Immunohistochemistry increases the accuracy of diagnosis of benign papillary lesions in breast core needle biopsy specimens

Invasive papillary carcinoma of the breast

Invasive papillary carcinoma is a rare form of breast cancer that is more likely to occur in postmenopausal women. Previous studies have been limited to case reports and small retrospective studies, leading to low awareness of this type of tumor and difficult clinical management. According to the available literature, invasive papillary carcinoma exhibits unique pathological features and biological behaviors. Invasive papillary carcinoma is mostly luminal type, with a low rate of lymph node metastasis, which underlies its favorable prognosis. The effectiveness of adjuvant therapy in reducing tumor burden and improving prognosis in patients with invasive papillary carcinoma remains uncertain. Due to the rarity of the lesion, conducting prospective clinical trials is impractical. The use of biological models, such as organoids, can help alleviate the impact of the scarcity of this condition on research. In addition, invasive papillary carcinoma is affected by specific genomic events, and more extensive studies of gene expression profiling may provide molecular-level insights to make optimal therapeutic decisions.

The appropriate number of preoperative core needle biopsy specimens for analysis in breast cancer

Ultrasound (US)-guided core needle biopsy (CNB) has been recognized as a crucial diagnostic tool for breast cancer. However, there is a lack of guidance for hospitals that are not equipped with adjunctive US. The aim of this study was to assess the sensitivity, specificity, and experience of freehanded CNB in the outpatient department, and to determine the minimum number of tissue strips required to obtain concordance for estrogen receptor (ER), progesterone receptor (PR), human epidermal growth factor receptor-2 (HER2), and tumor grade with the excised specimen.A prospective study was performed on 95 patients undergoing CNB and subsequent surgical procedures. The reliability of immunohistochemical assessments of the pathological type, tumor grade, ER, PR, and HER2 status in CNBs was compared with that of surgical specimens. Concordance between the CNBs and surgical samples was estimated as a percentage agreement, and analyzed using the chi-square test. A P < .05 was considered significant.The concordance rates of ER, PR, and HER2 status and tumor grade status between CNBs and surgically excised specimens were 97.9%, 91.6%, 82.1%, and 84.2%, respectively. The reliability of taking 2 tissue strips was similar to that of taking six tissue strips in distinguishing malignancy from benignancy, and determining the pathological type without the aid of US. Four tissue strips obtained by CNB showed good accuracy comparable to those obtained by surgical specimens in assessing ER, PR, and HER2 status and tumor grade.Two tissue strips obtained by CNB showed good accuracy in differentiating malignancy from benignancy, while at least 4 strips are recommended to obtain overall conformity of pathological biomarkers.

Patients with benign papilloma diagnosed on core biopsies and concordant pathology-radiology findings can be followed: experiences from multi-specialty high-risk breast lesion conferences in an academic center

BACKGROUND

To determine whether patients with benign papilloma diagnosed on core biopsy can be spared from surgery.

METHODS

We prospectively reviewed 150 consecutive core biopsy-diagnosed papilloma cases at a multi-specialty high-risk breast lesion conference to determine whether surgical excision was necessary. Of these 150 cases, 148 had concordant radiologic-pathologic features. Six were excluded due to lack of the first imaging follow-up until analysis. 112 were benign papillomas; 17 were papillomas involved by atypical ductal hyperplasia (atypical papilloma); 6 papillomas had ADH in adjacent tissue but not involving the papilloma; 2 papillomas were involved by atypical lobular hyperplasia (ALH); and 5 papillomas had ALH in adjacent tissue. Two were radiology-pathology (rad-path) discordant.

RESULTS

Thirty-nine of the 112 benign papillomas were excised with no upgrade to carcinoma; 73 were followed with no disease progression during follow-up (185-1279 days). Fifteen of 17 atypical papillomas were surgically excised with 4 (26.7%) upgraded to carcinoma. Four of the 6 patients with ADH adjacent to a benign papilloma underwent excision with 2 upgrades to carcinoma. None of the patients with papilloma, which was either involved by ALH or had ALH in adjacent tissue had upgrade or disease progression during follow-up (204-1159 days). Finally, the two cases with discordant path-rad discordant were excised with no upgrade.

CONCLUSIONS

Our data confirm that rad-path concordant benign papillomas diagnosed on core biopsy do not require surgery. It also supports the value of a formal multi-specialty review of all benign papilloma cases to create a consensus management plan.

