Intraductal Papillary Lesions of the Breast: Clinical and Pathological Correlation

Papillary lesions of the breast range from a spectrum of benign intraductal papillomas with and without atypia to papillary carcinoma. Distinction between benign and malignant lesions on core needle biopsy (CNB) is difficult without surgical excision. We examined if clinical findings in patients with benign intraductal papillomas (IP) on CNB correlate with pathology at surgical excision. Between 1998 and 2011, 103 patients were identified with a papillary lesion on CNB. Clinical variables were studied to determine if there was clinical correlation with pathological outcomes at final surgical excision. Of the 103 patients, 59 (57%) patients had IP on initial CNB and were included in our analysis. On final pathology, 17 (29%) of these were upstaged to intraductal papilloma with atypia and six (10%) were found to have carcinoma. A clinically palpable mass was the only significant predictor of upstaging to malignancy ( P < 0.05). No radiographic findings were found to be significant predictors of pathological upstaging. In conclusion, surgical excision is still recommended for benign papillary lesions diagnosed on CNB because the correlation with clinical and radiological findings does not assure benign pathology.

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Papillary lesions of the breast: Can larger core needle biopsy samples identify patients who may avoid surgical excision?

Journal of Clinical Oncology ◽

10.1200/jco.2012.30.27_suppl.44 ◽

2012 ◽

Vol 30 (27_suppl) ◽

pp. 44-44

Author(s):

Alice P. Chung ◽

Kelly T. Huynh ◽

Jaime Shamonki ◽

Myung-Shin Sim ◽

Camelia Lawrence ◽

...

Keyword(s):

Core Needle Biopsy ◽

Predictive Value ◽

Needle Biopsy ◽

Surgical Excision ◽

Tissue Samples ◽

Core Needle ◽

Ductal Hyperplasia ◽

Benign Histology ◽

Papillary Lesions ◽

Malignant Lesions

44 Background: Papillary lesions of the breast are frequently diagnosed on core needle biopsy (CNB). The ability to distinguish benign from atypical/malignant papillary lesions is limited by the representative nature of the biopsy method; thus follow-up excision is usually recommended. We aimed to determine if larger CNB samples can more reliably predict the true benign nature of a papillary lesion, thereby sparing certain patients a formal surgical excision. Methods: We reviewed medical records of 53 female patients diagnosed with histologically benign papillary lesions on CNB from 2000 to 2010, who subsequently underwent surgical excision. Pathology slides of the CNB were reviewed to document the benign histologic features of the papilloma, the number of cores sampled and the area of tissue biopsied (mm2). Statistical analysis was performed to identify the characteristics of the CNB that were associated with retention of benign histology on excision. Results: Atypical ductal hyperplasia (ADH) and carcinoma were identified in 6% (3/53) and 8% (4/53) of papillary lesions, respectively, when excised. Clinical and radiographic characteristics did not distinguish the ADH/malignant lesions from benign papillomas. The CNB needle sizes ranged from 9- to 18-gauge (median 14). The number of cores sampled ranged from 3-16 (mean 4.5). Patients with benign excisions had a significantly larger area of tissue sampled by CNB than those found to have ADH/malignant lesions on excision (mean ± SD: 95.6 ± 101.2 vs. 41.7 ± 21.9, respectively, p=0.003). By logistic regression, CNB tissue samples consisting of ≥7 cores, or measuring >96 mm2 in aggregate, had a negative predictive value for ADH/malignancy of 100% (AUC of 0.69 and 0.68, respectively). Conclusions: Although no clinical or radiologic features distinguished benign from pathologically significant papillary lesions, larger sample sizes significantly improved the predictive value of benign histology on CNB. A papilloma sampled by ≥ 7 cores or > 96 mm2 showing benign histology at CNB, retained benign features upon excision. Close surveillance may be a reasonable option for patients whose benign papillomas are generously sampled at the time of CNB.

