Benign papilloma without atypia diagnosed at US-guided 14-gauge core-needle biopsy: clinical and US features predictive of upgrade to malignancy

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.

Increased risk of upstage when combinations of breast lesions of uncertain malignant potential are found on core needle biopsy: The need for surgical excision

BACKGROUND

Management of breast lesions of uncertain malignant potential diagnosed at core needle biopsy (CNB) is controversial due to variable upstage rate (UR) with surgical excision (SE).

METHODS

We performed an IRB-approved retrospective analysis of adult women who underwent CNB demonstrating atypical ductal hyperplasia (ADH), flat epithelial atypia, radial scar, or intraductal papilloma then SE between 2010 and 2022. We evaluated CNB pathology for combination diagnoses (CD), defined as multiple primary lesions or primary with lobular neoplasia (LN), and surgical pathology for upstage.

RESULTS

719 patients were included. UR was 12.2% (88/719). CD experienced higher UR than pure (17.7% (45/254) vs. 9.2% (43/465), p ​= ​0.001). ADH/LN had the highest UR of all CD (34.6% (9/26), p ​= ​0.001). Increased size (15.6 vs. 10.5 ​mm, p ​< ​0.001), distance from nipple (79 vs. 66 ​mm, p ​< ​0.001), and personal history of breast cancer (p ​= ​0.04) were associated with UR.

CONCLUSIONS

CD was associated with increased UR. ADH/LN had the highest UR.

Nipple Discharge: When is it Worrisome?

Nipple discharge is the third most common breast related complaint seen in the breast clinics. Although the majority of cases are due to a benign etiology, 5%-12% cases of pathological nipple discharge may be harboring an underlying malignancy. A thorough radiological workup in cases of pathological nipple discharge is thus of utmost importance, with the initial imaging modality depending on the age of the patient. The imaging modalities include mammogram (MG) and ultrasound (US) with addition of breast MRI if the nipple discharge is clinically suspicious and no MG or US correlate is identified. Magnetic Resonance Imaging (MRI) also holds promise in demonstrating the exact extent of a pathology detected on US and thus aids in the planning of further management.

Upgrade Rate and Predictive Factors Associated With Breast Papillary Lesions on Core Biopsy: A Canadian Experience

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.

Clinicopathological and Imaging Features of Breast Papillary Lesions and Their Association with Pathologic Nipple Discharge

No studies have evaluated whether any clinicopathological or imaging characteristics of breast papillary lesions are associated with pathological nipple discharge (PND). We analyzed 301 surgically confirmed papillary breast lesions diagnosed between January 2012 and June 2022. We evaluated clinical (age of patient, size of lesion, pathologic nipple discharge, palpability, personal/family history of breast cancer or papillary lesion, location, multiplicity, and bilaterality) and imaging characteristics (Breast Imaging Reporting and Data System (BI-RADS), sonographic, and mammographic findings) and compared malignant versus non-malignant lesions and papillary lesions with versus without PND. The malignant group was significantly older than the non-malignant group (p < 0.001). Those in the malignant group were more palpable and larger (p < 0.001). Family history of cancer and peripheral location in the malignant group were more frequent than in the non-malignant group (p = 0.022 and p < 0.001). The malignant group showed higher BI-RADS, irregular shape, complex cystic and solid echo pattern, posterior enhancement on ultrasound (US), fatty breasts, visibility, and mass type on mammography (p < 0.001, 0.003, 0.009, <0.001, <0.001, <0.001, and 0.01, respectively). On multivariate logistic regression analysis, peripheral location, palpability, and age of ≥50 years were factors significantly associated with malignancy (OR: 4.125, 3.556, and 3.390, respectively; p = 0.004, 0.034, and 0.011, respectively). Central location, intraductal nature, hyper/isoechoic pattern, and ductal change were more frequent in the PND group (p = 0.003, p < 0.001, p < 0.001, and p < 0.001, respectively). Ductal change was significantly associated with PND on multivariate analysis (OR, 5.083; p = 0.029). Our findings will help clinicians examine patients with PND and breast papillary lesions more effectively.

Radiologic and Pathologic Findings of Axillary Intraductal Papilloma Arising in Accessory Breast Tissue: A Case Report and Literature Review

INTRODUCTION

This is a rare case report of axillary intraductal papilloma arising in accessory breast tissue.

CASE PRESENTATION

A 49-year-old woman presented to our clinic with a palpable right axillary mass that had first appeared 6 months earlier. Mammography and ultrasonography of the right axilla revealed an ovoid mass surrounding accessory breast tissue. Ultrasound-guided 14-G core-needle biopsy was performed and pathologically revealed intraductal papilloma without atypia.

CONCLUSION

Since ectopic breast tissue is affected by the same pathologic processes as normal breast tissue, a core-needle biopsy can be used to identify the suspicious lesions in axillary breast tissue.

Benign Breast Disease

Benign breast disease presents commonly in routine gynecologic care. Presenting symptoms such as breast mass, nipple discharge, or breast pain may raise concern for malignancy. Once breast cancer is ruled out, gynecologists must identify and appropriately treat benign breast disease. While most benign lesions can be managed conservatively, high-risk breast lesions can increase the future risk of breast cancer and may require additional screening imaging and surgical excision. Pharmacologic therapy may also have a role in certain conditions. Gynecologists should be proficient in the identification and management of benign breast disease.

Best Practice Guidelines for Breast Imaging: Breast Imaging Society, India: Part—2

Breast imaging is one of the prerequisites for providing high-quality breast health care. Choosing the appropriate investigation is central to diagnosing breast disease or the absence of it in women and men who present to health professionals for treatment. Patients with breast disease present to doctors of different subspecialties as well as general practitioners in our country. It is important, therefore, to provide uniform guidance to doctors in different health care setups of our country, urban and rural, and government and private, for breast diseases to be diagnosed and treated optimally. These guidelines framed by the task group set up by the Breast Imaging Society, India, have been formulated focusing primarily on the Indian patients and health care infrastructures. These guidelines aim to provide a framework for the referring doctors and practicing radiologists to enable them to choose the appropriate investigation for patients with breast symptoms and signs. The guidelines encompass all aspects of breast imaging including mammography, breast ultrasound, breast magnetic resonance imaging, as well as breast interventions. Algorithms for the investigation of specific common breast symptoms and signs have been provided in this document. The aim has been to keep this framework simple and practical so that it can guide not only subspecialists in breast care but also help doctors who do not routinely deal with breast diseases so that breast cancer is not missed. Breast screening is an integral part of breast imaging, and guidelines for the same have been incorporated in this document. In the absence of a population-based screening program in India, the guidelines to be followed for those women who wish to be screened by mammography have been provided. Overall, the aim of this document is to provide a holistic approach to standardize breast care imaging services in India.