Papilloma diagnosed on core biopsies has a low upgrade rate

CONTEXT

Surgical excision of benign intraductal papillomas (IDP) diagnosed on core needle biopsy (CNB) remains controversial.

OBJECTIVE

To examine the upgrade rate of IDPs diagnosed at core needle biopsy to carcinoma at surgical excision.

DESIGN

We identified 188 consecutive IDPs diagnosed at CNB from 2011 to 2016 with subsequent surgical excision. Radiologic, clinical, and histologic features were evaluated and correlated with upgrade rate at surgical excision.

RESULTS

Two of the 188 IDPs (1.1%) were upgraded to ductal carcinoma in situ or invasive carcinoma at excision. Features associated with upgrade rate include patient age (P = .03), largest size of papilloma on a single core at CNB (P = .04), and the presence of additional masses noted at ultrasound (P = .03).

CONCLUSIONS

Our study demonstrated a low 1.1% upgrade rate of surgically excised benign, concordant papillomas with no atypia or concurrent ipsilateral malignancy originally diagnosed on core biopsy. This data suggests that observation may be appropriate for radiologic-pathologic concordant benign IDPs diagnosed at CNB.

A papilloma in a large cyst of the breast: A case report

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Intracystic lesions of the breast prove to be benign more often than malignancy.

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Most intracystic lesions are benign papillomas.

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Generally sizes of cysts that contain papilloma are small. Relatively cysts that contain papillary carcinoma are large.

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We present a 53-year-old with a papilloma in a large cyst of the breast that presented a painless palpable mass.

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Excisional biopsy may be needed to make a proper diagnosis for the suspicious lesion.

Introduction

Intracystic lesions of the breast prove to be benign more often than malignancy, most intracystic lesions are benign papillomas. Generally sizes of cysts that contain papilloma are small. Relatively cysts that contain papillary carcinoma are large. A papilloma in a large cyst of the Breast is rare.

Presentation of case

We report a rare case of a papilloma in a large cyst of the breast that presented a painless palpable mass. A 53-yr-old woman noticed palpable mass in her right breast. Ultrasonography indicated a 7 × 7 cm sized large cyst. There is a 2 × 2.5 cm sized hyper-echoic, polypoid mass in the cyst. On fine-needle aspiration was not obtained malignant cells. Excisional biopsy was done. Pathologic finding was papilloma.

Discussion

Tumors in a large cyst of the breast is difficult in distinguish benign from malignancy by preoperative imaging, cytological and histological study.

Conclusion

Excisional biopsy should be performed before cancer surgery such as mastectomy to manage the cysts with intracystic growths.

Non-malignant breast papillary lesions - b3 diagnosed on ultrasound--guided 14-gauge needle core biopsy: analysis of 114 cases from a single institution and review of the literature

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).

Benign papillomas without atypia diagnosed on core needle biopsy: experience from a single institution and proposed criteria for excision

BACKGROUND

The management of benign papilloma (BP) without atypia identified on breast core needle biopsy (CNB) is controversial. In this study, we determined the upgrade rate to malignancy for BPs without atypia diagnosed on CNB and whether there are factors associated with upgrade.

METHODS

Through our pathology database search, we studied 80 BPs without atypia identified on CNB from 80 patients from 1997 to 2010, including 30 lesions that had undergone excision and 50 lesions that had undergone ≥ 2 years of radiologic follow-up. Associations between surgery or upgrade to malignancy and clinical, radiologic, and pathologic features were analyzed.

RESULTS

Mass lesions, lesions sampled by ultrasound-guided CNB, and palpable lesions were associated with surgical excision. All 3 upgraded cases were mass lesions sampled by ultrasound-guided CNB. None of the lesions with radiologic follow-up only were upgraded to malignancy. The overall upgrade rate was 3.8%. None of the clinical, radiologic, or histologic features were predictive of upgrade.

CONCLUSION

Because the majority of patients can be safely managed with radiologic surveillance, a selective approach for surgical excision is recommended. Our proposed criteria for excision include pathologic/radiologic discordance or sampling by ultrasound-guided CNB without vacuum assistance when the patient is symptomatic or lesion size is ≥ 1.5 cm.

