Upgrade rate of intraductal papilloma without atypia on breast core needle biopsy: A clinical, radiological and pathological correlation study

Nonneoplastic and neoplastic sclerosing lesions of the breast

Sclerosing lesions of the breast encompass a spectrum of benign and malignant entities and often pose a diagnostic challenge. Awareness of key morphologic features and pitfalls in the assessment of morphology and immunophenotype is essential to avoid over- or underdiagnosis and ensure optimal clinical management. This review summarizes nonneoplastic sclerosing lesions such as radial scar/complex sclerosing lesion, sclerosing adenosis, sclerosing intraductal papilloma, sclerosing variants of ductal adenoma and nipple adenoma, and fibroadenoma with extensive sclerosis, including their clinical presentation, characteristic morphology, differential diagnostic considerations, appropriate immunohistochemical work-up, when needed, and the clinical significance. In addition, atypical or neoplastic entities (such as atypical ductal hyperplasia, ductal carcinoma in situ, low-grade adenosquamous carcinoma, and fibromatosis-like metaplastic carcinoma) that can involve these sclerosing lesions are also briefly discussed.

Malignant upgrade rate and associated clinicopathologic predictors for concordant intraductal papilloma without atypia: A systematic review and meta-analysis

Previously reported upgrade rates for benign breast intraductal papilloma (IDP) are widely variable. However, many previous studies have failed to consider radiologic-pathologic discordance of lesions. This review aims to synthesize malignant upgrade data for benign, concordant IDP at surgical excision. Thirteen studies were included in our meta-analysis. The pooled estimate for percentage underestimation of carcinoma was 1.4% (95% CI: 0.8%-2.0%). We conclude that these lesions can be safely managed by active surveillance.

Management of Breast Intraductal Papilloma Diagnosed on Core Needle Biopsy: Excision or Follow-up?

Introduction Management of intraductal papillomas (IDPs) diagnosed on core needle biopsy (CNB) remains controversial. We report our experience of IDPs identified on CNB, our institutional rates of upgradation to atypia/malignancy as well as radiologic/pathologic features that may allow selection for surgery as well as those for safe observation. Methods The study is a retrospective review of patient records from 2012 to 2019, at a tertiary care hospital in Pakistan. Data was analyzed using Statistical Package for Social Sciences (SPSS), version 21.0 (IBM Corp., Armonk, NY). Associations between various patient factors were assessed using Pearson's chi-square test. Results This study included a total of 55 female patients with IDPs, with a mean age of 54.67 ± 15.57 years. On CNB, 69.1% (n = 38) of patients had IDP without atypia while 30.9% (n = 17) had IDP with atypia, with single IDPs being the most common lesions on excisional biopsy. Overall, of all CNB-diagnosed IDPs, only 4/55 (7.3%) demonstrated upgradation (3/4 to DCIS, 1/4 showed atypia) on excisional biopsy, and all these upgraded cases had failed to demonstrate atypia on initial CNB. Conclusion CNB-identified cases of IDPs are rarely upgraded on excision and thus routine excision in all cases may be unnecessary. Appropriate patient selection based on radiology-pathology findings should be done. Those with suspicious findings on imaging as well as those that demonstrate atypia on CNB must be excised.

Puzzling Papillomas: A Case of an Intraductal Papilloma Mimicking an Abscess

Intraductal papillomas (IDPs) are benign tumors found within breast ducts. Clinicians should be familiar with IDPs given their association with atypical and neoplastic lesions. In our case, the patient was initially diagnosed with and treated for an abscess given clinical symptoms of breast pain, erythema, and swelling, but upon returning to the clinic a year later due to persistent symptoms, she was found to have an IDP. This case underscores the importance of atypical imaging features and close follow-up when evaluating breast lesions.

Management of Intraductal Papilloma of the Breast Diagnosed on Core Needle Biopsy: Latest Controversies

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.

Solitary Dilated Ducts Revisited: Malignancy Rate and Implications for Management

RATIONALE AND OBJECTIVES

A solitary dilated duct (SDD) is a single asymmetrically dilated breast duct with diameter more than 2 mm. The Breast Imaging Reporting and Data System (BI-RADS) fifth edition recommends additional imaging and biopsy for SDDs without demonstrated benign etiology, however management of this rare entity remains controversial. This study describes practice patterns, malignancy rate, and features associated with high-risk/malignant SDDs to better stratify patients requiring biopsy versus follow-up.

MATERIALS AND METHODS

This IRB-approved retrospective study identified mammographic, sonographic and MRI exams utilizing the term "solitary dilated duct" at a multisite academic institution between 1/1/2010 and 12/31/2020. Clinical and imaging features, BI-RADS assessments, and outcomes were analyzed. Univariate and multivariate analyses identified predictors of high-risk/malignant histology.

RESULTS

SDDs identified in 49 women (mean age 56.1 years) were assessed as BI-RADS 4/5 (31/49, 63%), BI-RADS 3 (9/49, 18%), or BI-RADS 2 (9/49, 18%). Most sampled lesions were benign (16/31, 52%) and the remaining were high-risk (15/31, 48%, all papillary lesions). The only papilloma with atypia on core biopsy upgraded to grade 2 DCIS on excision (malignancy rate 1/49, 2%). All anechoic SDDs were benign (n=13), and all benign SDDs lacked internal vascularity. SDDs with associated masses were associated with malignant/high-risk outcomes on multivariate analysis (p < .001).