Comparative study of breast core needle biopsy (CNB) findings with ultrasound BI-RADS subtyping

&lt;b&gt; Introduction:&lt;/b&gt; Given the high prevalence of breast cancer, developing quick and accessible diagnostics solutions is critical. The BIRADS classification is a reliable method for assessing and estimating the risk of malignancy in breast lesions. &lt;/br&gt;&lt;/br&gt; &lt;b&gt;Aim:&lt;/b&gt; The aim of this study was to compare the results of core needle biopsy of breast lesions and sonographic findings based on the BIRADS category in Yazd. &lt;/br&gt;&lt;/br&gt; &lt;b&gt;Materials and methods:&lt;/b&gt; This retrospective analytical study was done on all core needle biopsy specimens referred to Mortaz hospital, Yazd, Iran from 2010 to 2019. Demographic data such as age, laterality of the lesion, BIRADS category, and pathology reports were extracted from patients&apos; hospital folders. Data were analyzed by SPSS version 21. P &lt; 0.05 was considered statistically significant. &lt;/br&gt;&lt;/br&gt; &lt;b&gt;Results:&lt;/b&gt; In total, 514 cases with a mean age of 43.9 9.4 years were studied. Among them, 104 cases (20.2%) were malignant and 410 cases (79.8%) were benign. The most common benign and malignant lesions were fibroadenoma (24.9%), and infiltrative ductal carcinoma (83.7%) respectively. The most common BIRADS was class 4A (54.9%). Patients with benign lesions were mostly in the 3rd and 4th decade of life, while malignant lesions were more in the 4th and 5th decades, and this difference was statistically significant (P = 0.001). The correlation between ultrasound diagnoses (BIRADS) and pathology findings was statistically significant (P &lt; 0.001). &lt;/br&gt;&lt;/br&gt; &lt;b&gt;Conclusion&lt;/b&gt;: Based on the results, there is a significant correlation between ultrasound outcomes according to BIRADS and pathology results, and the radiology-pathology accordance, owing to its high accuracy, can be very helpful in correctly diagnosing, monitoring, and managing the lesion.

The Role of Superb Microvascular Imaging and Shearwave Elastography in the Evaluation of Intraductal Papilloma-Like Lesions

OBJECTIVES

The aim of this study was to investigate the role of quantitative values obtained by superb microvascular imaging (SMI) and shearwave elastography (SWE) in the prediction of malignancy in intraductal papilloma-like lesions (IDPL).

METHODS

In the study, 61 patients between the ages of 14 to 73 years (mean age 44) diagnosed with IDPL on ultrasound (US) examination between the years 2020 and 2021 were included. The B-Mode US findings (shape, margins, size, echo pattern, and accompanying ductal dilatation), SMI vascular index (SMIvi), E-mean, and SWE-ratio values were recorded.

RESULTS

There was a statistically significant difference between malignant (n = 14) and benign (n = 47) groups in terms of symptoms (P = .005), size (P = .042), shape (P = .002), margins (P =  .001), echogenicity (P = .023), microcalcifications (P = .009), SMIvi (P = .031), E-mean (P < .005), and SWE-ratio (P = .007). According to receiver operating characteristic (ROC) curve analysis, sensitivity, specificity, accuracy, area under the curve (AUC), positive predictive values (PPV), and negative predictive values (NPV) were 57.1%, 87.2%, 80%, 0.722, 57.1%, 87.2% for US; 71.4%, 49%, 55.7%, 0.692, 30.3%, 85.7% for SMIvi; 85.7%, 71%, 74%, 0.864, 46%, 94.3% for E-mean, and 50%, 75.4%, 83%, 0.707, 91.5%, and 50% for SWE-ratio, respectively. Best results were obtained when SMI and SWE values were used together, achieving a sensitivity, specificity, accuracy, AUC, PPD, NPD of 78.6%, 93.6%, 93.4%, 0.872, 91.7%, and 93.9%, respectively.

CONCLUSIONS

The SMI and SWE examinations are successful in the differentiation of benign and malignant intraductal lesions. They complement each other and contribute to B-mode US in managing IDPLs especially when used together. Our study is the first to compare the quantitative data of SWE and SMI in the differentiation of IDPLs.

Papillary Lesions of the Breast: Addition of DWI and TIRM Sequences to Routine Breast MRI Could Help in Differentiation Benign from Malignant

AIM

We aimed to investigate the magnetic resonance imaging (MRI) features of benign, atypical or malignant papillary breast lesions and to assess additional value of diffusion-weighted imaging (DWI) and turbo inversion recovery magnitude (TIRM) sequences to routine breast MRI.

BACKGROUND

Differentiation between benign and malignant papillary breast lesions is essential for patient management. However, morphologic features and enhancement patterns of malignant papillary lesions may overlap with those of benign papilloma.

METHODS

Seventy two papillary breast lesions (50 benign, 22 atypical or malignant) were included in the current study, retrospectively. We divided the patients into two groups as benign papillary breast lesions and atypical or malignant papillary breast lesions. Morphologic, dynamic, turbo inversion recovery magnitude (TIRM) values and diffusion features of the papillary lesions were compared between two groups.

RESULTS

Benign papillary lesions were smaller in size (p=0.006 and p=0.005, for radiologist 1 and 2 respectively), closer to areola (p=0.045 and 0.049 for radiologist 1 and 2 respectively) and had higher ADC values (p=0.001 for two radiologists) than atypical or malignant group. ROC curves showed diagnostic accuracy for ADC (AUC=0.770 and 0.762, p<0.0001 for two radiologists) and showed a cut-off value of ≤957 x 10-6 mm2/s (radiologist 1) and ≤ 910 x 10-6 mm2/s (radiologist 2).

CONCLUSION

MRI is a useful method for differentiation between benign and malignant papillary breast lesions. Centrally located, lesser in size and higher ADC values should be considered benign, whereas peripherally located, larger in size and lower ADC values should be considered malignant.

Does previous history of cancer or atypia predict histologic upgrade for pure intraductal papillomas diagnosed via core biopsy? A study of 490 cases at a single institution

BACKGROUND

Management of pure intraductal papillomas (IDP) without atypia diagnosed on core needle biopsy (CNB) remains controversial given highly variable rates of upgrade in the literature.

AIM

We sought to identify clinical and histologic factors that predict upgrade to atypia or malignancy in a large population.

