Surgical excision versus clinical follow-up: Outcomes of benign intraductal papillomas diagnosed on core needle biopsy

OBJECTIVE

To compare outcomes between benign intraductal papillomas diagnosed on core need biopsy that were excised (BIP-E) versus those that were followed-up (BIP-F) at our institution.

METHODS

Patients were identified by an electronic data base search from January 2010 to October 2016. After exclusions, clinical, radiological and histologic variables were evaluated and biopsy and excision slides reviewed.

RESULTS

110 BIP from 104 females were analyzed. 84 BIP were excised and 26 BIP were followed up (mean 43.3 months, range 7-93 months).11 patients in BIP-E group had atypia on excision. There were no statistically significant differences between BIP-E with atypia and BIP-E without, except for clinical presentation with pain/discomfort (p ​= ​0.015) in the former. There were no true upgrades to malignancy in both groups on follow up. One patient from each group developed a new breast cancer distant from IP site after nearly 4 years of uneventful follow-up.

CONCLUSION

Clinical follow up is an oncologically safe alternative for radiologically concordant BIP. Excision may be considered if a diagnosis of atypia would impact surveillence and chemoprevention recommendations.

Distance of Biopsy-Confirmed High-Risk Breast Lesion from Concurrently Identified Breast Malignancy Associated with Risk of Carcinoma at the High-Risk Lesion Site

High-risk breast lesions including incidental intraductal papilloma without atypia (IPA), lobular hyperplasia (LCIS or ALH), flat epithelial atypia (FEA) and complex sclerosing lesion (CSL) are not routinely excised due to low upgrade rates to carcinoma. We aim to identify features of these lesions predictive of upgrade when identified concurrently with invasive disease. Methods: A single-center retrospective cohort study was performed for patients who underwent multi-site lumpectomies with invasive disease at one site and a high-risk lesion at another site between 2006 and 2021. A multinomial logistic regression was performed. Results: Sixty-five patients met the inclusion criteria. Four patients (6.2%) had an upgrade to in situ disease (DCIS) and one (1.5%) to invasive carcinoma. Three upgraded high-risk lesions were ipsilateral to the concurrent carcinoma and two were contralateral. In the multivariate model, a high-risk lesion within 5 cm of an ipsilateral malignancy was associated with increased risk of upgrade. The 3.8% upgrade rate for high-risk lesions located greater than 5 cm from ipsilateral malignancy or in the contralateral breast suggests that omission of excisional biopsy may be considered. Excisional biopsy of lesions within 5 cm of ipsilateral malignancy is recommended given the 25% upgrade risk in our series.

European guidelines for the diagnosis, treatment and follow-up of breast lesions with uncertain malignant potential (B3 lesions) developed jointly by EUSOMA, EUSOBI, ESP (BWG) and ESSO

INTRODUCTION

Breast lesions of uncertain malignant potential (B3) include atypical ductal and lobular hyperplasias, lobular carcinoma in situ, flat epithelial atypia, papillary lesions, radial scars and fibroepithelial lesions as well as other rare miscellaneous lesions. They are challenging to categorise histologically, requiring specialist training and multidisciplinary input. They may coexist with in situ or invasive breast cancer (BC) and increase the risk of subsequent BC development. Management should focus on adequate classification and management whilst avoiding overtreatment. The aim of these guidelines is to provide updated information regarding the diagnosis and management of B3 lesions, according to updated literature review evidence.

METHODS

These guidelines provide practical recommendations which can be applied in clinical practice which include recommendation grade and level of evidence. All sections were written according to an updated literature review and discussed at a consensus meeting. Critical appraisal by the expert writing committee adhered to the 23 items in the international Appraisal of Guidelines, Research and Evaluation (AGREE) tool.

RESULTS

Recommendations for further management after core-needle biopsy (CNB) or vacuum-assisted biopsy (VAB) diagnosis of a B3 lesion reported in this guideline, vary depending on the presence of atypia, size of lesion, sampling size, and patient preferences. After CNB or VAB, the option of vacuum-assisted excision or surgical excision should be evaluated by a multidisciplinary team and shared decision-making with the patient is crucial for personalizing further treatment. De-escalation of surgical intervention for B3 breast lesions is ongoing, and the inclusion of vacuum-assisted excision (VAE) will decrease the need for surgical intervention in further approaches. Communication with patients may be different according to histological diagnosis, presence or absence of atypia, or risk of upgrade due to discordant imaging. Written information resources to help patients understand these issues alongside with verbal communication is recommended. Lifestyle interventions have a significant impact on BC incidence so lifestyle interventions need to be suggested to women at increased BC risk as a result of a diagnosis of a B3 lesion.