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Ultrasonography-guided core needle biopsy in differential diagnosis of papillary breast tumors

Acta Radiologica ◽

10.1080/02841850902977963 ◽

2009 ◽

Vol 50 (7) ◽

pp. 722-729 ◽

Cited By ~ 19

Author(s):

M. K. Bode ◽

T. Rissanen ◽

M. Apaja-Sarkkinen

Keyword(s):

Core Needle Biopsy ◽

Predictive Value ◽

Needle Biopsy ◽

Malignant Tumors ◽

Surgical Excision ◽

Papillary Lesion ◽

Core Needle ◽

Final Histology ◽

Papillary Lesions ◽

Malignant Lesions

Background: Papillary lesions of the breast are considered diagnostically challenging for various reasons. A relatively high malignancy rate in final pathological analysis has in many cases necessitated excision of these lesions, regardless of core needle biopsy (CNB). Purpose: To assess mammographic, sonographic, and CNB findings of papillary lesions, and to correlate them with final histology obtained by surgical excision. Material and Methods: From 2000–2006, 29 benign and 19 malignant papillary tumors examined with CNB were surgically removed. Mammographic, sonographic, and CNB results were analyzed and correlated with final histology. Results: On ultrasonography (US), 69% (20/29) of the benign lesions were solid and 31% (9/29) were cystic, and 47% of the malignant lesions (9/19) were solid and 53% (10/19) were cystic. The mammographic findings were nonspecific, although most of the malignant tumors (67%, 12/18) were categorized as BI-RADS 4 lesions. The sensitivity, specificity, and positive predictive value of the core needle biopsy histology was 32% (6/19), 100% (29/29), and 100% (6/6), respectively, for papillary carcinoma. A negative predictive value of 91% (21/23) for malignancy and 48% (11/23) for either atypia or malignancy was shown. Of the lesions with CNB diagnosis of benign papillary lesion with atypia, 58% (11/19) turned out to be malignant and 11% (2/19) were benign on surgery. Conclusion: The probability of malignancy is low when the CNB result shows a benign papillary lesion with no atypia. However, the only way to reliably diagnose atypical papillary lesions is to surgically remove all papillary tumors, irrespective of the CNB result. Differentiation between benign and malignant lesions or malignant noninvasive and invasive tumors is not possible based on sonographic or mammographic appearance.

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

Breast Care ◽

10.1159/000489096 ◽

2018 ◽

Vol 13 (5) ◽

pp. 364-368 ◽

Cited By ~ 4

Author(s):

Doris Leithner ◽

Benjamin Kaltenbach ◽

Petra Hödl ◽

Volker Möbus ◽

Volker Brandenbusch ◽

...

Keyword(s):

Needle Biopsy ◽

Breast Biopsy ◽

Ductal Carcinoma ◽

Statistical Tests ◽

Menopausal Status ◽

Surgical Excision ◽

Lesion Size ◽

Intraductal Papilloma ◽

Image Guided ◽

Institutional Review

Background: The management of intraductal papilloma without atypia (IDP) in breast needle biopsy remains controversial. This study investigates the upgrade rate of IDP to carcinoma and clinical and radiologic features predictive of an upgrade. Methods: Patients with a diagnosis of IDP on image-guided (mammography, ultrasound, magnetic resonance imaging) core needle or vacuum-assisted biopsy and surgical excision of this lesion at a certified breast center between 2007 and 2017 were included in this institutional review board-approved retrospective study. Appropriate statistical tests were performed to assess clinical and radiologic characteristics associated with an upgrade to malignancy at excision. Results: For 60 women with 62 surgically removed IDPs, the upgrade rate to malignancy was 16.1% (10 upgrades, 4 invasive ductal carcinoma, 6 ductal carcinoma in situ). IDPs with upgrade to carcinoma showed a significantly greater distance to the nipple (63.5 vs. 36.8 mm; p = 0.012). No significant associations were found between upgrade to carcinoma and age, menopausal status, lesion size, microcalcifications, BI-RADS descriptors, initial BI-RADS category, and biopsy modality. Conclusion: The upgrade rate at excision for IDPs diagnosed with needle biopsy was higher than expected according to some guideline recommendations. Observation only might not be appropriate for all patients with IDP, particularly for those with peripheral IDP.

