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Salisbury T, Gurung A, Koonmee S, Ali L, Ondic O, Bhan R, Pivovarcikova K, Hes O, Alaghehbandan R. Upgrade Rate and Predictive Factors Associated With Breast Papillary Lesions on Core Biopsy: A Canadian Experience. Int J Surg Pathol 2023; 31:1206-1216. [PMID: 36437635 DOI: 10.1177/10668969221137515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/06/2023]
Abstract
Background: Papillary lesions of the breast are a heterogeneous group, encompassing a wide range of lesions. The histologic distinction between papillary breast lesions remains challenging, especially on core biopsy specimens. Aim: This study aimed to determine the rate of upgrade to atypia or malignancy of biopsy-proven papillary lesions on surgical follow-up and to assess for factors associated with an upgrade in Greater Vancouver, BC, Canada. Materials and Methods: This is a retrospective population-based study of all breast papillary lesions diagnosed on core biopsy between 2017 and 2019 in the Fraser Health Authority in Greater Vancouver, Canada. Patients were retrieved from the laboratory information system. Patient demographics, histopathologic, and radiologic findings were analyzed. Results: A total of 269 specimens from 269 patients (mean 61.1 years), including 265 female and 4 male patients, were included in the study. Of the 269 specimens, 129 (48%) were intraductal papillomas and 140 (52%) were atypical papillary lesions. The overall upgrade rate among papillomas was 11.6% (15 of 129) on final excision. The mean age of patients diagnosed with papilloma on core biopsy was significantly younger than those with atypical papillary lesions (55.6 vs 66.1 years, P < .0001). Lesion size in patients with papillomas on core biopsy was significantly smaller than those with atypical papillary lesions (11.1 vs 15.1 mm, P = .001). The upgrade rates in patients <55 and ≥55 years were 4.9% and 13.2%. Size (P = .004) and atypia on core biopsy (P = .009) were significantly associated with upgrade. Older age (>55 years) (OR = 5.3, 95% CI: 1.04-27.08) was an independent predictor of upgrade among papillomas. Size, location, and Breast Imaging-Reporting and Data System (BI-RADS) radiologic categories in our study were not associated with predicting the upgrade of papillomas. Conclusion: Our data suggest that the risk of upgrade to atypia or malignancy is sufficient to warrant the excision of benign papillomas of any size in patients aged ≥55 years. In patients younger than 55 years, observation with close clinical and radiological follow-up without surgery may be sufficient. Our findings also support surgical excision of papillomas diagnosed on core biopsy when associated with atypia.
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Affiliation(s)
- Taylor Salisbury
- Department of Pathology, Faculty of Medicine, The University of British Columbia, Vancouver, BC, Canada
| | - Ananta Gurung
- Department of Pathology, Faculty of Medicine, The University of British Columbia, Vancouver, BC, Canada
| | - Supinda Koonmee
- Department of Pathology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Leila Ali
- Department of Pathology, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Ondrej Ondic
- Department of Pathology, Faculty of Medicine, Charles University, Plzen, Czech Republic
| | - Rohan Bhan
- Department of Medicine, Saba University School of Medicine, The Bottom, Saba, Dutch Caribbean
| | | | - Ondrej Hes
- Department of Pathology, Faculty of Medicine, Charles University, Plzen, Czech Republic
| | - Reza Alaghehbandan
- Department of Anatomic Pathology, Robert J. Tomsich Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, OH, USA
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Tu S, Yin Y, Yuan C, Chen H. Management of Intraductal Papilloma of the Breast Diagnosed on Core Needle Biopsy: Latest Controversies. PHENOMICS (CHAM, SWITZERLAND) 2023; 3:190-203. [PMID: 37197642 PMCID: PMC10110831 DOI: 10.1007/s43657-022-00085-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 11/12/2022] [Accepted: 11/15/2022] [Indexed: 05/19/2023]
Abstract
Intraductal papillomas (IDPs), including central papilloma and peripheral papilloma, are common in the female population. Due to the lack of specific clinical manifestations of IDPs, it is easy to misdiagnose or miss diagnose. The difficulty of differential diagnosis using imaging techniques also contributes to these conditions. Histopathology is the gold standard for the diagnosis of IDPs while the possibility of under sample exists in the percutaneous biopsy. There have been some debates about how to treat asymptomatic IDPs without atypia diagnosed on core needle biopsy (CNB), especially when the upgrade rate to carcinoma is considered. This article concludes that further surgery is recommended for IDPs without atypia diagnosed on CNB who have high-risk factors, while appropriate imaging follow-up may be suitable for those without risk factors.