CONCLUSION

The BI-RADS fifth edition recommends biopsy for SDDs without demonstrated benign etiology. In our 11-year study period, practice patterns were variable with a low malignancy rate of 2%. Our findings suggest that anechoic SDDs may be followed, and SDDs with associated masses or internal vascularity require biopsy.

Upgrade Rates of Intraductal Papilloma with and without Atypia Diagnosed on Core Needle Biopsy and Clinicopathologic Predictors

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.

A retrospective study evaluating outcomes of surgical excision versus radiologic follow-up of benign breast papillomas without atypia

BACKGROUND

There is uncertainty whether benign breast papillomas without atypia (BP) can be followed by imaging or require surgical resection.

METHODS

A single-center, retrospective cohort study of patients diagnosed with BP (2011-2021) to determine the upgrade rate on surgery, and factors associated with surgical intervention and upgrade.

RESULTS

139 BPs were included. 27(19.4%) had upfront surgery; 112(80.6%) had imaging follow-up. The upfront surgery group had higher rates of pre-excision nipple inversion (n = 2(8.3%)vs.n = 0(0%),p = 0.003). In the imaging group, the median follow-up was 3.8years, and 9 had subsequent resection. Upgrade rate was 5.8%(8/139). Of all BPs undergoing surgery (n = 36), patients ≥60years (75.0%vs.25.0%,p = 0.049) or with family history of breast cancer (87.5%vs.48.1%,p = 0.048) were more likely to have upgrade.

CONCLUSIONS

Despite a low number of events, this study supports radiologic follow-up of BP except in patients ≥60 years or with family history of breast cancer, adding to the growing body of evidence supporting watchful waiting of BPs.

Breast papillomas in the United States: single institution data on underrepresented minorities with a multi-institutional update on incidence

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%.

Multidisciplinary Review of Intraductal Papilloma of the Breast can Identify Patients who may Omit Surgical Excision

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.

Upgrade Rate and Predictive Factors for Breast Benign Intraductal Papilloma Diagnosed at Biopsy: A Meta-Analysis

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.

Updates on Lobular Neoplasms, Papillary, Adenomyoepithelial, and Fibroepithelial Lesions of the Breast

CONTEXT.—

This review article is a result of the breast pathology lectures given at the Sixth Chinese American Pathologists Association annual diagnostic pathology course in October 2020 (held virtually due to the coronavirus disease 2019).

OBJECTIVE.—

To update recent developments, in this review article, the authors wrote minireviews in the following 4 areas: lobular neoplasm, adenomyoepithelial lesions, papillary lesions, and fibroepithelial lesions.

DATA SOURCES.—

The sources include extensive literature review, personal research, and experience.

CONCLUSIONS.—

With the wide practice of screening mammography, these lesions are not uncommon in image-guided core biopsies and excisional specimens. Many recent developments have emerged in understanding these lesions. We aim to provide readers with concise updates for each of these lesions with a focus on recent updates in definitions, diagnostic criteria, management, and molecular profiles that are most relevant to the daily practice of pathology and patient management.

Intraductal Papilloma of the Breast: Prevalence of Malignancy and Natural History Under Active Surveillance

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.

Papillary neoplasms of the breast including upgrade rates and management of intraductal papilloma without atypia diagnosed at core needle biopsy

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.

The Incidence of Adjacent Synchronous Invasive Carcinoma and/or Ductal Carcinoma In Situ in Patients with Intraductal Papilloma without Atypia on Core Biopsy: Results from a Prospective Multi-Institutional Registry (TBCRC 034)

BACKGROUND

Available retrospective data suggest the upgrade rate for intraductal papilloma (IP) without atypia on core biopsy (CB) ranges from 0 to 12%, leading to variation in recommendations. We conducted a prospective multi-institutional trial (TBCRC 034) to determine the upgrade rate to invasive cancer (IC) or ductal carcinoma in situ (DCIS) at excision for asymptomatic IP without atypia on CB.

METHODS

Prospectively identified patients with a CB diagnosis of IP who had consented to excision were included. Discordant cases, including BI-RADS > 4, and those with additional lesions requiring excision were excluded. The primary endpoint was upgrade to IC or DCIS by local pathology review with a predefined rule that an upgrade rate of ≤ 3% would not warrant routine excision. Sample size and confidence intervals were based on exact binomial calculations. Secondary endpoints included diagnostic concordance for IP between local and central pathology review and upgrade rates by central pathology review.

RESULTS

The trial included116 patients (median age 56 years, range 24-82) and the most common imaging abnormality was a mass (n = 91, 78%). Per local review, 2 (1.7%) cases were upgraded to DCIS. In both of these cases central pathology review did not confirm DCIS on excision. Additionally, central pathology review confirmed IP without atypia in core biopsies of 85/116 cases (73%), and both locally upgraded cases were among them.

CONCLUSION

In this prospective study of 116 IPs without atypia on CB, the upgrade rate was 1.7% by local review, suggesting that routine excision is not indicated for IP without atypia on CB with concordant imaging findings.