METHODS AND RESULTS

A retrospective review was performed of all cases of pure IDP diagnosed on CNB and then surgically excised at a single institution from 2008 to 2018. Clinical, radiologic, and pathologic factors were compared in the no upgrade, upgrade to atypia, or upgrade to cancer groups. Univariate analysis was performed comparing no upgrade and upgrade to cancer or atypia. Four hundred and thirty nine patients were identified with a total of 490 IDP and a median age of 50 years (range 16-85). Of these patients, 54 (12.3%) were upgraded to atypia after surgical excision and five (1.1%) were upgraded to cancer. The presence of multiple papillomas in a single patient was a significant predictor of upgrade to cancer or atypia (p < .01), as well as age over ≥55 years (p < .01) and a prior history of cancer (p < .01). No other clinical, radiologic and histologic factors were found to be significant predictors of upgrade. 40/439 (9.1%) patients in the total cohort had prior history of cancer, and of these, 2/40 (5%) were found to have a new cancer after excision.

CONCLUSIONS

In patients with pure IDP on CNB, the upgrade rate to malignancy was 1.1%, while 12.3% were upgraded to atypia. The clinical significance of identifying atypia in a papilloma is unknown, especially in a patient with a prior history of atypia or cancer. However, the majority of patients who were upgraded to either atypia or cancer had no prior history of high-risk or malignant breast disease and are therefore considered true clinical upgrades. As such excision for IDP should be considered.

Imaging Evaluation of Male Breast Masses with Histopathologic Correlation: A Case Series

The male breast can be afflicted with a wide spectrum of benign and malignant masses, similar to the female breast. A systematic radiological evaluation using mammography, ultrasonography, and when appropriate, magnetic resonance imaging, could aid this differentiation and provide clues to the diagnosis. In this article, we present six cases of male breast masses with an emphasis on the role of imaging in characterization and diagnosis.

Results of Excision of Unknown Papillary Neoplasms Detected on Core Biopsy

Objective

This study aimed to find out valuable parameters that predict the nature of breast papillary lesions before excision, and we compared our results with those in the literature.

Materials and Methods

We reviewed the medical records and pathology slides of patients diagnosed with papillary neoplasm after undergoing a core-needle biopsy between 2010 and 2020, who, subsequently, underwent surgical excision in a single tertiary care institution. The core biopsy results and pathology results of excision materials were compared with the radiological, pathological, and demographic findings.

Results

A total of 51 patients were included in the study. According to the excision results, the patients were divided into two groups: the atypical group, which included 20 patients (39.3%), and the benign group, which included 31 patients (61.7%). The results of the core biopsy showed that the loss of myoepithelial cell layer was identified in 18 patients in the atypical group, while it was present in all patients in the benign group. Tumor sizes were larger and patient ages were older in the atypical group compared with the benign group. No significant difference was found between atypical and benign groups in terms of breast imaging-reporting and data system (BI-RADS) classification and location (right vs left; central vs peripheral). The upgrade rate was between 0% and 16% in literature, while it was 4% in our study.

Conclusion

There is no consensus on whether patients diagnosed with papillary neoplasia as a result of core biopsy will undergo excision. According to our results, patients with following criteria should have their lesions excised: those who are advanced in age, those who are diagnosed with a papillary lesion as a result of core biopsies with loss of myoepithelial cell layer, and those who are diagnosed with large-sized lesions without loss of myoepithelial cell layer. Patients diagnosed with small-sized lesions without loss of myoepithelial cell layer and who are young in age are to be followed up without the need for lesion excision. The lesions should be adequately sampled.

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

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.

Breast Imaging Reporting and Data System Classification for Central-Type Intra-Ductal Papillary Masses: Current Problems and Evaluation of Modified Parameters

The Breast Imaging Reporting and Data System (BI-RADS) standards have limitations regarding classifying and managing central intra-ductal papillary masses. Changes to the standards are necessary to provide early and effective treatment. To summarize the ultrasonographic imaging features of central mammary ductal papillary masses, this retrospective study included 56 participants. In identifying benign versus malignant lesions, the most significant indicators were angular edges and the long diameter of the tumor parallel to the duct. In the comparison of diagnostic efficacy for central mammary ductal tumors, the post-operative pathologic malignant upgrade rate of BI-RADS was 33.3%, and that of the new standard criteria was 14.2%. The angle of the wall of the tumor relative to the duct was most helpful. When BI-RADS is used to evaluate a papillary mass in a central duct, it is more accurate when the tumor is parallel to the duct than parallel to the skin.

Upgrade rate of intraductal papilloma diagnosed on core needle biopsy in a single institution

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.

Breast papillary lesions diagnosed and treated using ultrasound-guided vacuum-assisted excision

Background

The management of papillary lesions of the breast remains controversial, and thus, we assessed the value of vacuum-assisted excision (VAE)-guided ultrasound in the diagnosis and treatment of breast papillary lesions.

Methods

We retrospectively reviewed the data of 108 patients with papillary lesions diagnosed using VAE between August 2014 and January 2019. Cases without postoperative breast imaging in the follow-up were excluded, and 85 cases were eligible for the study. The follow-up period ranged from 6 to 53 months, with 38 months on average. All the papillary lesions were located away from the skin or nipple with a size less than or equal to 30 mm, and the lesions categorized as C2-4b were completely excised using VAE. All VAEs were performed using an 8-gauge vacuum-assisted biopsy needle under the guidance of ultrasound using a 10 MHz linear probe.

Results

Most patients with breast papillary lesions were asymptomatic (56.5%), and when the size of the breast papillary lesion was more than 20 mm on ultrasound imaging, atypical hyperplasia may have been concomitant. Breast lesions might have been pathologically diagnosed as papilloma after biopsy when they were categorized as BI-RADS 4a on ultrasound images. The rate of underestimation was 7.7% in papillary lesions diagnosed with VAE, and the recurrence rate of papilloma after VAE was low.

Conclusions

Breast papilloma was a common lesion on ultrasonographic screening, and VAE was applicable for completely excising small papillomas, even papillomas with atypical hyperplasia, to obtain an accurate diagnosis with a low rate of underestimation and recurrence. We believe that papilloma diagnosed by VAE might not require immediate excision, and imaging follow-up may be safe for at least 3 years.

A retrospective observational study of intraductal breast papilloma and its coexisting lesions: A real-world experience

Background

Breast intraductal papilloma is a heterogeneous group. The aim of the study is to investigate the intraductal breast papilloma and its coexisting lesions retrospectively in real‐world practice.

Methods

We retrospectively identified 4450 intraductal breast papilloma and its coexisting lesions.

Results

About 18.36% of intraductal papilloma coexisted with malignant lesions of the breast, 37.33% coexisted with atypia hyperplasia (AH), 25.24% coexisted with benign lesions, and only 19.10% coexisted without concomitant lesions. In addition, 36.80% of intraductal breast papilloma had nipple discharge, 51.46% had a palpable breast mass, and 16.45% had both nipple discharge and a palpable breast mass. About 28.18% experienced discomfort or were asymptomatic. Furthermore, 98.99% had ultrasound abnormalities, and 53.06% had intraductal hypoechogenicity upon ultrasound. 31.89% had mammographic distortion, and 14.45% had microcalcification upon mammography. Intraductal breast papilloma with malignancy had significant correlations with clinical manifestations.