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Affiliation(s)
- Siyuan Tu
- Department of Breast Surgery, Longhua Hospital, Shanghai University of Traditional Chinese Medicine, 725 South Wanping Road, Shanghai, 200030 China
| | - Yulian Yin
- Department of Breast Surgery, Longhua Hospital, Shanghai University of Traditional Chinese Medicine, 725 South Wanping Road, Shanghai, 200030 China
| | - Chunchun Yuan
- Spine Institute, Longhua Hospital, Shanghai University of Traditional Chinese Medicine, 725 South Wanping Road, Shanghai, 200030 China
| | - Hongfeng Chen
- Department of Breast Surgery, Longhua Hospital, Shanghai University of Traditional Chinese Medicine, 725 South Wanping Road, Shanghai, 200030 China
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Corbin H, Bomeisl P, Amin AL, Marshall HN, Gilmore H, Harbhajanka A. Upgrade Rates of Intraductal Papilloma with and without Atypia Diagnosed on Core Needle Biopsy and Clinicopathologic Predictors. Hum Pathol 2022; 128:90-100. [PMID: 35863513 DOI: 10.1016/j.humpath.2022.07.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 07/11/2022] [Accepted: 07/12/2022] [Indexed: 11/04/2022]
Abstract
Surgical excision of breast intraductal papilloma (IDP) without atypia diagnosed on core needle biopsy (CNB) is controversial as the risk of upgrade to malignant lesions is not well established. This study investigates upgrade rates of benign and atypical IDP to ductal carcinoma in situ (DCIS) and invasive carcinoma (IC) and clinicopathologic predictors. We identified 556 cases of IDP diagnosed on CNB at a single institution from 2010-2020 after excluding patients with a history of breast carcinoma, ipsilateral high-risk lesion, radiologic/pathologic discordance, or less than 2 years of follow-up if no excision within one year. Of these, 97 biopsies were consistent with atypical IDP and 459 were benign IDP. Surgical excision was performed for 318 (57.2%), and the remaining 238 (42.8%) underwent active monitoring. The upgrade rate for IDP without atypia was 2/225 (0.9%; 1 DCIS and 1 IC). Of 93 surgically excised atypical IDPs, 19/93 (20.4%) upgraded (14 DCIS and 5 IC). Of 238 non-excised IDPs followed clinically (range 24-140 months, mean 60 months), there was no subsequent breast cancer diagnosed at the IDP site on follow-up. Mean age of patients was 56 yr±12.6sd without upgrade, 63 yr±10.6sd (p value=0.027) with DCIS, and 61 yr±10.8sd (p value=0.35) with IC. Atypical IDP was more likely to upgrade if biopsied by stereotactic guidance (8/19, 42.1% p=0.035). At our institution, we had an exceedingly low upgrade rate for benign IDP. Overall, patients with upgrade to DCIS were older. For atypical IDP, upgrade was seen in higher proportions of stereotactic biopsies.
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Affiliation(s)
- Haley Corbin
- Case Western Reserve University School of Medicine, 9501 Euclid Avenue, Cleveland, OH 44106, USA.
| | - Philip Bomeisl
- Department of Pathology, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106, USA
| | - Amanda L Amin
- Department of Surgery, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106, USA
| | - Holly N Marshall
- Department of Radiology, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106, USA
| | - Hannah Gilmore
- Department of Pathology, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106, USA
| | - Aparna Harbhajanka
- Department of Pathology, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106, USA
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Woodard S, Zamora K, Allen E, Choe AI, Chan TL, Li Y, Khorjekar GR, Tirada N, Destounis S, Weidenhaft MC, Hartsough R, Park JM. Breast papillomas in the United States: single institution data on underrepresented minorities with a multi-institutional update on incidence. Clin Imaging 2022; 82:21-28. [PMID: 34768222 DOI: 10.1016/j.clinimag.2021.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Revised: 09/24/2021] [Accepted: 10/26/2021] [Indexed: 01/07/2023]
Abstract
PURPOSE To assess the percentage of papillomas from all biopsies performed, comparing differences in patient age and race at a single institution. To assess trends in biopsied papillomas at institutions throughout the United States (US). METHODS This is a HIPPA-compliant IRB-approved single-institution (Southern1) retrospective review to assess race and age of all-modality-biopsied non-malignant papillomas as a percentage of all biopsies (percentage papillomas calculated as papilloma biopsies/all biopsies) from January 2012 to December 2019. To assess national variation, several academic or large referral centers were contacted to provide data regarding papilloma percentages, biopsy modalities, and trends in case numbers. Trends were estimated using the method of analysis of variance (ANOVA). Comparisons of differences in trends were assessed. RESULTS Southern1 institution demonstrated a significant association between race and percentage of papillomas (p < 0.0001). After adjustment for multiple comparisons with Bonferroni correction at 5% type I family error, the percentage of biopsied papillomas in Black and Asian patients remained significantly higher than in White patients (p < 0.0001 and p = 0.0032, respectively) using a Chi-square test. The regional variation in percentage of papillomas was found to be 3-9%. Southern1 institution showed a 7-year significant trend of increase in percentage of papillomas. Other institutions showed a decreasing trend (p < 0.05). CONCLUSION Black and Asian women had significantly higher papilloma percentages compared to white patients in our single institution review. This institution also showed a statistically significant trend of increasing percentage papillomas from 2012 to 2019. Multi-institutional survey found regional variation in percentage papillomas, ranging from 3% to 9%.