CONCLUSIONS

These guidelines provide a state-of-the-art overview of the diagnosis, management and prognosis of B3 lesions in modern multidisciplinary breast practice.

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.

Differential Diagnosis of Benign and Malignant Breast Papillary Neoplasms on MRI With Non-mass Enhancement

RATIONALE AND OBJECTIVES

To explore the differential diagnosis of benign and malignant papillary neoplasms on MRI with non-mass enhancement.

MATERIALS AND METHODS

A total of 48 patients with surgically confirmed papillary neoplasms showing non-mass enhancement were included. Clinical findings, mammography and MRI features were retrospectively analyzed, and lesions were described according to the breast imaging report and data system (BI-RADS). Multivariate analysis of variance was used to compare the clinical and imaging features of benign and malignant lesions.

RESULTS

Fifty-three papillary neoplasms were shown on MR images with non-mass enhancement, including 33 intraductal papilloma and 20 papillary carcinomas (9 intraductal papillary carcinoma, 6 solid papillary carcinomas, and 5 invasive papillary carcinoma). Mammography showed amorphous calcification in 20% (6/30), of which 4 were in papilloma and 2 were in papillary carcinoma. On MRI, papilloma mostly showed linear distribution in 54.55% (18/33), clumped enhancement in 36.36% (12/33). Papillary carcinoma showed segmental distribution in 50% (10/20), clustered ring enhancement in 75% (15/20). ANOVA showed age (p = 0.025), clinical symptoms (p < 0.001), apparent diffusion coefficient (ADC) value (p = 0.026), distribution pattern (p = 0.029) and internal enhancement pattern (p < 0.001) were statistically significant between benign and malignant of papillary neoplasms. Multivariate analysis of variance suggested that the internal enhancement pattern was the only statistically significant factor (p = 0.010).

CONCLUSIONS

Papillary carcinoma on MRI with non-mass enhancement mostly showed internal clustered ring enhancement, while papilloma mostly showed internal clumped enhancement; additional mammography is of limited diagnostic value, and suspected calcification occurs mostly in papilloma.

Selective surgical excision of high-risk lesions

Intraductal papilloma, flat epithelial atypia, radial scar, atypical lobular hyperplasia, and lobular carcinoma in situ have historically been referred to as high-risk lesions and managed with routine surgical excision after diagnosis on core needle biopsy. The misnomer high-risk stems from high rates of upgrade to malignancy reported in historic literature. However, recent studies have found much lower upgrade rates, <2%, than previously thought. These findings are explained by advances in imaging technology, larger-bore biopsy needles, and emphasis on radiology-pathology concordance. Concordant lesions have a low upgrade risk and can be managed with radiographic and clinical surveillance instead of surgical excision. Surgical de-escalation is feasible for many of these lesions with careful multidisciplinary review and a detailed risk-benefit discussion with patients.

The diagnostic value of contrast-enhanced ultrasonography in breast ductal abnormalities

BACKGROUND

Ductal lesions are an important, often overlooked, and poorly understood issue in breast imaging, which have a risk of underlying malignancy ranging from 5 to 23%. Ultrasonography (US), which has largely replaced galactography or ductography, has become an important imaging method to assess patients with ductal lesions. However, it is difficult to distinguish benign from malignant ductal abnormalities only by ultrasonography, most of which are recommended to be at least in subcategory 4A; these require biopsy according to the ACR BI-RADS®atlas 5th Edition-breast ultrasound. Contrast-enhanced ultrasound (CEUS) has been shown to be valuable for differentiating benign from malignant tumors, but its value is unclear in breast ductal lesions. Therefore, the purposes of this study were to explore the characteristics of malignant ductal abnormalities on US and CEUS imaging and the diagnostic value of CEUS in breast ductal abnormalities.

