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

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.

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.

Audit on Intraductal Papilloma of the Breast: Upgrade Rate, Management Pitfalls, and Updated Guidelines in a Tertiary Health Care Center

Background

Intraductal papillomas (IDPs) are typically classified as B3 lesions in histology as they may show intralesional heterogeneity with a potential upgrade to malignancy. On core needle biopsy (CNB), a distinction between papilloma versus papillary ductal carcinoma in situ (DCIS) may be difficult. It is well known that otherwise benign papillomas may harbor foci of atypical ductal hyperplasia or DCIS. In this study, we aimed to calculate the radiological (mammogram and ultrasound) accuracy of IDP and to analyze the accuracy of CNB to diagnose IDP. Furthermore, we calculated the percentage of upgrade to malignancy after surgical excision. Any case that had a co-existing in-situ or invasive carcinoma during surgical excision was considered as an “upgrade” to malignancy. Finally, we analyzed the current management protocol for IDP in the institution and suggested changes, if needed.

Methodology

This is a retrospective cross-sectional study. A total of 112 cases diagnosed as IDP radiologically and/or by histopathology over a one-year time frame were included. A retrospective analysis of the accuracy of the radiological diagnosis was done by comparing it with CNB and/or surgical excision biopsy reports. The number of cases diagnosed with a co-existing in-situ or invasive carcinoma was calculated. This was considered as an “upgrade” from a B3 lesion in CNB to carcinoma in surgical excision. Current institutional management protocols were evaluated and compared with international benchmarks.

Results

Out of the 112 cases, 91 were suspected to be papilloma by imaging. The remaining 21 cases who were positive for papilloma on biopsy but were not diagnosed radiologically were also studied separately. Among the biopsied patients, eight were positive for IDP with atypia in CNB. Five out of these eight cases had an in-situ or invasive component during the surgical excision, with one invasive lobular carcinoma, three lobular carcinomas in situ, and one DCIS on surgical excision histopathology. The upgrade percentage was calculated to be 22.72%.

Conclusions

Due to the large upgrade potential of IDP, it is recommended to biopsy every radiologically suspected lesion and excise pathology-proved lesions. If the biopsy shows papilloma without atypia, vacuum excision is sufficient; otherwise, surgical excision with a clearance of margins is advocated. Annual mammograms/surveillance is recommended for biopsy-proven cases. IDP has a high upgrade potential, and, hence, care should be taken to biopsy suspicious lesions. An excision of biopsy-proven lesions must be done.

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

BACKGROUND

Current standard management for intraductal papilloma (IDP) diagnosed at biopsy indicates complete surgical resection, but there are increasing controversies over whether and when routine excision is indeed necessary.

OBJECTIVE

The aim of this study was to determine the carcinoma upgrade rate and identify the associated predictive factors for IDP diagnosed at biopsy by meta-analysis.

METHODS

We searched the PubMed and EMBASE databases for studies published from 2009 to 2020 that investigated the upgrade rate and predictive factors of IDP diagnosed at biopsy.

RESULTS

A total of 7016 IDP cases diagnosed at biopsy and histologically examined after surgical excision were pooled from 44 original studies. The pooled prevalence of IDP in breast biopsy findings was 4.6% [95% confidence interval (CI) 4.4-4.7%] and the majority of IDP tumors were benign. The pooled upgrade rates to carcinoma for benign IDP and atypical IDP were 5.0% (95% CI 4.4-5.5%) and 36.0% (95% CI 32.7-39.2%), respectively. In addition, we identified 10 predictive upgrade factors for benign IDP, including Breast Imaging Reporting and Data System (BI-RADS) 5, BI-RADS 4C, mass and calcification in the mammographic finding, bloody nipple discharge, imaging-histological discordance, peripheral IDP, palpable mass, BI-RADS 4B, microcalcification, and lesion size ≥ 1 cm. The upgrade rates associated with these predictive factors ranged from 7.3 to 31.1%.

CONCLUSION

Surgical excision appears a reasonable recommendation for atypical IDP. Patients with benign IDP exhibiting one or more predictive factors might benefit from surgical excision, while patients with asymptomatic benign IDP without these predictive factors can be managed by imaging surveillance.

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.

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.

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.