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Affiliation(s)
- Stefanie Woodard
- Department of Radiology, Breast Imaging and Intervention, University of Alabama at Birmingham, 619 19th Street South, Birmingham, AL 35249, United States of America.
| | - Kathryn Zamora
- Department of Radiology, Breast Imaging and Intervention, University of Alabama at Birmingham, 619 19th Street South, Birmingham, AL 35249, United States of America.
| | - Elizabeth Allen
- Department of Radiology, Breast Imaging and Intervention, University of Alabama at Birmingham, 619 19th Street South, Birmingham, AL 35249, United States of America.
| | - Angela I Choe
- Department of Radiology, Breast Imaging Section, Penn State Health Milton S. Hershey Medical Center, 30 Hope Dr Suite 1800, Hershey, PA 17033, United States of America.
| | - Tiffany L Chan
- UCLA Department of Radiological Sciences, Ronald Reagan UCLA Medical Center, 757 Westwood Plaza, Suite 1638, Los Angeles, CA 90095, United States of America.
| | - Yufeng Li
- Comprehensive Cancer Center, The University of Alabama at Birmingham, MT 644, 1717 11th Ave SI, Birmingham, AL 35294-4410, United States of America.
| | - Gauri R Khorjekar
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland Medical Center and School of Medicine, 22 S Greene St, Baltimore MD-21201, United States of America.
| | - Nikki Tirada
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland Medical Center and School of Medicine, 22 S Greene St, Baltimore MD-21201, United States of America.
| | - Stamatia Destounis
- Partner, Elizabeth Wende Breast Care (EWBC), Chair Clinical Research and Medical Outcomes EWBC, 170 Sawgrass Drive, Rochester, NY 14620, United States of America.
| | - Mandy C Weidenhaft
- Department of Radiology, Tulane University School of Medicine, 1430 Tulane Avenue, New Orleans, LA 70112, United States of America.
| | - Richard Hartsough
- Touro Infirmary Imaging Center, 1401 Foucher Street, New Orleans, LA 70115, United States of America
| | - Jeong Mi Park
- Department of Radiology, Breast Imaging and Intervention, University of Alabama at Birmingham, 619 19th Street South, Birmingham, AL 35249, United States of America.
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Abbassi-Rahbar S, Sack S, Larson KE, Wagner JL, Kilgore LJ, Balanoff CR, Winblad OD, Amin AL. Multidisciplinary Review of Intraductal Papilloma of the Breast can Identify Patients who may Omit Surgical Excision. Ann Surg Oncol 2021; 28:5768-5774. [PMID: 34338925 DOI: 10.1245/s10434-021-10520-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 07/16/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND The purpose of this study was to define contemporary management recommendations regarding who would benefit from surgical excision of intraductal papilloma (IDP). METHODS A prospective database from a single institution identified patients with IDP on percutaneous biopsy from February 2015 to September 2020. Categorical patient demographic, biopsy, and pathologic variables were analyzed using Fisher's exact test and continuous demographic and imaging variables using the Mann-Whitney U test. RESULTS IDP was present in 416 biopsies, at a median age of 56 years. The median size was 0.9 cm, and the majority had greater than 50% of the target excised by biopsy. Surgical excision was performed for 124 of 416 biopsies (29.8%). Upgrade to malignancy was identified in 14 (11.3%): 8 to ductal carcinoma in situ (DCIS) and 6 to invasive cancer. Upgrade was significantly associated with concurrent ipsilateral breast cancer (p = 0.027), larger imaging size (p = 0.045), <50% excised with biopsy (p = 0.02), and atypia involving IDP (p = 0.045). Age, clinical presentation, and concurrent contralateral cancer were not significantly associated with upgrade. Lowest upgrade risk (0%) was in pure IDP ≤1 cm with >50% removed by biopsy. Of 401 biopsies that either did not upgrade or undergo excision, 7 (1.7%) developed subsequent breast cancer over a median follow-up of 23.5 months (interquartile range [IQR] 11,41), none at IDP site. CONCLUSIONS After multidisciplinary review, the management of IDP can be stratified into low- and high-risk for upgrade groups using key criteria. Low-risk group may omit surgical excision, because those patients have 0% risk of upgrade over the limited short-term follow-up.
