloma of the breast — management

“…The literature reports indicate that the diagnosis of intraductal papilloma without atypia at a standard core needle biopsy is associated with a 2.3-16% risk of BC underestimation [16,17]. Despite the fact that some authors, in case of clinical pathological concordance, advocate in favor of follow-up program [18], most clinicians lean towards radical local excision, either with the use of vacuum-assisted core biopsy or open surgical biopsy [19,20]. When IP is accompanied by atypical ductal hyperplasia, the risk for BC underestimation increases to 13-92%, in which case surgical excision is common practice [3,21].…”

Ultrasound-guided percutaneous microwave ablation of central intraductal papilloma: a prospective pilot study

“…In our study, we focused on ablation treatment of central IDP without atypia. For IDP with atypia diagnosed with a core needle biopsy, excision is generally recommended to rule out a potential concurrent malignant neoplasm; IDP with atypia has a confirmed upgrade rate as high as 40.8% [16,19]. However, for IDPs without atypia, the recommendations for excision versus observation vary.…”

“…However, for IDPs without atypia, the recommendations for excision versus observation vary. IDP without atypia is regarded as having a low potential for malignancy, with an upgrade rate to carcinoma of 6.0% per 100 excised IDPs [20], 6.8% per 250 excised benign IDPs without atypia, and 7% according to recent meta-analysis results [19,21]. The recommendation for IDPs diagnosed with core needle biopsy or VAB is to therapeutically excise the lesion seen on imaging using VAB, and no longer using open surgery, with follow-up surveillance imaging for 5 years [22].…”