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Papillary Breast Lesions: Association with Malignancy and Upgrade Rates on Surgical Excision

The American Surgeon ◽

10.1177/000313481708301134 ◽

2017 ◽

Vol 83 (11) ◽

pp. 1294-1297 ◽

Cited By ~ 4

Author(s):

Hanh-tam Tran ◽

Asma Mursleen ◽

Sahar Mirpour ◽

Omar Ghanem ◽

Maen J. Farha

Keyword(s):

Carcinoma In Situ ◽

Breast Lesion ◽

Ductal Carcinoma ◽

Surgical Excision ◽

Intraductal Papilloma ◽

Breast Lesions ◽

Aggressive Approach ◽

Papillary Lesions ◽

Benign Papilloma

Intraductal papilloma falls under the category of benign breast mass. However, recent studies show that it can harbor occult carcinoma. The management of benign intraductal papilloma remains controversial because of its nonspecific radiologic and histological findings, as well as its association with surrounding malignant pathology. The purpose of this study is to investigate upgrade rates of a benign intraductal papilloma on surgical excision and the need for surgical excision of papillary lesions diagnosed at core needle biopsy. A retrospective review of a single institution's pathology database between 2011 and 2015 identified 43 core biopsies with benign papilloma. We followed the upgrade rates of these lesions on surgical excision. There were 90 biopsies with the diagnosis of benign intraductal papilloma. The average age was 55.2 (range from 24–87 years old). Forty-three had benign intraductal papilloma; 28 of the 43 core biopsies had surgical excision. Two (7.1%) had an upgrade from benign intraductal papilloma to intraductal papilloma with atypia. One (3.6%) had an upgrade to ductal carcinoma in situ. None had invasive cancer. Surgical findings were in agreement with core biopsies in 25 (89.3%) of 28 cases (κ = 0.80, P < 0.0001). Core biopsies have a statistically significant correlation with pathologies on surgical excision in detecting atypia in breast lesion as demonstrated by κ = 0.80. However, the study shows benign intraductal papillomas on core biopsy have an upgrade rate of 10.7 per cent after undergoing surgical excision. As such, we recommend a more aggressive approach including surgical excision of all benign intraductal papillary lesions.

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Papillary lesions of the breast: a review

Breast Cancer Management ◽

10.2217/bmt-2020-0028 ◽

2020 ◽

Author(s):

Denny Lara Nuñez ◽

Fernando Candanedo González ◽

Mónica Chapa Ibargüengoitia ◽

Rosaura Eugenia Fuentes Corona ◽

Antonio Carlos Hernández Villegas ◽

...

Keyword(s):

Gold Standard ◽

Needle Biopsy ◽

Imaging Modality ◽

Surgical Excision ◽

Breast Tumors ◽

Breast Lesions ◽

Core Needle ◽

Lesion Core ◽

Papillary Lesions ◽

Solid Lesions

Papillary breast lesions are rare breast tumors that comprise a broad spectrum of diseases. Pathologically they present as mass-like projections attached to the wall of the ducts, supported by fibrovascular stalks lined by epithelial cells. On mammogram they appear as masses that can be associated with microcalcifications. Ultrasound is the most used imaging modality. On ultrasound papillary lesions appear as homogeneous solid lesions or complex intracystic lesions. A nonparallel orientation, an echogenic halo or posterior acoustic enhancement associated with microcalcifications are highly suggestive of malignancy. MRI has proven to be useful to establish the extent of the lesion. Core needle biopsy is the gold standard for diagnosis. Surgical excision is usually recommended, although treatment for papillomas without atypia is still controversial.

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Development and Validation of a Simple-to-Use Nomogram for Predicting the Upgrade of Atypical Ductal Hyperplasia on Core Needle Biopsy in Ultrasound-Detected Breast Lesions

Frontiers in Oncology ◽

10.3389/fonc.2020.609841 ◽

2021 ◽

Vol 10 ◽

Author(s):

Yun-Xia Huang ◽

Ya-Ling Chen ◽

Shi-Ping Li ◽

Ju-Ping Shen ◽

Ke Zuo ◽

...