Microcalcification is an important factor in the management of breast intraductal papillomas diagnosed on core biopsy

The follow-up excision (FUE) results were analyzed from 370 cases diagnosed as intraductal papilloma on breast core needle biopsy (CNB) with no history of malignancy or other risk factors. Of these cases, 98.6% were rendered a Breast Imaging Reporting and Data System score of 4 on mammography before the CNB. Fifty-one cases (13.8%) were found to have microcalcifications on microscopic examination of CNB. A total of 7 (1.9%) of 370 cases were upgraded to invasive carcinoma, ductal carcinoma in situ, or pleomorphic lobular carcinoma in situ on FUE. Six of 51 (11.8%) cases with microcalcifications found on imaging and CNB were upgraded to ductal carcinoma in situ or invasive carcinoma, whereas only 1 (0.3%) of 319 cases without microcalcifications was upgraded to pleomorphic lobular carcinoma in situ (P = .003). Results of a multivariate analysis adjusted for age confirmed that microcalcifications was a risk factor for upgrading to cancer, independent of age. Our results indicate that surgical excision is required for intraductal papilloma diagnosed on CNB if microcalcifications are present. However, excision may not be required for those who have no microcalcifications on CNB and no other known risk factors.

Histological analysis of benign breast imaging reporting and data system categories 4c and 5 breast lesions in imaging study

PURPOSE

The objective of this study was to analyze the histology of breast lesions categorized as Breast Imaging Reporting and Data System (BI-RADS) 4c or 5 breast lesions during the imaging evaluation, but diagnosed as benign during the histological evaluation.

MATERIALS AND METHODS

We retrospectively reviewed 71 breast lesions categorized as BI-RADS 4c or 5 during imaging study, but diagnosed as benign upon histological evaluation.

RESULTS

Breast lesions were classified into six groups upon histological analysis: intraductal papilloma (18 cases), inflammatory group (15 cases), fibroepithelial tumor (14 cases), clustered microcalcification (10 cases), minimal histological alteration (10 cases), and adenosis (4 cases). Sclerosis and architectural complexity were associated with most of the biopsies that were morphologically similar to malignancy.

CONCLUSION

Among 71 cases categorized as 4c or 5 during the imaging study, but diagnosed as benign upon histological examination, intraductal papilloma was the most frequently identified histological lesion. These 71 cases exhibited histological characteristics of sclerosis and/or complex/complicated features that should be histologically differentiated from malignancy during evaluation.

Papillary lesions of the breast: impact of breast pathology subspecialization on core biopsy and excision diagnoses

BACKGROUND

Classifying papillary lesions of the breast on core biopsy (CB) is challenging. Although traditionally all such lesions were surgically excised, at present, conservative management of benign lesions is being advocated; therefore, accurately classifying papillary lesions on CB is all the more imperative. The extent to which subspecialty training in breast pathology might mitigate such difficulties in diagnosis has not yet been reported. We investigated change in diagnoses from CB to surgical excision according to subspecialist training in breast pathology and interobserver agreement between specialized breast pathologists (BPs) and nonbreast pathologists (NBPs) in classifying these lesions.

DESIGN

CBs of 281 papillary lesions from 266 patients diagnosed between 2000 and 2010 were classified by both a BP and NBP into benign, atypical, ductal carcinoma in situ/encapsulated papillary carcinoma, or invasive carcinoma categories. Rates of change in diagnostic category in the surgical excision specimen were calculated on the basis of: (i) the original diagnosis, (ii) diagnosis made by the BP, and (iii) diagnosis made by the NBP. Comparisons were made using the χ test. Kappa values were calculated for interobserver agreement.

RESULTS

Of 162 lesions with subsequent excision, 90 were originally diagnosed as benign, 38 as atypical, 25 as ductal carcinoma in situ/encapsulated papillary carcinoma, and 9 as invasive on CB. The upgrade rate for benign papillomas to an atypical or malignant lesion on surgical excision was 22.2% according to the original diagnosis. This rate fell to 16.3% when the BP diagnoses were considered, compared with 26.3% for the NBP diagnoses. There was no significant difference between BPs and NBPs in the rate of upgrade from a benign to an atypical/malignant diagnosis, although downgrades from atypical/malignant to benign papillomas were more commonly seen among NBPs (P=0.002). Overall, the BP diagnosis on CB was less likely to differ from the excision diagnosis (P=0.0001). Benign papillomas upgraded on excision were more likely to occur with larger radiologic mass size (P=0.033) compared with those that were not upgraded. Of 8 benign papillomas upgraded to a malignant lesion on excision, 7 were discordant on radiology. Interobserver agreement between BP and NBP diagnoses was in the "fair agreement" range (κ=0.38), with perfect agreement in 66.4% of cases.