METHODS

Overall, 82 patients with 82 suspicious ductal lesions were recruited for this prospective study. They were divided into benign and malignant groups according to the pathological results. Morphologic features and quantitative parameters of US and CEUS were analyzed by comparison and multivariate logistic regression to determine the independent risk factors. The diagnostic performance was assessed by receiver operating characteristic (ROC) curve analysis.

RESULTS

Shape, margin, inner echo, size, microcalcification and blood flow classification on US, wash-in time, enhancement intensity, enhancement mode, enhancement scope, blood perfusion defects, peripheral high enhancement and boundary on CEUS were identified as features correlated with malignant ductal lesions. However, multivariate logistic regression showed that only microcalcification (OR = 8.96, P = 0.047) and enhancement scope (enlarged, OR = 27.42, P = 0.018) were independent risk factors for predicting malignant ductal lesions. The sensitivity, specificity, positive predictive value, negative predictive value, accuracy and area under the ROC curve of microcalcifications combined with an enlarged enhancement scope were 0.895, 0.886, 0.872, 0.907, 0.890, and 0.92, respectively.

CONCLUSIONS

Microcalcification and enlarged enhancement scope are independent factors for predicting malignant ductal lesions. The combined diagnosis can greatly improve the diagnostic performance, indicating that CEUS can be useful in the differentiation of benign and malignant lesions to formulate more appropriate management for ductal lesions.

High-Risk Lesion Management

High-risk lesions or lesions of uncertain malignant potential are frequent findings on image-guided needle biopsy of the breast and comprise a number of distinct entities. These lesions are known for having risk of underlying malignancy and are usually associated with an increased lifetime risk for breast cancer. Surgical excision was traditionally recommended for all high-risk lesions but recent studies have demonstrated that vacuum-assisted excision or surveillance may be adequate for some lesions. While management of high-risk lesion varies among institutions, this chapter describes the management recommendations based on recent literature of the most frequent types of lesions.

Nipple Discharge Imaging Evaluation with Mammography, Ultrasound, Galactography, and MRI

RATIONALE AND OBJECTIVE

To determine the diagnostic yield of various imaging tests used to evaluate nipple discharge.

MATERIALS AND METHODS

A single institution, IRB-approved, retrospective study was performed of 320 consecutive patients presenting with nipple discharge. Imaging and pathology were reviewed to determine the yield for malignancy, atypical high-risk lesions (HRLs), and intraductal papillomas (IDPs).

RESULTS

Of the 320 patients, pathology or follow up confirmed 40 breast malignancies (40/320, 12.5%),14 atypical HRLs (14/320, 4.4%), 71 IDPs (71/320, 22.2%), 48 other benign pathologies (48/320,15.0%), and 147 unknown but benign cases (147/320, 45.9%). Physiologic discharge characteristics were observed in a minority of malignant cases: nonspontaneous (4/40, 10.0%); neither bloody nor clear (4/40, 10.0%); bilateral (3/40, 7.5%). Malignancy was associated with older age (p < 0.001) and bloody discharge (odds ratio 6.5, p < 0.0001). The combination of digital mammography and ultrasound had a 93% sensitivity and a 98% NPV, while contrast enhanced MRI (CE-MRI) had a 100% sensitivity and a 100% NPV for malignancy. Only three galactography examinations were performed among the malignant cohort, with minimal contribution (1 of 3) to the diagnostic evaluation. In this case, galactography findings helped determine imaging-pathology discordance, prompting a recommendation for surgical excision and subsequently a malignant diagnosis.

CONCLUSION

The combination of mammography and ultrasonography detected 93% of breast malignancies associated with nipple discharge and had a 98% NPV for malignancy. The value of CE-MRI is its ability to detect the remaining malignancies, not detected on mammography or ultrasound, and its ability to obviate the need for surgical duct excision.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

PURPOSE

To assess the percentage of papillomas from all biopsies performed, comparing differences in patient age and race at a single institution. To assess trends in biopsied papillomas at institutions throughout the United States (US).

METHODS

This is a HIPPA-compliant IRB-approved single-institution (Southern1) retrospective review to assess race and age of all-modality-biopsied non-malignant papillomas as a percentage of all biopsies (percentage papillomas calculated as papilloma biopsies/all biopsies) from January 2012 to December 2019. To assess national variation, several academic or large referral centers were contacted to provide data regarding papilloma percentages, biopsy modalities, and trends in case numbers. Trends were estimated using the method of analysis of variance (ANOVA). Comparisons of differences in trends were assessed.