Conclusion

Coexisting malignancy was also related to ultrasound abnormality (BIRADS 4C and 5), mammographic distortion, and microcalcification upon mammography but was not related to the intraductal hypoechoic upon ultrasound. Coexisting atypical hyperplasia correlated with nipple discharge but not palpable mass, mammographic distortion, or intraductal hypoechoic upon ultrasound. The coexisting AH was also related to abnormality upon ultrasound or microcalcification compared with the benign lesions. The intraductal papilloma coexists with malignancy or AH accounted for more than 50%, and the clinical information on papilloma and its coexisting lesions is nonspecific. We recommended surgical treatment for benign intraductal papillary lesions.

Factors associated with disease upgrading in patients with papillary breast lesion in core-needle biopsy

Background

Traditionally, surgical excision is recommended for benign papillary lesions in core-needle biopsy (CNB) because of their malignant potency. The aim of this study was to identify factors associated with disease upgrading to malignancy in patients with benign papillary lesions in CNB.

Methods

A total of 179 female patients were evaluated retrospectively who were diagnosed as having a benign papillary lesion in CNB and underwent a subsequent surgical excision between January 2007 and December 2016. Ultrasonography-guided CNB was performed using a 14-gauge needle gun method.

Results

The rate of upgrade to malignancy was 10.6% (7.6% in papillary lesions without atypia vs. 33.3% in papillary lesions with atypia; P=0.001). The univariable analysis revealed that older age at diagnosis (≥50 years old), menopause, lesion size on ultrasonography, palpability, multifocality, and atypia in CNB were associated with upgrading. The multivariable analysis revealed that age ≥50 years (OR, 4.6; 95% CI, 1.5-14.1; P=0.008), lesion size of ≥2 cm (OR, 6.4; 95% CI, 1.9-21.1; P=0.002), and atypia in CNB (OR, 5.1; 95% CI, 1.5-18.2; P=0.011) were significantly associated with upgrading to malignancy.

Conclusions

Upgrading to malignancy in patients with benign papillary lesions in CNB was associated with age ≥50 years, lesion size ≥2 cm, and atypia in CNB.

External Validation of a Risk Stratification Score for B3 Breast Lesions Detected at Ultrasound Core Needle Biopsy

OBJECTIVE

The aim of this study was to externally validate the feasibility and robustness of a risk-stratification score for B3 lesions based on clinical, pathological, and radiological data for improved clinical decision making.

METHODS

129 consecutive histologically confirmed B3 lesions diagnosed at ultrasound-guided biopsy at our institution were included in this retrospective study. Patient- and lesion-related variables were independently assessed by two blinded breast radiologists (R1, R2), by assigning each feature a score from 0 to 2 (maximum sum-score of 5). Sensitivity, specificity, positive and negative predictive values were calculated at two different thresholds (≥1 and 2). Categorical variables were compared using Chi-squared and Fisher exact tests. The diagnostic accuracy of the score to distinguish benign from malignant B3 lesions was assessed by receiver operating characteristic (ROC) analysis.

RESULTS

Surgery was performed on 117/129 (90.6%) lesions and 11 of these 117 (9.4%) lesions were malignant. No cancers were found at follow-up of at least 24 months. Area under the ROC-curve was 0.736 (R1) to 0.747 (R2), with no significant difference between the two readers (p = 0.5015). Using a threshold of ≥1, a sensitivity, specificity, PPV, and NPV of 90%/90% (R1/R2), 39%/38% (R1/R2), 11%/12% (R1/R2) and 97%/98% (R1/R2) were identified. Both readers classified 47 lesions with a score ≤1 (low risk of associated malignancy). Of these, only one malignant lesion was underdiagnosed (Ductal carcinoma in situ-G1).

CONCLUSIONS

In our external validation, the score showed a high negative predictive value and has the potential to reduce unnecessary surgeries or re-biopsies for ultrasound-detected B3-lesions by up to 39%.

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

BACKGROUND

The aim of the study was to determine the upgrade rate on excision of intraductal papilloma (IDP) without atypia diagnosed on breast core needle biopsy (CNB).

METHODS

We searched our pathology department database for breast CNB with a diagnosis of IDP from 2013 to 2018. The exclusion criteria included radiologic-pathologic discordance, atypia on the same CNB, absence of histologic slides to review or absence of excision information. Upgrade was defined as ductal carcinoma in situ (DCIS) or invasive cancer identified on excision.

RESULTS

126 IDP without atypia cases from 94 patients were identified. The upgrade rate was 1.58% (2/126). Both upgrade cases showed DCIS with low and intermediate nuclear grade. Histologic size of IDP ≥1 cm was the only statistically significant predictor factor for an upgrade on excision.

CONCLUSION

The results suggest that non-surgical management of patients with radiologic-pathologic concordant IDP without atypia diagnosed on CNB may be appropriate in routine practice.

Apparent diffusion coefficient value in breast papillary lesions without atypia at core needle biopsy

PURPOSE

The main aim of the study was to assess if the mean apparent diffusion coefficient (ADC) value was significantly different between papillary lesions (PL) without atypia and PLs with atypical or malignant foci. A secondary objective was to evaluate if patients mean age, MRI BI-RADS® descriptors and assessment category were significantly different between these two PL groups.

METHODS

In this eight year retrospective study were included 122 patients (mean age, 51 years; range, 24-78) with 122 PLs without atypia at micro-histological examination after core needle biopsy (CNB) performed under sonographic guidance. All patients underwent surgical excision biopsy within 3 months after CNB. All patients underwent MRI examination before surgical excision, including STIR, DWI and Dynamic Contrast-Enhanced sequences.

RESULTS

Mean ADC value difference between PLs without and with atypia or malignant foci was statistically significant (p < 0.0001). Mean ADC value optimal threshold in order to distinguish the two groups was 1.418 × 10^-3 mm²/s. A mean ADC value ≤ 1.418 × 10^-3 mm²/s could predict atypical or malignant foci within a PL with 83.9% sensitivity and 75.8% specificity. No statistically significant difference was found with regard to patients mean age, MRI BI-RADS® descriptors and assessment category between these two PL groups.

CONCLUSIONS

Mean ADC value of PLs without atypia at CNB is an efficient tool in order to help distinguish between PLs without and with atypical or malignant foci at final pathology on surgical excision, and it could be used to help decide how to manage these lesions.