Keyword(s):

Core Needle Biopsy ◽

Needle Biopsy ◽

Atypical Ductal Hyperplasia ◽

Surgical Excision ◽

Training Set ◽

Good Discrimination ◽

Core Needle ◽

Ductal Hyperplasia ◽

Malignant Lesions ◽

Validation Set

BackgroundThe rate of carcinoma upgrade for atypical ductal hyperplasia (ADH) diagnosed on core needle biopsy (CNB) is variable on open excision. The purpose of the present study was to develop and validate a simple-to-use nomogram for predicting the upgrade of ADH diagnosed with ultrasound (US)-guided core needle biopsy in patients with US-detected breast lesions.MethodsTwo retrospective sets, the training set (n = 401) and the validation set (n = 186), from Fudan University Shanghai Cancer Center between January 2014 and December 2019 were retrospectively analyzed. Clinicopathological and US features were selected using univariate and multivariable logistic regression, and the significant features were incorporated to build a nomogram model. Model discrimination and calibration were assessed in the training set and validation set.ResultsOf the 587 ADH biopsies, 67.7% (training set: 267/401, 66.6%; validation set: 128/186, 68.8%) were upgraded to cancers. In the multivariable analysis, the risk factors were age [odds ratio (OR) 2.739, 95% confidence interval (CI): 1.525–5.672], mass palpation (OR 3.008, 95% CI: 1.624–5.672), calcifications on US (OR 4.752, 95% CI: 2.569–9.276), ADH extent (OR 3.150, 95% CI: 1.951–5.155), and suspected malignancy (OR 4.162, CI: 2.289–7.980). The model showed good discrimination, with an area under curve (AUC) of 0.783 (95% CI: 0.736–0.831), and good calibration (p = 0.543). The application of the nomogram in the validation set still had good discrimination (AUC = 0.753, 95% CI: 0.666–0.841) and calibration (p = 0.565). Instead of surgical excision of all ADHs, if those categorized with the model to be at low risk for upgrade were surveillanced and the remainder were excised, then 63.7% (37/58) of surgeries of benign lesions could have been avoided and 78.1% (100/128) malignant lesions could be treated in time.ConclusionsThis study developed a simple-to-use nomogram by incorporating clinicopathological and US features with the overarching goal of predicting the probability of upgrade in women with ADH. The nomogram could be expected to decrease unnecessary surgery by nearly two-third and to identify most of the malignant lesions, helping guide clinical decision making with regard to surveillance versus surgical excision of ADH lesions.

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Atypical papillary lesions after core needle biopsy and subsequent breast carcinoma

Asian Biomedicine ◽

10.5372/1905-7415.0502.031 ◽

2011 ◽

Vol 5 (2) ◽

pp. 243-248

Author(s):

Tuenchit Khamapirad ◽

Caitlin Andrews ◽

Jenjeera Prueksadee ◽

Morton Leonard ◽

Louisea Bonoan-Deomampo ◽

...

Keyword(s):

Core Needle Biopsy ◽

Needle Biopsy ◽

Surgical Excision ◽

Excisional Biopsy ◽

Papillary Lesion ◽

Architectural Distortion ◽

Core Needle ◽

Multiple Imaging ◽

Papillary Lesions ◽

Benign Papilloma

Abstract Background: Papillary lesions of the breast cause diagnostic problem because papillary structures are found in benign and malignant processes. Core needle biopsy is important to make an initial diagnosis, but it still has potential pitfalls. Comparison between core needle biopsy and excisional biopsy can predict the possibility of malignant change in atypical papillary lesions. Objective: Evaluate the concordance between core needle biopsy and excisional results in atypical papillary lesions of the breast. Materials and methods: The pathology database of University of Texas Medical Branch at Galveston, USA was searched for patients with atypical papillary lesions at core needle biopsy who subsequently underwent surgical excision. Pathology reports from the excisional biopsies was also examined to assign each case to one of three categories, downgrade to benign papilloma, no change (remained atypical papillary lesion), and upgrade to carcinoma. The mammograms and ultrasounds were reviewed for each case. They characterized the lesions according to multiple imaging criteria. Results: Twenty-four patients with atypical papillomas at core biopsy subsequently underwent surgical excision. The lesions were downgraded to benign papilloma in 25%, remained atypical papillary lesion in 33%, and upgraded to carcinoma in 42%. On mammographic presentations (n = 23), masses were in 61%, architectural distortion in 4.3%, mass with calcifications in 9%, mass with architectural distortion and calcifications in 4.3%, calcifications alone in 17.4%, and architectural distortion and calcifications in 4.3%. On ultrasound findings (n = 21), solid masses were in 90%, intracystic masses in 10%, peripheral in locations in 81%, and subareolar in location in 19%. Conclusion: Due to the high upgrade rate of atypical papillary lesions to carcinoma (42%), excision of all atypical papillary lesions with wide excision margin is recommended for cases with pathologic diagnosis of atypical papillary lesion on core-needle biopsy.