RESULTS

Southern1 institution demonstrated a significant association between race and percentage of papillomas (p < 0.0001). After adjustment for multiple comparisons with Bonferroni correction at 5% type I family error, the percentage of biopsied papillomas in Black and Asian patients remained significantly higher than in White patients (p < 0.0001 and p = 0.0032, respectively) using a Chi-square test. The regional variation in percentage of papillomas was found to be 3-9%. Southern1 institution showed a 7-year significant trend of increase in percentage of papillomas. Other institutions showed a decreasing trend (p < 0.05).

CONCLUSION

Black and Asian women had significantly higher papilloma percentages compared to white patients in our single institution review. This institution also showed a statistically significant trend of increasing percentage papillomas from 2012 to 2019. Multi-institutional survey found regional variation in percentage papillomas, ranging from 3% to 9%.

Comparison of vacuum-assisted excision (VAE) and breast lesion excision system (BLES) in the treatment of intraductal papillomas

PURPOSE

This study aims to compare the feasibility of VAE and BLES in the treatment of intraductal papillomas.

MATERIAL AND METHODS

Patients with a suspected intraductal papilloma who underwent a BLES or a VAE procedure were included in this retrospective study. The BLES procedures were performed between November 2011 and June 2016 and the VAE procedures between May 2018 and September 2020 at the Department of Radiology of Helsinki University Hospital (HUH). The procedures were performed with an intent of complete removal of the lesions.

RESULTS

In total, 72 patients underwent 78 BLES procedures and 95 patients underwent 99 VAE procedures. Altogether 52 (60%) papillomas with or without atypia were completely removed with VAE, whereas 24 (46%) were completely removed with BLES, p = 0.115. The median radiological size of the high-risk lesions completely removed with BLES was 6 mm (4-12 mm), whereas with VAE it was 8 mm (3-22 mm), p = 0.016. Surgery was omitted in 90 (94.7%) non-malignant breast lesions treated with VAE and in 66 (90.4%) treated with BLES, p = 0.368.

CONCLUSION

Both VAE and BLES were feasible in the treatment of intraductal papillomas. In most non-malignant lesions surgery was avoided, but VAE was feasible in larger lesions than BLES. However, follow-up ultrasound was needed more often after VAE. The histopathologic assessment is more reliable after BLES, as the lesion is removed as a single sample.

Efficacy and Safety of Vacuum-Assisted Excision for Benign Breast Mass Lesion: A Meta-Analysis

Background and Objective: Breast mass lesions are common; however, determining the malignant potential of the lesion can be ambiguous. Recently, to evaluate breast mass lesions, vacuum-assisted excision (VAE) biopsy has been widely used for both diagnostic and therapeutic purposes. This study aimed to investigate the therapeutic role of VAE. Materials and Methods: Relevant articles were obtained by searching PubMed and EMBASE on 3 September 2021. Meta-analyses were performed using odds ratios and proportions. To assess heterogeneity, we conducted a subgroup analysis and meta-regression tests. Results: Finally, 26 studies comprising 18,170 patients were included. All of these were observational studies. The meta-analysis showed that the complete resection rate of VAE was 0.930. In the meta-regression test, there was no significant difference. The meta-analysis showed a recurrence rate of 0.039 in the VAE group. The meta-regression test showed no statistical significance. Postoperative hematoma, pain, and ecchymosis after VAE were 0.092, 0.082, and 0.075, respectively. Conclusion: VAE for benign breast lesions showed favorable outcomes with respect to complete resection and complications. This meta-analysis suggested that VAE for low-risk benign breast lesions is a reasonable option for both diagnostic and therapeutic purposes.

Image-guided Microinvasive Percutaneous Treatment of Breast Lesions: Where Do We Stand?