Outcomes of classic lobular neoplasia diagnosed on breast core needle biopsy: a retrospective multi-center study

Management of classic lobular neoplasia (cLN) diagnosed on core needle biopsy (CNB) is controversial. Our aim in this study was to review cases of cLN diagnosed on CNB to determine the rate and risk factors of an upgrade to ductal carcinoma in situ (DCIS) or invasive carcinoma on excision. All breast CNBs with a diagnosis of atypical lobular hyperplasia (ALH) or classic lobular carcinoma in situ (cLCIS) from three different institutions within a single health care system between 2013 and 2018 were retrieved. Cases with any additional high-risk lesions in the same CNB or discordant radiological-pathological correlation were excluded. Information about age, personal history of prior or concurrent breast cancer (P/CBC), and radiological and histological findings were recorded. A total of 287 cLN cases underwent surgical excision. Analysis of these 287 cLN cases showed 11 (3.8%) upgrade lesions on excision. Among the 172 ALH cases, there were 3 (1.7%) upgrades, which were all invasive lobular carcinomas (ILCs). On the other hand, 8 of 115 (7%) cLCIS cases revealed upgrade on excision (2 ILC, 5 DCIS. and 1 ILC + DCIS). Statistical analysis revealed that cLN cases with P/CBC, radiological asymmetry, or architectural distortion had a statistically significant higher upgrade rate on excision. Our findings revealed a low upgrade rate (3.8%) on the excision of classic lobular neoplasia diagnosed on breast core needle biopsy. Clinicoradiological surveillance can be appropriate when lobular neoplasia is identified on core biopsy with pathological radiological concordance in patients without a history of breast cancer, with the caveat that radiological asymmetry and architectural distortion are associated with a significant increase in an upgrade on excision.

Treatment and Outcome of 341 Papillary Breast Lesions

BACKGROUND

Papillary breast lesions constitute a pathological heterogeneous group and display diverse clinical and imaging features. This study was conducted to analyze the upgrade rate of intraductal papilloma diagnosed on core needle biopsy and to assess the possible risk factors associated with upgrade to higher-risk lesions. We also examined the long-term outcomes in patients who received resection of the papillary lesions.

MATERIALS AND METHODS

The clinical and pathology records of 324 female patients who were diagnosed with papillary lesions based on core needle biopsy (CNB) from February 2010 to October 2016 at our institution were retrospectively analyzed. Patients were grouped by initial diagnosis into two groups (papilloma with or without atypia) and followed-up for long-term outcomes. For the upgrade to higher-risk lesions after excision, upgraded lesions were compared with benign papillomas for the collected variables.

RESULTS

A total of 341 lesions were included for final analysis, and all were available for follow-up. Papillomas with or without atypia diagnosed by CNB were found in 9 and 332 lesions, respectively. Papillomas without atypia on CNB were treated by open excision (n = 265) or vacuum-assisted biopsy (VAB) (n = 67), which yielded similar event-free rate (p = 0.19). The upgrade rate of this group to higher-risk lesions was 9.9%. Peripheral (p = 0.011) lesions in postmenopausal (p = 0.001) or older (p = 0.001) patients with papillomas without atypia based on CNB showed significantly higher upgrade rates. Papillomas with atypia on CNB were all managed by open excision, and concurrent malignancy was found in two lesions.

CONCLUSION

In conclusion, our results support benign papillary lesions based on CNB require further treatment. Peripheral lesions occurring in older or postmenopausal women are at higher risk for upgrade.

Management of BIRADS 3, 4A, and 4B Lesions Diagnosed as Pure Papilloma by Ultrasound-Guided Core Needle Biopsy: Is Surgical Excision Necessary?

RATIONALE AND OBJECTIVES

There is lack of consensus on managing papillomas due to varied upgrade rates in the literature related to variability in the studied populations. We specifically studied upgrade rates of pure papilloma diagnosed with ultrasound core biopsy (UCB) using spring-loaded (SLB) and vacuum-assisted (VAB) biopsy devices in patients with low-to-intermediate pre-test probability for malignancy on imaging.

MATERIALS & METHODS

From 01/01/2008 to 06/30/2016, 227 patients with 248 pure papillomas classified as BI-RADS 3, 4a, and 4b were diagnosed by UCB and underwent surgical excision or clinical and/or imaging follow-up. Imaging features, biopsy device, and final pathology were documented.

RESULTS

177 lesions were biopsied with SLB (14-gauge) and 71 lesions with VAB (9-13 gauges). At surgery, upgrade rates to high-risk lesions and malignancy for SLB were 14.3% (22/154) and 1.9% (3/154), and for VAB were 3.5% (2/57) and 0% (0/57), respectively (p < 0.05). The combined surgical upgrade rate to high-risk lesions and malignancy was 11.4% (24/211) and 1.4% (3/211), respectively. The overall upgrade rate (including surgical and clinical and/or imaging follow-up) to high-risk lesions and malignancy was 9.7% (24/248) and 1.2% (3/248), respectively. No ultrasound features were predictive of upgrade. Rates of complete excision were 7.1% (11/154) for SLB and 19.3% (11/57) for VAB (p < 0.05).

CONCLUSION

BI-RADS 3, 4a, or 4b masses biopsied with UCB revealed pure papilloma upgrade to malignancy in less than 2% of cases. SLB was associated with greater upgrades compared with VAB. Therefore, follow-up imaging is a reasonable alternative to excision, particular in those sampled by VAB. Excision could be considered if the diagnosis of a high-risk lesion would change clinical management.

SONOELASTOGRAPHIC FEATURES OF HIGH-RISK BREAST LESIONS AND DUCTAL CARCINOMA IN SITU - A PILOT STUDY

The aim of this study was to evaluate the quantitative sonoelastographic values recorded on shear-wave sonoelastography (SWE) of high-risk breast lesions and ductal carcinoma in situ (DCIS). We retrospectively analyzed histopathologic and SWE data (quantitative maximum, minimum and mean stiffness, lesion-to-fat ratio (E-ratio), lesion size) of 228 women referred to our Department for core needle breast biopsy during a four-year period. Among 230 lesions, histopathologic findings showed 34 high-risk breast lesions and 29 DCIS, which were compared with 167 ductal invasive carcinomas. High-risk lesions had lower values of all sonoelastographic features than ductal in situ and invasive carcinoma, however, only E-ratio showed a statistically significant difference in comparison to DCIS (3.7 vs. 6, p<0.001). All sonoelastographic features showed significant difference between in situ and invasive carcinoma. There was a significant correlation between lesion size and stiffness (r=0.36; p<0.001). Stiffness measured by SWE is an effective predictor of the histopathologic severity of sonographically detectable breast lesions. Elasticity values of high-risk lesions are significantly lower than those of malignant lesions. Furthermore, we showed that along with the sonographic appearance, which in most cases shows typical microcalcifications, DCIS had significantly different elasticity parameters than invasive carcinoma.