CONCLUSIONS

Correlation between CB and excision diagnoses for breast papillary lesions is significantly greater for BPs than for NBPs. This is largely because of a tendency to overcall atypia or malignancy on CB by NBPs. However, upgrades from benign to atypical or malignant did not significantly differ according to subspecialization. With accurate pathologic assessment and radiologic-pathologic correlation, the upgrade rate of benign papillomas to malignancy can be minimized significantly.

Papillary lesions of the breast diagnosed using core needle biopsies

Papillary lesions of the breast include a broad spectrum of lesions, from benign papillomas to papillary carcinomas. It is difficult to determine whether a lesion is benign or malignant based on the fragmented material of a core needle biopsy (CNB). This study evaluated patients with papillary lesions examined using CNB. We retrospectively reviewed 31 papillary lesions diagnosed using CNB between 2004 and 2007. The clinical findings of benign and malignant papillary lesions were compared. The average patient age was 48.9 years. Twelve patients presented with a discharge and 10 patients presented with a lump. Eight patients were asymptomatic. The initial diagnoses by CNB of the 31 lesions were 25 intraductal papillomas, 4 intracystic papillomas and 2 adenomas. After CNB, excisional biopsies were performed in 23 patients and biopsies with a Mammotome(®) in 2 patients. Seven patients underwent regular follow-up. Five (16%) of the 31 patients with papillary lesions were ultimately diagnosed with breast cancer. The average distance from the nipple to a tumor diagnosed as malignant was 2.46 cm, which was longer than for a tumor diagnosed as benign. Ultimately, 5 papillary lesions (16%) were diagnosed as breast cancer. To avoid overlooking a malignancy, surgical excision is advantageous for papillary lesions, particularly those located far from the nipple.

Papillary lesions initially diagnosed at ultrasound-guided vacuum-assisted breast biopsy: rate of malignancy based on subsequent surgical excision

PURPOSE

To prospectively determine the rate of malignancy after surgery in papillary lesions initially diagnosed at ultrasound (US)-guided 11-gauge vacuum-assisted breast biopsies.

METHODS

Between May 2007 and December 2009, a total of 85 papillary lesions, including 73 benign papillomas and 12 atypical papillomas were diagnosed in 83 patients by US-guided 11-gauge vacuum-assisted breast biopsy. Surgical excision was recommended for all patients and 60 nonmalignant papillary lesions (49 benign papillomas and 11 atypical papillomas) in 60 patients (age range, 24-66 years; mean age, 45.0 years) were surgically excised. On a per-lesion basis, the upgrade rate to malignancy was calculated. Associations between clinical, lesion, and biopsy variables and the results of surgical excision were examined with a χ(2) test.

RESULTS

Surgical excision revealed the presence of benign papillomas in 34 cases, no residual lesion in 15 cases, atypical papillomas in nine cases, and ductal carcinoma-in-situ in two cases. The upgrade rate was 0% (0 of 49; 95% confidence interval 0-7.2) for benign papillomas and 18.2% (2 of 11; 95% confidence interval 2.3-51.8) for atypical papillomas. The core findings of atypical papillomas (P = 0.031) and age (P = 0.046) were associated with malignancy at excision, whereas personal or family history, presence of symptoms, multiplicity, lesion type, size, distance from the nipple, Breast Imaging Reporting and Data System (BI-RADS) category, and lesion removal at US showed no correlation to upgrade.

CONCLUSIONS

Surgical excision may not be required for lesions with a diagnosis of benign papilloma after US-guided 11-gauge vacuum-assisted breast biopsy, and a diagnosis of atypical papilloma should prompt excision for a definitive diagnosis.

Outcome of breast lesions diagnosed as lesion of uncertain malignant potential (B3) or suspicious of malignancy (B4) on needle core biopsy, including detailed review of epithelial atypia

AIMS

To provide updated evidence of the outcome of breast lesions of uncertain malignant potential (B3) and suspicious of malignancy (B4) diagnosed on needle core biopsy (NCB) and analyse the outcome of the different types of intraductal epithelial atypia.