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Affiliation(s)
| | - Stephen Sack
- University of Kansas Medical Center, Kansas City, KS, USA
| | - Kelsey E Larson
- Department of Surgery, The University of Kansas Health System, Kansas City, KS, USA
| | - Jamie L Wagner
- Department of Surgery, The University of Kansas Health System, Kansas City, KS, USA
| | - Lyndsey J Kilgore
- Department of Surgery, The University of Kansas Health System, Kansas City, KS, USA
| | - Christa R Balanoff
- Department of Surgery, The University of Kansas Health System, Kansas City, KS, USA
| | - Onalisa D Winblad
- Department of Radiology, The University of Kansas Health System, Kansas City, KS, USA
| | - Amanda L Amin
- Department of Surgery, The University of Kansas Health System, Kansas City, KS, USA.
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Zhang X, Liu W, Hai T, Li F. Upgrade Rate and Predictive Factors for Breast Benign Intraductal Papilloma Diagnosed at Biopsy: A Meta-Analysis. Ann Surg Oncol 2021; 28:8643-8650. [PMID: 34331160 DOI: 10.1245/s10434-021-10188-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 04/29/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Current standard management for intraductal papilloma (IDP) diagnosed at biopsy indicates complete surgical resection, but there are increasing controversies over whether and when routine excision is indeed necessary. OBJECTIVE The aim of this study was to determine the carcinoma upgrade rate and identify the associated predictive factors for IDP diagnosed at biopsy by meta-analysis. METHODS We searched the PubMed and EMBASE databases for studies published from 2009 to 2020 that investigated the upgrade rate and predictive factors of IDP diagnosed at biopsy. RESULTS A total of 7016 IDP cases diagnosed at biopsy and histologically examined after surgical excision were pooled from 44 original studies. The pooled prevalence of IDP in breast biopsy findings was 4.6% [95% confidence interval (CI) 4.4-4.7%] and the majority of IDP tumors were benign. The pooled upgrade rates to carcinoma for benign IDP and atypical IDP were 5.0% (95% CI 4.4-5.5%) and 36.0% (95% CI 32.7-39.2%), respectively. In addition, we identified 10 predictive upgrade factors for benign IDP, including Breast Imaging Reporting and Data System (BI-RADS) 5, BI-RADS 4C, mass and calcification in the mammographic finding, bloody nipple discharge, imaging-histological discordance, peripheral IDP, palpable mass, BI-RADS 4B, microcalcification, and lesion size ≥ 1 cm. The upgrade rates associated with these predictive factors ranged from 7.3 to 31.1%. CONCLUSION Surgical excision appears a reasonable recommendation for atypical IDP. Patients with benign IDP exhibiting one or more predictive factors might benefit from surgical excision, while patients with asymptomatic benign IDP without these predictive factors can be managed by imaging surveillance.
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Affiliation(s)
- Xiaoli Zhang
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Wenqing Liu
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Tao Hai
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Fei Li
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing, China.
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Roknsharifi S, Wattamwar K, Fishman MDC, Ward RC, Ford K, Faintuch S, Joshi S, Dialani V. Image-guided Microinvasive Percutaneous Treatment of Breast Lesions: Where Do We Stand? Radiographics 2021; 41:945-966. [PMID: 34197250 DOI: 10.1148/rg.2021200156] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Treatment of breast lesions has evolved toward the use of less-invasive or minimally invasive techniques. Minimally invasive treatments destroy focal groups of cells without surgery; hence, less anesthesia is required, better cosmetic outcomes are achieved because of minimal (if any) scarring, and recovery times are shorter. These techniques include cryoablation, radiofrequency ablation, microwave ablation, high-intensity focused US, laser therapy, vacuum-assisted excision, and irreversible electroporation. Each modality involves the use of different mechanisms and requires specific considerations for application. To date, only cryoablation and vacuum-assisted excision have received U.S. Food and Drug Administration approval for treatment of fibroadenomas and have been implemented as part of the treatment algorithm by the American Society of Breast Surgeons. Several clinical studies on this topic have been performed on outcomes in patients with breast cancer who were treated with these techniques. The results are promising, with more data for radiofrequency ablation and cryoablation available than for other minimally invasive methods for treatment of early-stage breast cancer. Clinical decisions should be made on a case-by-case basis, according to the availability of the technique. MRI is the most effective imaging modality for postprocedural follow-up, with the pattern of enhancement differentiating residual or recurrent disease from postprocedural changes. ©RSNA, 2021.