Excision recommended in high-risk patients: Revisiting the diagnosis of papilloma on core biopsy in the context of patient risk

We investigate the clinical history, past medical history, and risk status in women with benign intraductal papillomas(IDP). We observed an upgrade rate of 3.9% to ductal carcinoma in situ (DCIS) and upgrade rate of 10.7% to a high-risk lesion. Prior or concurrent atypia or cancer and high-risk status had a significant increase risk of upgrade. Surgical excision of papillomas is recommended especially in high-risk patients and women with concurrent or history of atypia or malignancy.

Management of papillary lesions without atypia of the breast diagnosed on needle biopsy

BACKGROUND

Current surgical practice often leads to excision of all papillary lesions of the breast diagnosed on percutaneous biopsy. This study aims to identify a subset of patients with papillary lesions who may be able to avoid surgery.

METHODS

Between January 2000 and December 2015, 157 cases of papillary lesions with complete surgical excision pathology results were reviewed retrospectively to compare the clinical, imaging and pathology features. Of these, 50 patients with benign papillary lesions without atypia and 19 patients with benign papillary lesions with atypia on needle biopsy were analysed to determine the rate of upgrade to malignancy after surgery.

RESULTS

Of the 50 patients with benign papillary lesions without atypia on biopsy, two (4%) were upgraded to low grade ductal carcinoma in situ after surgical excision. Both these patients had suspicious features on imaging. Of the 19 patients with papillary lesions with atypia diagnosed on needle biopsy, eight (42%) were upgraded to malignancy after surgery. The differences between benign, atypical and malignant papillary lesions were further compared. Malignant lesions were more suspicious radiologically (P = 0.001), more likely to have architectural distortion (P = 0.001), more peripherally located (P = 0.001) and were larger in size (P = 0.01). Patients diagnosed with malignant lesions were also older (P = 0.001).

CONCLUSION

Younger patients diagnosed with small central benign papillary lesions without atypia on needle biopsy, and without suspicious imaging, may be managed conservatively with surveillance.

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

Background

The management of intraductal papilloma without atypia (IDP) in breast needle biopsy remains controversial. This study investigates the upgrade rate of IDP to carcinoma and clinical and radiologic features predictive of an upgrade.

Methods

Patients with a diagnosis of IDP on image-guided (mammography, ultrasound, magnetic resonance imaging) core needle or vacuum-assisted biopsy and surgical excision of this lesion at a certified breast center between 2007 and 2017 were included in this institutional review board-approved retrospective study. Appropriate statistical tests were performed to assess clinical and radiologic characteristics associated with an upgrade to malignancy at excision.

Results

For 60 women with 62 surgically removed IDPs, the upgrade rate to malignancy was 16.1% (10 upgrades, 4 invasive ductal carcinoma, 6 ductal carcinoma in situ). IDPs with upgrade to carcinoma showed a significantly greater distance to the nipple (63.5 vs. 36.8 mm; p = 0.012). No significant associations were found between upgrade to carcinoma and age, menopausal status, lesion size, microcalcifications, BI-RADS descriptors, initial BI-RADS category, and biopsy modality.

Conclusion

The upgrade rate at excision for IDPs diagnosed with needle biopsy was higher than expected according to some guideline recommendations. Observation only might not be appropriate for all patients with IDP, particularly for those with peripheral IDP.

Do clinical and radiologic features help predict malignancy of B3 breast lesions without epithelial atypia (B3a)?

OBJECTIVES

To evaluate excision histology outcome of B3a lesions diagnosed at imaging-guided core biopsy and assess whether clinical and radiologic features may predict upgrade to malignancy.

METHODS

A total of 153 B3a lesions (74 papillomas, 51 radial scars and 28 fibro-epithelial lesions) that underwent surgical excision were assessed. PPV for malignancy in all B3a lesions and specific for each sub-category was evaluated. Multivariate analysis was conducted to identify association between clinical (age, family or personal history of breast cancer, symptoms), diagnostic findings (imaging modality, lesion size, final BI-RADS category) and final excision outcome.

RESULTS

Eleven (7%) of 153 B3a lesions were upgraded to malignancy. All carcinomas diagnosed on excision were non-high grade DCIS. Following features were significantly associated with malignancy: lesions identified only on mammography (3/21; 14%), both mammography and ultrasound (7/44; 16%), lesion size > 10 mm (10/74; 13.5%) and BI-RADS category 4-5 (8/29; 27.6%). The absence of residual microcalcification after biopsy was associated with decreased risk for malignancy (15/16[93.7%]; p = 0.0297). Lesion size > 10 mm (OR = 9.3832; 95%; p = 0.0398) and BI-RADS category 4-5 (OR = 12.6004; 95%; p = 0.0006) were found to be independent predictors of upgrade to malignancy.

CONCLUSIONS

B3a lesions are associated with low risk of malignancy at excision. Lesion size > 10 mm and BI-RADS 4-5 category may represent useful predictors of upgrade to malignancy.

Are we overtreating intraductal papillomas?

BACKGROUND

The management of intraductal papillomas (IDPs) diagnosed on core needle biopsy (CNB) remains controversial regarding whether excision is required. We evaluated whether excision of IDPs might be overtreatment based on a consecutive patient population where all IDPs were routinely excised.

MATERIALS AND METHODS

We retrospectively reviewed the records of consecutive patients treated with excision of IDPs at our institution from 2009 to 2016. We evaluated the rate of upgrade of IDPs on CNB and factors predicting for malignant upgrade.

RESULTS

Of 153 CNB specimens, 136 (88.9%) were IDPs without atypia and 14 (9.2%) showed atypia. The overall upgrade rate on final pathology was 7.3% with 1.3% for invasive cancer, 2.7% for ductal carcinoma in situ, and 3.3% for atypical ductal hyperplasia. Of the 14 patients with atypia on CNB, two of these patients (14.2%) were found to have ductal carcinoma in situ. In the absence of atypia on CNB, upgrade rates were 1.5% for invasive and 1.5% for in situ carcinoma. Personal history of breast cancer and magnetic resonance imaging-guided biopsy predicted for malignant upgrade.

CONCLUSIONS

IDPs on CNB have a low chance of harboring an occult malignancy. Given the low probability of upgrade to invasive breast cancer, it is reasonable to consider watchful surveillance in the absence of a prior personal history of breast cancer or atypia on CNB.

Benign Intraductal Papilloma without Atypia on Core Needle Biopsy Has a Low Rate of Upgrading to Malignancy after Excision

PURPOSE

The management of benign intraductal papilloma (IDP) without atypia diagnosed on core needle biopsy (CNB) remains controversial. This study was performed to evaluate the rate of upgrading to malignancy or high-risk lesions after excision and to identify factors associated with upgrading using a large series of benign IDP cases without atypia.

