Predictive Factors for Upgrading Patients with Benign Breast Papillary Lesions Using a Core Needle Biopsy

Abstract

PurposeIntraductal papilloma (IDP) is a benign breast disease with malignant potential, for which complete surgical excision is usually recommended. The aim of the present study was to investigate predictive factors for upgrading patients with a benign papillary lesion (BPL).MethodsThis study was an observational study using a prospectively collected cohort. In total, 13,049 patients who underwent a core needle biopsy (CNB) for a breast lesion between January 2009 and May 2015 were enrolled. We reviewed all patients with pathologically confirmed BPL from a CNB.ResultsSurgical treatment was performed for 363 out of a total of 592 lesions. According to the pathological differences, the lowest upgrade rate was shown in IDP without atypia (without atypia, 6.0%; with atypia, 26.8%; papillary neoplasm, 31.5%; p<0.001). The univariate analysis showed that, in IDP without atypia, the age at diagnosis, size of BPL on ultrasonography, and density on mammography were associated with upgrading. The multivariate analysis revealed that age >54 years and lesion size >1 cm were significantly associated with upgrade to malignancy (odds ratio [OR]=4.351, p=0.005 and OR=4.236, p=0.001, respectively).ConclusionThe indications for surgical treatment can be defined as age >54 years and mass size >1 cm, even in IDP without atypia in the CNB results; this also includes cases of IDP with atypia or papillary neoplasm. Therefore, we suggest that close observation without surgery is sufficient for younger women with a small IDP without atypia.

Management of intraductal papilloma without atypia of the breast diagnosed on core biopsy: Size and sampling matter

“…The increased risk of upgrade in larger lesions has been reported repeatedly . In the 5.8% of cases reported as “underestimated” (ie, upgraded) by Boufelli et al, all were greater than 1 cm .…”

“…Moreover, observing nonatypical histology (on biopsy) in a greater proportion of the lesion should theoretically lower the chance of unexpected atypia or malignancy on excision. In agreement with this logic, multiple studies are advocating that nonsurgical management should hinge on RPC in addition to a size cut‐off . Reportedly, lesions sized >1 cm or >1.5 cm should undergo excision, but these numbers are somewhat arbitrary; further studies long‐term studies will be needed to establish an evidence‐based size cutoff over large sample sizes.…”

“…Size (>1.5 cm) was identified by Kil et al as an indicator for excision . Last year, Hong et al highlighted age (>54 years) and lesion size (>1 cm) as significantly predictive of increased upgrade risk …”

“…The upgrade rate, defined as atypia and/or malignancy identified on surgical excision following a core biopsy diagnosis of benign (ie, nonatypical) intraductal papilloma (BIP) has been reported as high as 29% but the “true” upgrade rate is unknown. Studies published from 2010‐2017 have reported upgrade rates ranging from 0%‐8.9% and are based on larger cohorts of nonatypical biopsies than the 2009 Tseng et al study (N = 24) . Faced with risk ranging from 0% to 29% many institutions err on the side of caution (ie, reflex surgical excision protocols) and perhaps needlessly subject a number of patients to the risks and costs of surgery.…”

“…Many studies have attempted to identify surgical and nonsurgical candidates by exploring the clinical, radiologic, and histologic features that predict upgrade following a core biopsy diagnosis of BIP. [3][4][5][6][7][8][9][10][11][12][13][14][15][16] Histological features (percentage of core involved, longest continuous focus of lesion, presence/absence of necrosis, and presence/ absence of calcifications) and clinical features (patient age, symptomatology, and biopsy to excision time interval) examined by Qarmali et al in 2016 (N = 115) revealed no statistically significant predictors of malignancy. 13 Other data show that microcalcifications (identified histologically), lesion size (at least >1 cm), older patient age and certain histologic features are amongst the factors most predictive of upgrade.…”