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Affiliation(s)
- Shima Roknsharifi
- From the Department of Radiology, Montefiore Medical Center/Albert Einstein College of Medicine, 111 E 210th St, Bronx, NY 10467 (S.R., K.W.); Department of Radiology, Boston Medical Center/Boston University School of Medicine, Boston, Mass (M.D.C.F.); Department of Diagnostic Imaging, Rhode Island Hospital/Alpert Medical School of Brown University, Providence, RI (R.C.W.); Department of Radiology, Memphis Radiological PC, University of Tennessee Health Science Center, Memphis, Tenn (K.F., S.J.); and Department of Radiology, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, Mass (S.F., V.D.)
| | - Kapil Wattamwar
- From the Department of Radiology, Montefiore Medical Center/Albert Einstein College of Medicine, 111 E 210th St, Bronx, NY 10467 (S.R., K.W.); Department of Radiology, Boston Medical Center/Boston University School of Medicine, Boston, Mass (M.D.C.F.); Department of Diagnostic Imaging, Rhode Island Hospital/Alpert Medical School of Brown University, Providence, RI (R.C.W.); Department of Radiology, Memphis Radiological PC, University of Tennessee Health Science Center, Memphis, Tenn (K.F., S.J.); and Department of Radiology, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, Mass (S.F., V.D.)
| | - Michael D C Fishman
- From the Department of Radiology, Montefiore Medical Center/Albert Einstein College of Medicine, 111 E 210th St, Bronx, NY 10467 (S.R., K.W.); Department of Radiology, Boston Medical Center/Boston University School of Medicine, Boston, Mass (M.D.C.F.); Department of Diagnostic Imaging, Rhode Island Hospital/Alpert Medical School of Brown University, Providence, RI (R.C.W.); Department of Radiology, Memphis Radiological PC, University of Tennessee Health Science Center, Memphis, Tenn (K.F., S.J.); and Department of Radiology, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, Mass (S.F., V.D.)
| | - Robert C Ward
- From the Department of Radiology, Montefiore Medical Center/Albert Einstein College of Medicine, 111 E 210th St, Bronx, NY 10467 (S.R., K.W.); Department of Radiology, Boston Medical Center/Boston University School of Medicine, Boston, Mass (M.D.C.F.); Department of Diagnostic Imaging, Rhode Island Hospital/Alpert Medical School of Brown University, Providence, RI (R.C.W.); Department of Radiology, Memphis Radiological PC, University of Tennessee Health Science Center, Memphis, Tenn (K.F., S.J.); and Department of Radiology, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, Mass (S.F., V.D.)
| | - Kelly Ford
- From the Department of Radiology, Montefiore Medical Center/Albert Einstein College of Medicine, 111 E 210th St, Bronx, NY 10467 (S.R., K.W.); Department of Radiology, Boston Medical Center/Boston University School of Medicine, Boston, Mass (M.D.C.F.); Department of Diagnostic Imaging, Rhode Island Hospital/Alpert Medical School of Brown University, Providence, RI (R.C.W.); Department of Radiology, Memphis Radiological PC, University of Tennessee Health Science Center, Memphis, Tenn (K.F., S.J.); and Department of Radiology, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, Mass (S.F., V.D.)
| | - Salomao Faintuch
- From the Department of Radiology, Montefiore Medical Center/Albert Einstein College of Medicine, 111 E 210th St, Bronx, NY 10467 (S.R., K.W.); Department of Radiology, Boston Medical Center/Boston University School of Medicine, Boston, Mass (M.D.C.F.); Department of Diagnostic Imaging, Rhode Island Hospital/Alpert Medical School of Brown University, Providence, RI (R.C.W.); Department of Radiology, Memphis Radiological PC, University of Tennessee Health Science Center, Memphis, Tenn (K.F., S.J.); and Department of Radiology, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, Mass (S.F., V.D.)
| | - Surekha Joshi
- From the Department of Radiology, Montefiore Medical Center/Albert Einstein College of Medicine, 111 E 210th St, Bronx, NY 10467 (S.R., K.W.); Department of Radiology, Boston Medical Center/Boston University School of Medicine, Boston, Mass (M.D.C.F.); Department of Diagnostic Imaging, Rhode Island Hospital/Alpert Medical School of Brown University, Providence, RI (R.C.W.); Department of Radiology, Memphis Radiological PC, University of Tennessee Health Science Center, Memphis, Tenn (K.F., S.J.); and Department of Radiology, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, Mass (S.F., V.D.)