METHODS AND RESULTS

One-hundred and forty-nine B3 and 26 B4 NCBs diagnosed over a 2-year period (2007-2008) were compared with those diagnosed over a previous 2-year period (1998-2000). The proportion of B3 diagnoses increased from 3.1% to 4.5%, and the positive predictive value (PPV) of malignancy of a B3 core decreased from 25% to 10%. Increased diagnosis of radial scar and reductions in the PPV of lobular neoplasia and of atypical intraductal proliferation may explain the reduction in the PPV of the B3 group as a whole. There were no significant changes in the proportion of B4 diagnosis (1.1% and 0.8%) or the PPV of B4 (83% and 88%). Review of cores with intraductal atypia showed a wide range of PPVs, from 100% for suspicious of ductal carcinoma in situ, to 40% for atypical ductal hyperplasia categorized as B3, and 14% for isolated flat epithelial atypia.

CONCLUSION

The study has found a decrease in the PPV for a B3 diagnosis and suggests possible explanations.

Myoepithelial Carcinoma: A Rare Neoplasm of the Breast

BACKGROUND: Malignant myoepitheliomas of the breast are extremely rare. There has been a limited number of published reports of myoepithelial carcinomas originating from the breast. CASE REPORT: We describe a malignant myoepithelioma of the breast in a 56-year-old woman. Histological examination showed polygonal epithelioid cells and spindle cells with moderate to marked nuclear atypia. Immunohistochemistry showed reactivity in the spindle cells for smooth muscle actin, cytokeratin (AE1/AE3), and p63, indicating a myoepithelial cell lineage of tumor cells. The patient underwent radical surgical excision of the lesion and axillary lymph node dissection. She demonstrated no evidence of recurrence over an 11-month follow-up. CONCLUSIONS: We suggest myoepithelial carcinomas of the breast be managed with appropriate surgical clearance. A multidisciplinary approach is usually required.

Diagnostic evaluation of papillary lesions of the breast on core biopsy

The management of asymptomatic intraductal papillary lesions of the breast diagnosed on core biopsy poses a challenge for patients and clinicians, as the distinction between common benign lesions and atypical or malignant varieties may be difficult without formal excision. The aim of this study was to determine whether a combination of histopathologic and biomarker features could be used to accurately identify benign papillary lesions on core biopsy. An inclusive group of 127 excised papillary lesions was characterized by detailed histopathologic review and immunohistochemical staining for the basal markers cytokeratin 5/6 (CK5/6) and P63 and the proliferation marker Ki67. Comparison of benign, atypical, and malignant lesions revealed that the combination of broad, sclerotic fibrovascular cores, and epithelial CK5/6 staining was most commonly seen in benign papillomas. Ki67 staining revealed striking intralesional heterogeneity, but there was no difference between the high scores of benign, atypical, or malignant lesions (P=0.173). In a non-overlapping set of 42 cases, a binary classifier specifying benign lesions on the basis of thick fibrovascular cores and epithelial CK5/6 staining on core biopsy gave an overall misclassification rate of 4/42 (10%) when compared with the final excision diagnosis. Misclassified cases included 2/27 lesions ultimately diagnosed as benign and 2/2 atypical papillomas. All malignant lesions (n=13) were correctly assigned. The combined assessment of fibrovascular core thickness and CK5/6 staining on core biopsy distinguished benign from malignant papillary lesions, but did not separate benign from atypical cases. This approach may form a useful addition to the clinicopathologic evaluation of papillary lesions of the breast.

Papillary carcinoma of the breast: an overview

Papillary carcinoma of the breast represents approximately 0.5% of all newly diagnosed cases of breast cancer. The prevalence of both invasive and in situ papillary carcinoma seems to be greater in older postmenopausal women and, in relative terms, in males. Histologic features of the tumor include cellular proliferations surrounding fibrovascular cores, with or without invasion. In this review, characteristics of both in situ and invasive disease are outlined. Immunohistochemical analyses of papillary carcinoma suggest the utility of markers such as smooth muscle myosin heavy chain, calponin, p63, and high molecular weight keratins, which can characterize the myoepithelial cell layer. With respect to radiographic evaluation of papillary carcinoma, ultrasonography is the most extensively studied imaging modality, though magnetic resonance mammography has potential utility. Available data suggest improved outcome for papillary carcinoma as compared to invasive ductal carcinoma. Treatment-related information for patients with papillary carcinoma is limited, and patterns noted in available series suggest a variable approach to this disease. The scarcity of information underscores the need for further treatment- and outcome-related studies in papillary carcinoma of the breast.