METHODS

We included patients who were diagnosed as having benign IDP without atypia on CNB and underwent surgical or vacuum-assisted excision between 2010 and 2015. We analyzed the clinical, radiologic, and histopathologic features of IDPs that were upgraded to malignancy or high-risk lesions after excision.

RESULTS

A total of 511 benign IDPs without atypia diagnosed via CNB were identified, of which 398 cases were treated with excision. After reviewing these cases, four cases of high-risk lesions in adjacent tissue on CNB, two cases which were revealed as papilloma with atypia, and nine cases of malignancy in the same breast were excluded. In the remaining 383 cases, the rate of upgrading to malignancy and high-risk lesions after excision was 0.8% and 4.4%, respectively. The presence of concurrent contralateral breast cancer, the presence of symptoms, and multifocality were factors significantly associated with upgrading to malignancy on subsequent excision. Surgical excision rather than vacuum-assisted excision was significantly associated with upgrading to high-risk lesions or malignancy.

CONCLUSION

The rate of upgrading to malignancy for benign IDP without atypia was very low, suggesting that close clinical and radiologic observation may be sufficient for patients with benign IDP without atypia on CNB under proper settings.

Retroareolar masses and intraductal abnormalities detected on screening ultrasound: can biopsy be avoided?

To investigate the malignancy rate of retroareolar masses and intraductal abnormalities discovered in asymptomatic females during screening whole breast ultrasound (US-S) and determine if biopsy can be avoided.

METHODS:

This is a HIPAA compliant retrospective study. Our radiology electronic medical records were searched for the phrases "retroareolar mass" or "intraductal mass" combined with "screening whole breast ultrasound" performed between 10/1/2009 and 5/30/2015. Inclusion criteria included retroareolar masses in asymptomatic females with normal mammography, mammographically dense breast tissue and imaging or biopsy follow-up.

RESULTS:

1136 charts were reviewed. 87 BI-RADS 3 and 4 retroareolar findings were included in final analysis. The average lesion size was 9.5 mm (range 4-28 mm). 47/87 lesions were classified as BI-RADS 3 and 40/87 BI-RADS 4. Of the 47 BI-RADS 3 lesions, 36 were stable on follow-up; 6 benign lesions were biopsied at patients' request; and 5 biopsied due to suspicious interval change on follow-up imaging, including 4 benign lesions and a 5 mm Grade 2 ductal carcinoma in situ . 3/40 BI-RADS 4 lesions were not biopsied and stable at follow-up; 37/40 lesions underwent benign biopsy. The malignancy rate of BI-RADS 3 and 4 lesions was 2.1% [CI (0.4-11.1)] and 0% [CI (0.0-8.8)], respectively. The overall combined malignancy rate was 1/87 [1.1%, CI (0.2-6.2)].

CONCLUSION:

The malignancy rate for BI-RADS 3 and 4 retroareolar masses and intraductal abnormalities detected on US-S is low (<2%).

ADVANCES IN KNOWLEDGE:

Careful imaging surveillance in lieu of biopsy of these lesions may be appropriate in asymptomatic females with negative mammography.

Management of benign papilloma without atypia diagnosed at ultrasound-guided core needle biopsy: Scoring system for predicting malignancy

BACKGROUND

The management of benign intraductal papilloma diagnosed on core needle biopsy (CNB) remains unclear. This study was designed to evaluate factors predicting malignancy in patients diagnosed with benign papilloma without atypia at ultrasound-guided CNB and to develop a scoring system predicting malignancy based on clinical, radiological and pathological factors on further excisional biopsy.

METHODS

The study enrolled patients diagnosed with benign papillomas (including benign and atypical papillary lesions) at CNB. Multivariate analysis was used to identify relevant clinical, radiological and pathological factors that may predict malignancy.

RESULTS

A total of 520 CNBs were diagnosed with benign or atypical papilloma. Of these, 452 were benign papilloma without atypia. Of the 250 lesions subsequently excised surgically from 234 women, 17 (6.8%) were diagnosed with malignancy. Multivariate analysis revealed that bloody nipple discharge, size on imaging ≥15 mm, BI-RADS≥4b, peripheral location and palpability were independent predictors of malignancy. A scoring system was developed based on logistic regression models and beta coefficients for each variable. The area under the ROC curve was 0.947 (95% CI: 0.913-0.981, p < 0.001) and a negative predictive value was 100%. In a validation set of 62 patients, an area under the ROC curve was 0.926 (95% CI: 0.857-0.995, p < 0.001).

CONCLUSIONS

A scoring system predicting malignancy in patients diagnosed by CNB with benign papilloma without atypia was developed. This system was able to identify a subset of patients with lesions likely to be benign, indicating that imaging follow-up rather than surgical excision may be appropriate.

Clinics in diagnostic imaging (180). Ductal carcinoma in situ (DCIS)

A 26-year-old woman presented with a slow-growing right breast lump. Excision biopsy of the lump showed invasive ductal carcinoma with adjacent ductal carcinoma in situ (DCIS). Preoperative imaging was performed to assess the extent of disease. Magnetic resonance (MR) imaging of the breasts showed an area of clustered ring enhancement deep to the biopsy site, which was representative of residual DCIS. DCIS is a common noninvasive malignancy that manifests as a primary breast tumour or in association with other lesions. The radiological features of DCIS are discussed herein, with special attention to the clustered ring enhancement pattern on MR imaging.

Ultrasonographic evaluation of women with pathologic nipple discharge

Nipple discharge is a common symptom that is alarming for the patient since it can be a presenting symptom of breast cancer. Breast imaging is used to examine women with pathologic nipple discharge in order to detect any lesions that may be present and to assist in the differential diagnosis. The modalities of breast imaging include mammography, breast ultrasonography (US), and magnetic resonance imaging. Breast US is currently considered to be useful for the visualization of ductal structures and intraductal lesions that cause nipple discharge. In this review, we discuss US techniques that assist in the clear visualization of ductal structures and intraductal lesions in patients with nipple discharge. Controversy remains regarding the evaluation and management of patients with nipple discharge, and we summarize the results available in the currently published literature.

The Management Strategy of Benign Solitary Intraductal Papilloma on Breast Core Biopsy

BACKGROUND

Intraductal papilloma (IDP) is well-known as one of the common benign breast lesions requiring excision. However, treatment of IDP without atypia is controversial. The aim of our study was to determine the proper management of solitary IDP by core needle biopsy (CNB).