| | - Vandana Dialani
- From the Department of Radiology, Montefiore Medical Center/Albert Einstein College of Medicine, 111 E 210th St, Bronx, NY 10467 (S.R., K.W.); Department of Radiology, Boston Medical Center/Boston University School of Medicine, Boston, Mass (M.D.C.F.); Department of Diagnostic Imaging, Rhode Island Hospital/Alpert Medical School of Brown University, Providence, RI (R.C.W.); Department of Radiology, Memphis Radiological PC, University of Tennessee Health Science Center, Memphis, Tenn (K.F., S.J.); and Department of Radiology, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, Mass (S.F., V.D.)
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Analysis of 612 Benign Papillomas Diagnosed At Core Biopsy: Rate of Upgrade to Malignancy, Factors Associated with Upgrade, and A Proposal For Selective Surgical Excision. AJR Am J Roentgenol 2021; 217:1299-1311. [PMID: 34008998 DOI: 10.2214/ajr.21.25832] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background: Despite numerous published studies, management of benign papillomas without atypia remains controversial. Objective: To determine the malignancy upgrade rate of benign papillomas, identify risk factors for upgrade, and formulate criteria for selective surgery. Methods: This retrospective study included benign papillomas without atypia diagnosed on percutaneous biopsy between 12/01/2000 and 12/31/2019. Papillomas that did not undergo surgical excision or at least 2 years of imaging and/or clinical follow-up were excluded. Clinical, imaging, and histopathologic features were extracted from the electronic medical record. Features associated with upgrade to malignancy were identified. Multivariable logistic regression was performed. Results: The study included 612 benign papillomas in 543 women (mean age 54.5 ± 12.1 years); 466 papillomas were excised, and 146 underwent imaging/clinical surveillance. The upgrade rate to malignancy was 2.3% (14/612). Upgrade rate was associated (p<.05) with radiology-pathology correlation (50.0% if discordant vs 2.1% if concordant), patient age (5.6% for age ≥60 vs 0.7% for age <60), presenting symptoms (6.7% if palpable mass or pathologic nipple discharge vs 1.3% if no symptoms), and lesion size (7.3% if ≥10 mm vs 0.6% if <10 mm). Three of 14 upgraded papillomas were associated with ≥4 metachronous or concurrent peripheral papillomas. No incidental papilloma or papilloma reported as completely excised on core biopsy histopathologic analysis was upgraded. A predictive model combining radiology-pathology discordance, symptoms (palpable mass or nipple discharge), age ≥60, size ≥10 mm, and presence of ≥4 metachronous or concurrent peripheral papillomas achieved AUC 0.91, sensitivity 79%, and specificity 89% for upgrade. Selective surgery based on presence of any of these five factors, while excluding from surgery incidental papillomas and papillomas reported as completely excised on histopathology, would spare 294 of 612 lesions from routine excision, while identifying all 14 upgraded lesions. Conclusion: Benign non-atypical papillomas have a low malignancy upgrade rate; routine surgical excision may not be necessary. Selective excision is recommended for lesions satisfying any of the 5 criteria. Incidental papillomas or papillomas completely excised on histopathology may undergo imaging follow-up. Clinical Impact: The proposed criteria for selective surgery of benign papillomas on core biopsy would reduce surgeries without delaying diagnosis of malignancy.
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9
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Marti JL. ASO Author Reflections: A Plea Against Blind Fear of Benign 'High-Risk' Lesions of the Breast: Five Recommendations to Minimize Unnecessary Treatment. Ann Surg Oncol 2021; 28:6041-6043. [PMID: 33876357 DOI: 10.1245/s10434-021-09978-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 03/25/2021] [Indexed: 11/18/2022]
Affiliation(s)
- Jennifer L Marti
- Divisions of Breast and Endocrine Surgery, Department of Surgery, Weill Cornell Medicine, Weill Cornell Breast Center, New York-Presbyterian Hospital, New York, NY, USA.