Treatment of breast lesions has evolved toward the use of less-invasive or minimally invasive techniques. Minimally invasive treatments destroy focal groups of cells without surgery; hence, less anesthesia is required, better cosmetic outcomes are achieved because of minimal (if any) scarring, and recovery times are shorter. These techniques include cryoablation, radiofrequency ablation, microwave ablation, high-intensity focused US, laser therapy, vacuum-assisted excision, and irreversible electroporation. Each modality involves the use of different mechanisms and requires specific considerations for application. To date, only cryoablation and vacuum-assisted excision have received U.S. Food and Drug Administration approval for treatment of fibroadenomas and have been implemented as part of the treatment algorithm by the American Society of Breast Surgeons. Several clinical studies on this topic have been performed on outcomes in patients with breast cancer who were treated with these techniques. The results are promising, with more data for radiofrequency ablation and cryoablation available than for other minimally invasive methods for treatment of early-stage breast cancer. Clinical decisions should be made on a case-by-case basis, according to the availability of the technique. MRI is the most effective imaging modality for postprocedural follow-up, with the pattern of enhancement differentiating residual or recurrent disease from postprocedural changes. ^©RSNA, 2021.

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.

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

BACKGROUND

The optimal management of intraductal papillomas (IPs) without atypia diagnosed on needle core biopsy (NCB) is unclear. This study analyzed the malignancy risk of immediately excised IPs and characterized the behavior of IPs under active surveillance (AS).

METHODS

We retrospectively reviewed the pathology and imaging records of patients diagnosed with IPs without atypia on NCB during a 10-year period (1999-2019). The malignancy upgrade rate was assessed in patients who had an immediate surgical excision, and the rates of both radiographic progression and development of malignancy were assessed in a cohort of patients undergoing AS.

RESULTS

The inclusion criteria were met in 152 patients with 175 IPs with a mean age of 51 ± 13 years. The average size of the IPs on initial imaging was 8 ± 4 mm. Most of the lesions (57%, n = 99) were immediately excised, whereas 76 (43%) underwent AS with interval imaging with a median follow-up period of 15 months (range, 5-111 months). Among the immediately excised IPs, surgical pathology revealed benign findings in 97% (n = 96) and ductal carcinoma in situ in 3% (n = 3). In the AS cohort, 72% (n = 55) of the IPs remained stable, and 25% (n = 19) resolved or decreased in size. At 2 years, 4% had increased in size on imaging and were subsequently excised, with ductal carcinoma in situ (DCIS, n = 1) and benign pathology (n = 1) noted on final pathology.

CONCLUSIONS

In a large series of breast IPs without atypia, no invasive carcinoma was observed after immediate excision, and 96% of the lesions had not progressed on AS. This suggests that patients with IP shown on NCB can safely undergo AS, with surgery reserved for radiographic lesion progression.

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

Papillary neoplasms of the breast are a heterogeneous group of epithelial tumors nearly entirely composed of papillae. Their classification rests on the characteristics of the epithelium and the presence and distribution of the myoepithelial cells along the papillae and around the tumor. Papillary neoplasms of the breast can be diagnostically challenging, especially if only core needle biopsy (CNB) material is available. This review summarizes salient morphological and immunohistochemical features, clinical presentation, and differential diagnoses of papillary neoplasms of the breast. We include a contemporary appraisal of the upgrade rate to carcinoma (invasive carcinoma and ductal carcinoma in situ [DCIS]) and atypical hyperplasias in surgical excision specimens obtained following CNB diagnosis of papilloma without atypia, and a review of the available follow-up data in cases without immediate surgical excision.

Management of High-Risk Breast Lesions

High-risk breast lesions (HRLs) are a group of heterogeneous lesions that can be associated with a synchronous or adjacent breast cancer and that confer an elevated lifetime risk of breast cancer. Management of HRLs after core needle biopsy may include close imaging and clinical follow-up or excisional biopsy to evaluate for cancer. This article reviews histologic features and clinical presentation of each of the HRLs, current evidence with regard to management, and guidelines from the American Society of Breast Surgeons and National Comprehensive Cancer Network. In addition, imaging surveillance and risk-reduction strategies for women with HRLs are discussed.

Benign Breast Intraductal Papillomas Without Atypia at Core Needle Biopsies: Is Surgical Excision Necessary?

PURPOSE

The aim of this study was to determine the upgrade rate of image-guided core needle biopsy (CNB)-proven benign breast intraductal papillomas (IDPs) without atypia to high-risk benign lesions or malignancy after surgical excision.