Cytokeratin 5 and estrogen receptor immunohistochemistry as a useful adjunct in identifying atypical papillary lesions on breast needle core biopsy

The presence of atypical or usual epithelial proliferations within papillary breast lesions complicates their interpretation on core biopsy. We evaluated the combination of estrogen receptor (ER) and cytokeratin 5 (CK5) as an aid in the distinction of usual duct hyperplasia from atypical proliferations in this setting. Core biopsies from 185 papillary lesions were reviewed and of these, 82 cases were selected for immunohistochemical study based on the presence of an epithelial proliferation between the fibrovascular cores. Fifty-two cases were used as the test set and 30 cases, with subsequent surgical excision, were used as the validation set. The epithelial proliferation was evaluated for staining intensity and percentage of positive cells using CK5 and ER. Expression of both CK5 and ER was significantly different in nonatypical lesions when compared with atypical lesions (P<0.0001). Nonatypical lesions typically showed an ER-low/CK5-high profile and atypical lesions showed an ER-high/CK5-low profile with ER-high expression defined as diffuse strong staining in >90% of cells. CK5-high expression was defined as a mosaic pattern of staining in >20% of cells and CK5-low as absent or staining in <20% of cells. On the basis of their staining profile, 29 of the 30 validation cases were correctly classified using the excision specimen as the gold standard. Patterns and extent of ER and CK5 staining, when used together, are valuable adjunct stains to differentiate usual duct hyperplasia from atypical proliferations within papillary lesions on core biopsy.

Papillary neoplasms of the breast: a review

CONTEXT

Interpretation of papillary lesions of the breast remains a challenging task because of the wide morphologic spectrum encountered in the benign, atypical, and malignant subtypes. Data on clinical significance and outcome of papillary lesions, with superimposed atypia or areas similar to ductal carcinoma in situ partially replacing the benign elements, are sparse. Furthermore, complete excision of even a fully developed papillary carcinoma confined to a dilated or cystic duct is associated with an excellent prognosis, whereas a complex papilloma extending into multiple branches of a duct may ultimately recur as a carcinoma because of incomplete excision of microscopic foci. This makes an outcome-based classification difficult.

OBJECTIVE

An arbitrary yet practical approach to classification is outlined, with discussion of methods to circumvent the various diagnostic difficulties. The limitations in precise diagnosis of papillary lesions in aspirates are addressed, and the implications of finding papillary lesions in core biopsies are discussed. Although the focus is on intraductal lesions, associated invasive carcinomas and invasive micropapillary carcinoma are also presented.

DATA SOURCES

The literature on papillary lesions and invasive micropapillary carcinoma is reviewed.

CONCLUSIONS

It would be prudent to completely excise any papillary lesion that has not been entirely removed by the initial core biopsy. The optimal management of localized papillary lesions is complete excision with a small rim of uninvolved breast tissue without any prior needle instrumentation if and when the papillary nature can be determined by imaging. Thus managed, most of these lesions behave indolently, and outcome is usually excellent.

Predictive value of needle core biopsy diagnoses of lesions of uncertain malignant potential (B3) in abnormalities detected by mammographic screening

AIMS

Breast needle core biopsy (NCB) is now a commonplace diagnostic procedure in breast cancer screening, providing accurate diagnoses of both benign and malignant lesions. However, NCB may result in the borderline diagnoses of lesion of uncertain malignant potential (B3) or suspicious of malignancy (B4). The aim was to study a large series of B3 cases from population-based screening subjects in order to evaluate positive predictive values (PPVs) for malignancy.

METHODS AND RESULTS

The results of 523 NCBs of women screened over a 7-year period (1999-2006) in the East Midlands region, UK, with a B3 diagnosis who underwent surgical excision, were reviewed and compared with the final excision histology. Five percent of NCBs were reported as B3. The most frequent histological subtypes were atypical intraductal epithelial proliferation (AIDEP) and radial scar/complex sclerosing lesion (RS/CSL). Final excision histology was benign in 417 (80%) and malignant in 106 (20%) subjects (60 ductal carcinoma in situ and 46 invasive carcinoma). Lesion-specific PPVs were as follows: AIDEP 32%; lobular neoplasia (LN) 30%; RS/CSL with AIDEP or LN 24%; RS/CSL without atypia 9%; papillary lesion with AIDEP or LN 36%; and papillary lesion without atypia 4%. Five of the 32 fibroepithelial lesions with cellular stroma were phyllodes tumours (four benign and one borderline). None of the five mucinous lesions on NCB was malignant.