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Desmoplastic Fibroma Recurrence Associated with Tuberous Sclerosis in a Young Patient

Case Reports in Dentistry ◽

10.1155/2018/1370184 ◽

2018 ◽

Vol 2018 ◽

pp. 1-4

Author(s):

A. M. Espinoza-Coronado ◽

J. P. Loyola-Rodríguez ◽

J. H. Olvera-Delgado ◽

J. O. García-Cortes ◽

J. F. Reyes-Macías

Keyword(s):

Tuberous Sclerosis ◽

Surgical Excision ◽

Clinical Findings ◽

Desmoplastic Fibroma ◽

Volume Increase ◽

Benign Pathology ◽

The Brain ◽

Recurrence Frequency ◽

Hard Consistency

Case Report. A nine-year-old patient with a diagnosis of tuberous sclerosis (with no pathological record) that showed calcifications at the brain level. Besides, the case showed the Vogt triad (epilepsy, mental retardation, and sebaceous adenoma). The patient clinically showed a volume increase of hard consistency, without suppuration and no sessile that included the following teeth 73, 74, and 75. Cone beam computed tomography (CBCT) was obtained, and it displayed a delimited unilocular lesion. After surgical excision, the histopathological report was desmoplastic fibroma (DF). It was observed that the patient had an aggressive recurrence of DF at four months after surgery treatment. Due to these clinical findings, resective osseous surgery and curettage were carried out. It is uncommon to find these two pathologies together (DF and tuberous sclerosis). Since DF is a benign pathology but very invasive and destructive, it is necessary a constant follow-up examination due to a high recurrence frequency.

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Pseudoangiomatous Stromal Hyperplasia on Core Needle Biopsy Does Not Require Surgical Excision

The American Surgeon ◽

10.1177/000313481608200213 ◽

2016 ◽

Vol 82 (2) ◽

pp. 117-121 ◽

Cited By ~ 1

Author(s):

Adam Protos ◽

Kim T. Nguyen ◽

Jamie L. Caughran ◽

Michael Naski ◽

Jessica L. Keto

Keyword(s):

Core Needle Biopsy ◽

Needle Biopsy ◽

Group Versus ◽

Surgical Excision ◽

Excisional Biopsy ◽

Data Set ◽

Palpable Mass ◽

Core Needle ◽

Pseudoangiomatous Stromal Hyperplasia

Pseudoangiomatous stromal hyperplasia (PASH) is an uncommon, benign localized fibrotic lesion. Historically, PASH has been difficult to differentiate from angiosarcoma. This difficulty has led to recommendations of surgical excision. We sought to identify the incidence of upgraded pathology to atypia or malignancy on surgical excisional biopsy after identification of PASH on core needle biopsy (CNB). A 5-year retrospective review at a single institution was conducted including all cases of PASH confirmed on CNB. The data set was divided into patients who underwent excisional biopsy and those followed only by imaging. Primary end points included the incidence of subsequent malignancy or high-risk pathology on histologic analysis or the presentation of suspicious imaging. Thirty-seven patients were reviewed, 19 (51.4%) underwent surgical excision and 18 (48.6%) were followed with imaging alone. A palpable mass was noted in 36.8 per cent of patients in the excisional group versus 5.6 per cent in the imaging group ( P = 0.02). The median follow-up for the excisional and imaging groups were 43 and 35 months, respectively ( P = 0.85). The 95 per cent confidence interval for the presence of malignancy was 0 to 9.4 per cent. Although further characterization of PASH is needed, our data support using CNB with follow-up imaging as a safe alternative to excisional biopsy in the absence of symptoms or other clinical factors. However, further research in this area is needed.

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