Excision is indicated for intraductal papilloma of the breast diagnosed on core needle biopsy

Department of Pathology, Mount Sinai Medical Center, New York, New York 10029, USA.
Cancer (Impact Factor: 4.9). 07/2009; 115(13):2837-43. DOI: 10.1002/cncr.24321
Source: PubMed

ABSTRACT Although it has been accepted that intraductal papillomas with atypia or malignancy diagnosed on core needle biopsy require surgical excision, the management of pure intraductal papillomas has been controversial. Because some series reported a small but definite incidence of atypia or malignancy, whereas others claimed that radiologic follow-up was adequate, this study evaluated results of excision of all pure intraductal papillomas diagnosed on core needle biopsy at this institution.
By using computerized pathology files from January of 2000 to December of 2004, 200 cases of intraductal papillomas on core needle biopsy were identified. Information regarding excision was available in 104 cases. All specimens were reviewed to confirm both the diagnoses as well as the presence of biopsy site changes in excision specimens, and the findings were correlated with radiologic data.
The age of the patients ranged from 25 to 82 years (mean, 55.5). The diagnoses on excision were as follows: intraductal papillomas = 71 cases (68.3%), no residual intraductal papillomas = 16 (15.3%), atypical duct hyperplasia = 8 (7.7%), ductal carcinoma in situ = 6 (5.8%), and invasive carcinoma = 3 (2.9%). In cases with atypia or malignancy, these findings were adjacent to but not in the biopsy site. In cases with atypical duct hyperplasia or ductal carcinoma in situ, a spectrum of histologic changes ranging from florid to atypical duct hyperplasia (14 cases), to ductal carcinoma in situ (6 cases) were present, all involving intraductal papillomas.
The upstage rate of pure intraductal papillomas on core needle biopsy to atypia or malignancy on excision was 16.4%. Because of sampling error and the close proximity of atypia or malignancy to the intraductal papillomas (suggesting precancerous potential), excision was recommended of these lesions diagnosed on core needle biopsy. Close radiologic-pathologic correlation was important in the evaluation of these lesions.

  • [Show abstract] [Hide abstract]
    ABSTRACT: Purpose To determine the significance of small, often mammographically occult and asymptomatic papillomas of the breast 15 mm and smaller. Methods Four-year retrospective review of papillomas of the breast in a community-based dedicated breast imaging center, with a selected cohort of 179 papillomas 15 mm or smaller in 147 patients, all completing image-guided core biopsy followed by surgical excision. Results Of 179 papillomas 15 mm or smaller, 36 % were abnormal (24 % atypia; 12 % cancer). Twenty-one percent had a surgical upgrade diagnosis. One hundred forty-six benign papillomas by core biopsy yielded 7 (4.7 %) cancers and 25 (17 %) atypias (atypical ductal hyperplasia (ADH), atypical lobular hyperplasia (ALH), or lobular carcinoma-in situ) at surgical excision. Seven of 34 (14 %) of very small papillomas (5 mm or smaller) showed cancer. Twelve of 72 (11 %) and 8 of 36 (13 %) papillomas showed cancer in normal-risk and high-risk patients, respectively. Increasing age (70+ years) associated strongly with increasing risk of papillomas with cancer (10 of 35, 29 %). Thirteen unsuspected papillomas in 10 patients with new nonpapillary breast cancers yielded 3 atypias and 3 additional cancers, changing surgical management in half of these patients. Breast ultrasound identified 44 % of papillomas as incidental findings, all mammographically occult and asymptomatic. Conclusions There is no size threshold below which a papilloma of the breast can be safely watched or ignored without risking a missed diagnosis of atypia or cancer. Identification of papillomas in patients with new nonpapillary breast cancers can change patient management in up to half of these patients. Finally, breast ultrasound significantly enhances identification of unsuspected papillomas.
    Annals of Surgical Oncology 10/2014; 22(4). DOI:10.1245/s10434-014-4128-1 · 3.94 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: One-hundred-fourteen consecutive cases of breast ultrasound-guided 14-gauge needle core biopsy (14G NCB) performed from January 2001 to June 2013 and diagnosed as non-malignant papillary lesion (PL)-B3, were reviewed and compared with definitive histological diagnosis on surgical excision (SE) to evaluate the diagnostic accuracy of ultrasound-guided 14G NCB. PL with epithelial atypia on 14G NCB were associated to malignancy on definitive histological diagnosis on SE in 22 (7 DCIS and 15 invasive carcinomas) of 46 cases with an underestimation rate of 47.8 %, while 9 (4 DCIS and 5 invasive carcinomas) cases out of 68 cases of PL without epithelial atypia were upgraded to carcinoma with an underestimation rate of 13.2 %. In cases of PL with epithelial atypia on ultrasound-guided 14G NCB, SE appears mandatory due to the high risk of associated malignancy. The diagnosis of PL without epithelial atypia on ultrasound-guided 14G NCB does not exclude malignancy at subsequent SE, consequently further assessment (by surgical or vacuum-assisted excision) is recommended to avoid the risk of delaying a diagnosis of malignancy, although this tends to be lower (1 in 8 patients).
    Pathology & Oncology Research 01/2015; DOI:10.1007/s12253-014-9882-7 · 1.81 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Background Intraductal papillomas (IPs) are commonly seen breast lesions with variable clinical presentation. For a palpable lesion and/or evidence of cellular atypia and/or pathologic nipple discharge, excision is warranted to rule out adjacent carcinoma, while for asymptomatic IPs lacking atypia current data for excision vs. observation are controversial. We reviewed outcomes of IPs diagnosed at our institution. Methods With IRB approval, we reviewed consecutive patients with IPs seen on core biopsy (CBx) between 2005 and 2013. All patients had an excision, with subspecialty breast pathology review of CBx and excisions. The rate of upgrade to cancer on excision was recorded. Differences between atypia and no-atypia groups were determined by two-tailed t test and Fisher’s exact test. Results We identified 97 patients (age range 31–83 years) with IPs on CBx. Among 52 atypical IPs, DCIS was seen in 11 (upgrade 21 %). In 45 IPs without atypia, 3 cancers were seen (upgrade 6. %): 2 had palpable lesions and were found to have DCIS, and 1 invasive cancer was found in a non-palpable mammographically detected BIRADS 4C lesion, whose Cbx result was discordant. If the 2 palpable lesions are excluded, the upgrade rate for IPs without atypia is 2.2 %. Conclusions This series shows a low upgrade rate for IP without atypia seen on CBx in the absence of a palpable mass and radiographic/pathologic discordance, suggesting that a surgical biopsy may not be necessary. Further prospective studies to better estimate the upgrade rate for IPs without atypia may be helpful.
    Annals of Surgical Oncology 11/2014; 22(5). DOI:10.1245/s10434-014-4091-x · 3.94 Impact Factor