CONCLUSIONS

Our results show that approximately one-fifth of NCB of screen-detected breast lesions classified as B3 are malignant on excision, and the likelihood of malignancy varies substantially between different histological subtypes.

The role of immunohistochemistry in the differential diagnosis of papillary lesions of the breast

Papillary lesions of the breast represent a heterogeneous group with differing biological behaviour. Correct diagnosis is crucial but may be difficult, as many benign and malignant papillary lesions have similar appearances. Immunohistochemistry plays a useful role in their differentiation. Myoepithelial markers can help in differentiating papilloma from papillary carcinoma, as the former usually shows a continuous layer of myoepithelial cells. In intracystic papillary carcinoma, there is controversy as to the presence of a complete myoepithelial cell layer around these lesions. p63 is the marker of choice as the staining is nuclear, cross-reactivity is minimal, and sensitivity is high. Papilloma may frequently be complicated by superimposed different types of epithelial hyperplasia, which range from usual to atypical or even ductal carcinoma in situ, and they many be morphologically similar. Basal cytokeratins (CKs) are useful to differentiate these entities; as usual hyperplasia is positive for basal CKs with a mosaic staining pattern. CK5/6 is probably the best marker. Neuroendocrine markers (chromogranin A and synaptophysin) may be positive in papillary carcinoma, particularly in the solid type, and there may be some overlap with the ductal carcinoma in situ with spindle cells or endocrine ductal carcinoma in situ. A panel of CK5/6, p63 and neuroendocrine markers can be useful in the diagnostic investigation of problematic papillary lesions of the breast. As the experience with these markers remains rather limited, it is too early to recommend basing treatment choices on these marker studies alone. Complete removal of lesion is probably still the treatment of choice.

The significance of lobular neoplasia on needle core biopsy of the breast

The management of a core biopsy diagnosis of lobular neoplasia is controversial. Detailed radiological–pathological review of 47 patients with cores showing classical lobular neoplasia was performed (patients with pleomorphic lobular carcinoma in situ (LCIS) or associated risk lesions were considered separately). Immediate surgical excision in 25 patients showed invasive carcinoma in 7, ductal carcinoma in situ (DCIS) in 1 and pleomorphic LCIS in 1; radiological–pathological review showed that the core biopsy missed a mass in 5, missed calcification in 2 and that calcification appeared adequately sampled in 2. Nineteen patients had follow-up of at least 2 years. Four patients developed malignancy at the site of the core biopsy (invasive carcinoma in three, DCIS in one); one carcinoma was mammographically occult, one patient had dense original mammograms and two had calcifications apparently adequately sampled by the core. In conclusion, most carcinomas identified at the site of core biopsy showing lobular neoplasia were the result of the core missing the radiological lesion, emphasising the importance of multidisciplinary review and investigation of any discordance. Some carcinomas were found after apparently adequate core biopsy, raising the question of whether excision biopsy should be considered after all core biopsy diagnoses of lobular neoplasia.

Clinicopathologic features of papillary lesions on core needle biopsy of the breast predictive of malignancy

BACKGROUND

The necessity for surgical excision of papillary lesions identified on percutaneous breast biopsy remains controversial. We reviewed data from patients with papillary lesions found on core needle biopsies to identify features associated with carcinoma.

METHODS

A retrospective chart review was performed on patients with papillary lesions diagnosed from image-guided breast biopsies over a 10-year period. Patients had surgical excision or were followed-up radiographically for a 2-year minimum.

RESULTS

Papillary lesions were identified in 154 core needle biopsies. Ninety-five lesions were diagnosed as either benign or atypical. Eighty-nine of these patients had surgical excisions of their lesions. Malignancy was discovered in 22 (25%) of these lesions. Only atypical lesions on biopsy were malignant (P < .005). Forty-six percent of patients age 65 or older were found to have cancer at surgical excision (P < .01).

CONCLUSIONS

Papillary lesions found on core needle biopsy frequently harbor malignancy (25%). Atypia and age 65 or older are significant risk factors for malignancy.