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10
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Limberg J, Kucher W, Fasano G, Hoda S, Michaels A, Marti JL. Intraductal Papilloma of the Breast: Prevalence of Malignancy and Natural History Under Active Surveillance. Ann Surg Oncol 2021; 28:6032-6040. [PMID: 33876349 DOI: 10.1245/s10434-021-09870-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 03/04/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND The optimal management of intraductal papillomas (IPs) without atypia diagnosed on needle core biopsy (NCB) is unclear. This study analyzed the malignancy risk of immediately excised IPs and characterized the behavior of IPs under active surveillance (AS). METHODS We retrospectively reviewed the pathology and imaging records of patients diagnosed with IPs without atypia on NCB during a 10-year period (1999-2019). The malignancy upgrade rate was assessed in patients who had an immediate surgical excision, and the rates of both radiographic progression and development of malignancy were assessed in a cohort of patients undergoing AS. RESULTS The inclusion criteria were met in 152 patients with 175 IPs with a mean age of 51 ± 13 years. The average size of the IPs on initial imaging was 8 ± 4 mm. Most of the lesions (57%, n = 99) were immediately excised, whereas 76 (43%) underwent AS with interval imaging with a median follow-up period of 15 months (range, 5-111 months). Among the immediately excised IPs, surgical pathology revealed benign findings in 97% (n = 96) and ductal carcinoma in situ in 3% (n = 3). In the AS cohort, 72% (n = 55) of the IPs remained stable, and 25% (n = 19) resolved or decreased in size. At 2 years, 4% had increased in size on imaging and were subsequently excised, with ductal carcinoma in situ (DCIS, n = 1) and benign pathology (n = 1) noted on final pathology. CONCLUSIONS In a large series of breast IPs without atypia, no invasive carcinoma was observed after immediate excision, and 96% of the lesions had not progressed on AS. This suggests that patients with IP shown on NCB can safely undergo AS, with surgery reserved for radiographic lesion progression.
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Affiliation(s)
- Jessica Limberg
- Department of Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY, USA
| | - Whitney Kucher
- Department of Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY, USA
| | - Genevieve Fasano
- Department of Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY, USA
| | - Syed Hoda
- Department of Pathology, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY, USA
| | - Aya Michaels
- Department of Radiology, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY, USA
| | - Jennifer L Marti
- Department of Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY, USA.
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11
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Brogi E, Krystel-Whittemore M. Papillary neoplasms of the breast including upgrade rates and management of intraductal papilloma without atypia diagnosed at core needle biopsy. Mod Pathol 2021; 34:78-93. [PMID: 33106592 DOI: 10.1038/s41379-020-00706-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 10/02/2020] [Accepted: 10/02/2020] [Indexed: 11/09/2022]
Abstract
Papillary neoplasms of the breast are a heterogeneous group of epithelial tumors nearly entirely composed of papillae. Their classification rests on the characteristics of the epithelium and the presence and distribution of the myoepithelial cells along the papillae and around the tumor. Papillary neoplasms of the breast can be diagnostically challenging, especially if only core needle biopsy (CNB) material is available. This review summarizes salient morphological and immunohistochemical features, clinical presentation, and differential diagnoses of papillary neoplasms of the breast. We include a contemporary appraisal of the upgrade rate to carcinoma (invasive carcinoma and ductal carcinoma in situ [DCIS]) and atypical hyperplasias in surgical excision specimens obtained following CNB diagnosis of papilloma without atypia, and a review of the available follow-up data in cases without immediate surgical excision.
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Affiliation(s)
- Edi Brogi
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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12
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Nuñez DL, González FC, Ibargüengoitia MC, Fuentes Corona RE, Hernández Villegas AC, Zubiate ML, Vázquez Manjarrez SE, Ruiz Velasco CC. Papillary lesions of the breast: a review. BREAST CANCER MANAGEMENT 2020. [DOI: 10.2217/bmt-2020-0028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
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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Affiliation(s)
- Denny Lara Nuñez
- Department of Radiology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Fernando Candanedo González
- Department of Pathology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Mónica Chapa Ibargüengoitia
- Department of Radiology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | | | | | - Mariana Licano Zubiate
- Department of Radiology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | | | - Carlos Casian Ruiz Velasco
- Department of Radiology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
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13
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Lin LH, Ozerdem U, Cotzia P, Lee J, Chun J, Schnabel F, Darvishian F. Upgrade rate of intraductal papilloma diagnosed on core needle biopsy in a single institution. Hum Pathol 2020; 110:43-49. [PMID: 33159966 DOI: 10.1016/j.humpath.2020.10.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 10/28/2020] [Accepted: 10/30/2020] [Indexed: 11/17/2022]
Abstract
The management of intraductal papilloma (IDP) diagnosed on core needle biopsy (CNB) is controversial due to the variable upgrade rates to breast carcinoma (BC) on subsequent surgical excision reported in the literature. The purpose of our study was to investigate the upgrade rate of IDP diagnosed on CNB to BC in subsequent surgical excision and the impact of clinical, pathologic, and radiologic variables. This is a retrospective cohort of all women who had a diagnosis of IDP on a CNB between 2005 and 2018 in a tertiary academic center with subsequent surgical excision. Upgrade was defined as ductal carcinoma in situ (DCIS) and invasive carcinoma on surgical excision. Statistical analyses included Pearson's chi-square, Wilcoxon rank-sum, and logistic regression. A total of 216 women with IDP in a CNB were included. Nineteen patients (8.8%) upgraded to BC in the overall cohort, including 14 DCIS and 5 invasive carcinomas. An upgrade rate of 27% was found in atypical IDP (14 of 51 cases), while only 3% of pure IDP upgraded to BC (5 of 165 cases). Older age (>53 years) at the time of biopsy (odds ratio [OR] = 1.05, 95% confidence interval [CI] = 1.01-1.09, p = 0.027) and concomitant atypical ductal hyperplasia (ADH) (OR = 9.69, 95% CI = 3.37-27.81, p < 0.0001) were significantly associated with upgrade. Our results support surgical excision of IDP on CNB when associated with ADH or diagnosed in women aged older than 53 years. The low surgical upgrade rate of 3% for pure IDP on CNB in younger women should be part of the management discussion.