METHODS

A retrospective database search at a single institution identified 102 adult female patients with benign breast IDPs without atypia diagnosed on imaging-guided CNBs who subsequently had surgical excisions between 2011 and 2016. Patient characteristics, imaging features, biopsy techniques, and the pathology reports from imaging-guided CNBs and subsequent surgical excisions were reviewed. The upgrade rate to malignancies or high-risk benign lesions was determined at the patient level.

RESULTS

The upgrade rate to malignancy was 2.9% (3/102), including two cases of ductal carcinoma in situ (DCIS) and one case of microinvasive (< 1 mm) ductal carcinoma arising from DCIS. The upgrade rate to high-risk benign lesions was 7.8% (8/102), with seven cases of atypical ductal hyperplasia and one case of atypical lobular hyperplasia. A personal history of breast cancer and a larger mean lesion size were significantly associated with an upgrade to malignancy (p < 0.05).

CONCLUSIONS

The management of benign breast IDPs without atypia detected on imaging-guided CNBs is controversial. Our results suggest risk stratification is important in approaching these patients. Although surgical excision should be considered for all benign breast IDPs without atypia, observation with serial imaging may be appropriate in selected low-risk patients. This approach will save many women from surgeries and decrease the cost of medical care.

Benign breast papillomas without atypia diagnosed with core needle biopsy: Outcome of surgical excision and imaging follow-up

PURPOSE

To evaluate the surgical upgrade rate to malignancy and high-risk lesions in cases of papilloma without atypia diagnosed with imaging-guided percutaneous core needle biopsy (CNB) and to determine whether any lesion imaging features, biopsy techniques, and pathological factors can predict lesion upgrade to help guide clinical management.

MATERIALS AND METHODS

Benign papillomas without atypia (n = 399) diagnosed with CNB were retrospectively reviewed. The surgical upgrade rate to malignancy or high-risk lesion (atypical ductal hyperplasia, atypical lobular hyperplasia, lobular carcinoma in-situ, flat epithelial atypia and atypical papilloma) was determined. Detection modality (i.e. mammography, ultrasonography (US), magnetic resonance imaging (MRI)), lesion type and size, biopsy-guidance modality (US, stereotactic, MRI), biopsy needle size (<14 G vs ≥14 G), use of vacuum assistance, and presenting symptoms were statistically analyzed. The reference standard for evaluation of upgrade was either excision or at least 24 months of imaging follow-up. Chi Square test and Fisher exact tests were performed for categorical variables, and the Mann-Whitney-U test was used for continuous variables.

RESULTS

Ultrasound was the predominant biopsy modality (78.4 %, p < 0.001). Of the 399 benign papilloma lesions in 329 women, 239 (59.9 %) were excised and 93 others were followed for at least 24 months (total of 332). Of these 332 lesions, 7 (2.1 %) were upgraded to ductal carcinoma in-situ and 41 (12.3 %) to high-risk lesions at excision. Larger lesion size (≥15 mm, p = 0.009), smaller biopsy needle size (≥14 G, p = 0.027), and use of spring-loaded biopsy device (p = 0.012) were significantly associated with upgrade to atypia. Only lesion size (≥15 mm, p = 0.02) was associated with upgrade to cancer.

CONCLUSION

Upgrade to malignancy of biopsy-proven benign papillomas without atypia at the time of surgery was sufficiently low (2.1 %) to support non-operative management. Surgery may be performed for selected cases- those with larger lesion size and those whose biopsies were performed with smaller spring-loaded biopsy needles.

Multimodality approach to the nipple-areolar complex: a pictorial review and diagnostic algorithm

The anatomic and histologic characteristics of the nipple-areolar complex make this breast region special. The nipple-areolar complex can be affected by abnormal development and a wide spectrum of pathological conditions, many of which have unspecific clinical and radiological presentations that can present a challenge for radiologists. The nipple-areolar complex requires a specific imaging workup in which a multimodal approach is essential. Radiologists need to know the different imaging modalities used to study the nipple-areolar complex, as well as their advantages and limitations. It is essential to get acquainted with the acquisition technique for each modality and the spectrum of findings for the different conditions. This review describes and illustrates a combined clinical and radiological approach to evaluate the nipple-areolar complex, emphasizing the findings for the normal morphology, developmental abnormalities, and the most common benign and malignant diseases that can affect this region. We also present a diagnostic algorithm that enables a rapid, practical approach to diagnosing condition involving the nipple-areolar complex.

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.