Papillary lesions of the breast discovered on percutaneous large core and vacuum-assisted biopsies: reliability of clinical and pathological parameters in identifying benign lesions

BACKGROUND

A review of the literature reveals conflicting evidence on whether core biopsy, complemented with concordant imaging, is sufficient in differentiating benign from malignant papillary lesions. Our objective was to evaluate whether in our patient population, commonly used clinical and pathological parameters could predict benignity, thus eliminating the need to proceed with excision.

METHODS

A retrospective review of clinical variables and pathologic slides of 39 patients in whom both core biopsy and excisional biopsy were available for evaluation.

RESULTS

Excision revealed malignancy in 44%. Risk factors for malignancy, palpability, size, or Breast Imaging Reporting and Data System (American College of Radiology, Reston, VA) did not help differentiate benign from malignant disease. Younger age and core biopsies revealing minimal or no atypia were predictive of benignity. However, 4 (25%) of 20 patients whose core biopsies were classified as probably benign were found to have malignancy on excision.

CONCLUSIONS

Caution should be used in recommending nonoperative management after a core biopsy revealing a papillary lesion.

Breast Papillomas in the Era of Percutaneous Needle Biopsy

BACKGROUND

The significance of breast papillomas detected on core needle biopsy (CNB) remains unclear. While those associated with malignancy or atypia are excised, no clear solution exists for benign papillomas. We sought to determine the indication for surgical excision, incidence of malignancy, significance, and natural history.

METHODS

In this retrospective review, patients were divided into benign, atypical, or malignant cohorts based on initial results. While patients with malignant or atypical features were encouraged to undergo surgical excision, no standard recommendation was given for benign papillomas. Mammographic features, method of initial diagnosis, pathology results, and follow-up data were analyzed.

RESULTS

Between January 1994 to December 2005, 5,257 CNBs were performed at our tertiary level medical center. 206 patients were diagnosed with 215 breast papillomas. 174 (81%) papillomas were benign, 26 (12%) were associated with atypia, and 15 (7%) were associated with malignancy. Two benign papillomas (1.1%) developed into cancer over an average of 53 months. Average follow-up of those patients not undergoing excision for benign papilloma was 41 months; we had 92 patients with greater than two year follow-up and 57 patients with greater than four year follow-up. Of patients with atypia or malignancy associated with papilloma, there was a 26% and 87% associated rate of malignancy, respectively.

CONCLUSIONS

Benign breast papillomas diagnosed by CNB have a low risk of malignancy and do not need excision. However, they should be considered high risk lesions which require serial radiographic monitoring. Papillomas associated with atypia or malignancy should continue to be excised.

Borderline breast core needle histology: predictive values for malignancy in lesions of uncertain malignant potential (B3)

Breast core needle biopsy (CNB) is an accurate test but may result in borderline histology (lesions of uncertain malignant potential or B3). This is an evaluation of the largest series (to date) of B3 histology, which focuses on estimating positive predictive values (PPV) for malignancy. We identified all B3 CNBs over a 10-year period in a single institution (N=372) from a series of 4035 consecutive needle biopsies. We describe the imaging findings, and report excision histology outcomes (N=279) and category-specific PPV for B3 lesions using two approaches including estimates based on subjects who had either excision or follow-up (N=328). B3 represented 9.2% of all CNB results. Excision histology was benign in 181 (64.9%) and malignant in 98 (35.1%) subjects (61 ductal carcinoma in situ, 37 invasive carcinoma). Positive predictive value for malignancy (based on excision histology) was 35.1% (95% CI: 29.5-40.7) and PPV (based on excision or review) was 29.9% (95% CI: 24.9-34.8). Lesion-specific PPV (estimates in parentheses for excision or follow-up) was atypical ductal hyperplasia 44.7% (40.6%); lobular intraepithelial neoplasia 60.9% (58.3%); papillary lesion 22.7% (15.9%); radial scar 16.7% (12.3%); phyllodes tumour 12.5% (12.5%); and B3 not specified 20.0%. Approximately one-third of CNB results classified as B3 are malignant on excision, and the likelihood of malignancy varies substantially between specific lesion groups. Whereas cases may be selectively managed without surgery, the majority warrant excision biopsy based on our estimates. Research is needed to improve differentiation between malignant and benign diseases in B3 lesions using diagnostic or predictive methods.