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Affiliation(s)
- Lawrence Hsu Lin
- New York University Langone Health, Department of Pathology, New York, NY, 10016, United States
| | - Ugur Ozerdem
- New York University Langone Health, Department of Pathology, New York, NY, 10016, United States
| | - Paolo Cotzia
- New York University Langone Health, Department of Pathology, New York, NY, 10016, United States
| | - Jiyon Lee
- New York University Langone Health, Department of Radiology, NYU Perlmutter Cancer Center, New York, NY, 10016, United States
| | - Jennifer Chun
- New York University Langone Health, Department of Surgery, Division of Breast Surgical Oncology, NYU Perlmutter Cancer Center, New York, NY, 10016, United States
| | - Freya Schnabel
- New York University Langone Health, Department of Surgery, Division of Breast Surgical Oncology, NYU Perlmutter Cancer Center, New York, NY, 10016, United States
| | - Farbod Darvishian
- New York University Langone Health, Department of Pathology, New York, NY, 10016, United States.
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14
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Moseley T, Desai B, Whitman GJ, Robinson EK, Saunders T, Gonzalez A, He H. Benign Breast Intraductal Papillomas Without Atypia at Core Needle Biopsies: Is Surgical Excision Necessary? Ann Surg Oncol 2020; 28:1347-1355. [PMID: 32860176 DOI: 10.1245/s10434-020-09061-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Accepted: 08/08/2020] [Indexed: 11/18/2022]
Abstract
PURPOSE The aim of this study was to determine the upgrade rate of image-guided core needle biopsy (CNB)-proven benign breast intraductal papillomas (IDPs) without atypia to high-risk benign lesions or malignancy after surgical excision. METHODS A retrospective database search at a single institution identified 102 adult female patients with benign breast IDPs without atypia diagnosed on imaging-guided CNBs who subsequently had surgical excisions between 2011 and 2016. Patient characteristics, imaging features, biopsy techniques, and the pathology reports from imaging-guided CNBs and subsequent surgical excisions were reviewed. The upgrade rate to malignancies or high-risk benign lesions was determined at the patient level. RESULTS The upgrade rate to malignancy was 2.9% (3/102), including two cases of ductal carcinoma in situ (DCIS) and one case of microinvasive (< 1 mm) ductal carcinoma arising from DCIS. The upgrade rate to high-risk benign lesions was 7.8% (8/102), with seven cases of atypical ductal hyperplasia and one case of atypical lobular hyperplasia. A personal history of breast cancer and a larger mean lesion size were significantly associated with an upgrade to malignancy (p < 0.05). CONCLUSIONS The management of benign breast IDPs without atypia detected on imaging-guided CNBs is controversial. Our results suggest risk stratification is important in approaching these patients. Although surgical excision should be considered for all benign breast IDPs without atypia, observation with serial imaging may be appropriate in selected low-risk patients. This approach will save many women from surgeries and decrease the cost of medical care.
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Affiliation(s)
- Tanya Moseley
- Breast Imaging Section, Department of Diagnostic Radiology, Division of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Bella Desai
- Breast Imaging Section, Department of Diagnostic Radiology, Division of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Department of Diagnostic and Interventional Imaging, The University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 2.130B, Houston, TX, 77030, USA
| | - Gary J Whitman
- Breast Imaging Section, Department of Diagnostic Radiology, Division of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Emily K Robinson
- Department of Surgery, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Tamara Saunders
- Department of Surgery, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Anneliese Gonzalez
- Division of Oncology, Department of Internal Medicine, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Hongying He
- Department of Diagnostic and Interventional Imaging, The University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 2.130B, Houston, TX, 77030, USA.
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