PATIENTS AND METHODS

We retrospectively reviewed patients with solitary IDP confirmed by CNB from March 2003 to March 2015. We collected data about final pathology after excision, as well as clinical, histologic, and radiologic findings at initial diagnosis. The final pathology was categorized as benign or malignant. We evaluated the rate of upgrade to malignancy and factors associated with malignancy.

RESULTS

We identified 405 patients who presented benign solitary IDP by CNB. The mean age was 46.1 years (range, 15-86 years). In total, 135 patients underwent surgical excision, and 211 underwent vacuum-assisted excision. Of 346 patients, malignant lesions were found in 8 patients (2.3%): 7 underwent surgical excision, and 1 underwent vacuum-assisted excision. Only the size of IDP was significantly associated with cancer upgrade (P = .003).

CONCLUSIONS

Our study shows that overall malignancy upgrade rate of benign solitary IDP after excision is very low (2.3%). Even when the size of IDP was less than 1 cm, the upgrade rate to cancer was only 0.9%. Therefore, for patients with small solitary IDP, we recommend close follow-up with ultrasound instead of excision.

Shear-Wave Elastography for the Differential Diagnosis of Breast Papillary Lesions

OBJECTIVE

To evaluate the diagnostic performance of shear-wave elastography (SWE) for the differential diagnosis of breast papillary lesions.

METHODS

This study was an institutional review board-approved retrospective study, with a waiver of informed consent. A total of 79 breast papillary lesions in 71 consecutive women underwent ultrasound and SWE prior to biopsy. Ultrasound features and quantitative SWE parameters were recorded for each lesion. All lesions were surgically excised or excised using an ultrasound-guided vacuum-assisted method. The diagnostic performances of the quantitative SWE parameters were compared using the area under the receiver operating characteristic curve (AUC).

RESULTS

Of the 79 lesions, six (7.6%) were malignant and 12 (15.2%) were atypical. Orientation, margin, and the final BI-RADS ultrasound assessments were significantly different for the papillary lesions (p < 0.05). All qualitative SWE parameters were significantly different (p < 0.05). The AUC values for SWE parameters of benign and atypical or malignant papillary lesions ranged from 0.707 to 0.757 (sensitivity, 44.4-94.4%; specificity, 42.6-88.5%). The maximum elasticity and the mean elasticity showed the highest AUC (0.757) to differentiate papillary lesions.

CONCLUSION

SWE provides additional information for the differential diagnosis of breast papillary lesions. Quantitative SWE features were helpful to differentiate breast papillary lesions.

Management of Clinically and Mammographically Occult Benign Papillary Lesions Diagnosed at Ultrasound-Guided 14-Gauge Breast Core Needle Biopsy

OBJECTIVES

To determine how to manage clinically and mammographically occult benign papillary lesions diagnosed at ultrasound (US)-guided 14-gauge breast core needle biopsy (CNB) by evaluating their upgrade rates.

METHODS

From our pathologic database of US-guided 14-gauge breast CNB, 69 benign papillomas and 9 atypical papillomas with available subsequent excisional findings (surgery or vacuum-assisted removal with additional US follow-up for ≥2 years) or US follow-up alone (≥2 years) were included in this study. We analyzed their upgrade rates by using excisional or US follow-up findings, with no change at 2 years as the reference standard. Patient age, lesion size, lesion distance from the nipple, multiplicity, imaging-histologic concordance, and histologic findings were compared between groups with and without upgrades by statistical analysis.

RESULTS

Surgical excision was performed in 53 (67.9%) of 78 benign papillary lesions and revealed 5 upgrades (11.4%) to atypical papillomas in 44 benign papillomas and 2 upgrades (22.2%) to ductal carcinomas in situ in 9 atypical papillomas. Among 12 benign papillomas (15.4%) with vacuum-assisted removal and US follow-up (≥2 years), 1 (8.3%) was upgraded to atypical papilloma. The remaining 13 benign papillomas (16.7%) were followed with US and were stable after a 2-year follow-up period. There were no significant differences in the variables between the groups.

CONCLUSIONS

Uniform surgical excision is not a reasonable management strategy for clinically and mammographically occult benign papillary lesions diagnosed at US-guided 14-gauge breast CNB. Clinically and mammographically occult benign papillary lesions may be subsequently managed by vacuum-assisted removal or imaging follow-up if atypia is not found.

Practical Considerations in Breast Papillary Lesions: A Review of the Literature

Context.—Diagnosis of papillary breast lesions, especially in core biopsies, is challenging for most pathologists, and these lesions pose problems for patient management. Distinction between benign, premalignant, and malignant components of papillary lesions is challenging, and the diagnosis of invasion is problematic in lesions that have circumscribed margins. Obtaining a balance between overtreatment and undertreatment of these lesions is also challenging.

Objectives.—To provide a classification and a description of the histologic and immunohistochemical features and the differential diagnosis of papillary breast lesions, to provide an update on the molecular pathology of papillary breast lesions, and to discuss the recommendations for further investigation and management of papillary breast lesions. This review provides a concise description of the histologic and immunohistochemical features of the different papillary lesions of the breast.

Data Sources.—The standard pathology text books on breast pathology and literature on papillary breast lesions were reviewed with the assistance of the PubMed database (http://www.ncbi.nlm.nih.gov/pubmed).

Conclusions.—Knowledge of the clinical presentation, histology, immunoprofile, and behavior of papillary breast lesions will assist pathologists with the diagnosis and optimal management of patients with papillary breast lesions.

Short-term follow-up in 6 months is unnecessary for asymptomatic breast lesions with benign concordant results obtained at ultrasonography-guided 14-gauge core needle biopsy

BACKGROUND

We investigated whether short-term follow-up in 6 months was appropriate for asymptomatic benign concordant lesions on ultrasonography-guided core needle biopsy (ultrasonography-guided CNB).

METHODS

Of 1,111 lesions, 944 underwent follow-up within 4 to 9 months after CNB, and 359 of 944 underwent a 2nd follow-up within 9 to 15 months. One hundred sixty-seven underwent a 1st follow-up within 9 to 15 months. Follow-up intervals were classified according to an interval of 6 and 12 months with 2 different methods. First, 944 and 167 lesions were classified into the 6- and 12-month groups. Second, 944 and 526 lesions (sum of 167 and 359 lesions) were classified into the 6- and 12-month groups. Clinicopathologic factors were compared between the 2 groups.

RESULTS

None of the benign concordant lesions were malignant; 1.4% of the lesions showed progression in the 6-month group, not significantly different from 1.2% and .8% of the 12-month group. Mean age, mean lesion size, final assessments, and specific or nonspecific pathologies were not different between the 2 groups.

CONCLUSIONS

Short-term follow-up in 6 months is unnecessary for asymptomatic benign concordant breast lesions at ultrasonography-guided CNB.