Risk factors of breast intraductal lesions in patients without pathological nipple discharge

The majority of breast cancer arises from the ductal epithelium. It is crucial in the diagnosis and treatment of breast cancer by detecting intraductal lesions at an early stage. The typical clinical characteristic of intraductal lesions is pathological nipple discharge (PND), although many patients with intraductal lesions do not exhibit PND. It is a serious challenge for clinicians to detect patients with intraductal lesions without PND at an early stage. The aim of the present study was to investigate the risk factors associated with intraductal lesions in patients without PND. This retrospective database review, conducted between April 2016 and April 2017, included 370 lesions from 255 patients with intraductal lesions (intraductal papilloma, atypical intraductal hyperplasia, intraductal carcinoma in situ) and non-intraductal lesions (fibroadenoma, adenosis, cysts, lobular carcinoma in situ), diagnosed through surgical pathology. The patients were divided into two groups based on pathological diagnosis and clinical parameters were evaluated using univariate and multivariate analyses. Univariate analysis revealed that 9 of 14 factors were statistically significant. Five factors were identified to be associated risk factors in patients without PND through the multivariate logistic regression analysis: Age between 35 and 49 years and age ≥50 years [odds ratio (OR)=4.749, 95% confidence interval (CI)=2.371-9.513, P<0.001; OR=2.587, 95% CI=2.587-14.891, P<0.001; respectively], non-menstrual breast pain (OR=1.922, 95% CI=1.037-3.564, P=0.038), breast duct dilatation as seen using ultrasonography (OR=9.455, 95% CI=3.194-27.987, P<0.001), lesion distance from nipple ≤2 cm (OR=2.747, 95% CI=1.668-4.526, P<0.001) and lesion size ≤1 cm (OR=1.903, 95% CI=1.155-3.136, P=0.012). In conclusion, for patients without PND but with risk factors, such as the patient being >35 years, with non-menstrual breast pain, breast duct ectasia, lesion distance from nipple ≤2 cm and lesion size ≤1 cm as seen using ultrasonography, clinicians should be highly concerned about the possibility of intraductal lesions, in order to prevent misdiagnosis and reduce the misdiagnosis rate.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

Papilloma diagnosed on core biopsies has a low upgrade rate

CONTEXT

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

OBJECTIVE

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

DESIGN

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

RESULTS

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

CONCLUSIONS

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

Papillary breast lesions diagnosed by percutaneous needle biopsy: management approach

Papillary breast lesions are a heterogeneous group of neoplasms of diverse imagenological, clinical and morphological presentation that display different behaviour, prognosis and, therefore, controversial diagnosis and management. The aim of this study is to propose an algorithm for the management of mammary lesions.

A case of giant complicated intraductal papilloma of breast on MRI and literature review

BACKGROUND

With the increasing use of image-guided biopsy, more breast intraductal papillomas are found than ever. Most intraductal papillomas are small, ranging from several milimeters to 2 cm.

CASE

We described a case of giant intraductal papilloma of breast in a 19-year-old girl with nipple bloody discharge and rapid growth. Magnetic resonance imaging diagnostic evaluation and pathologic correlation along with review of relevant literatures are documented. The lesion was characterized by presence of mixture of cystic and solid component with cystic component occupying a large space. The solid component showed morphologic, kinetic, and diffusion weighted imaging features suggestive of malignancy. Infarction with no enhancement was noted. Cystic compartments contained hemorrhage with fluid-fluid level formation. The patient undertook lumpectomy.

CONCLUSION

For a giant breast tumor with mixed solid and cystic component, intraductal papilloma should be considered in the differential diagnosis.

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.

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.

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.

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.

Breast intraductal papillomas without atypia in radiologic-pathologic concordant core-needle biopsies: Rate of upgrade to carcinoma at excision

BACKGROUND

The surgical management of mammary intraductal papilloma without atypia (IDP) identified at core-needle biopsy (CNB) is controversial. This study assessed the rate of upgrade to carcinoma at surgical excision (EXC).

METHODS

This study identified women with a CNB diagnosis of intraductal papilloma without atypia or carcinoma at a cancer center between 2003 and 2013. Radiologic-pathologic concordance was assessed for all cases, and discordant cases were excluded. The radiologic and clinicopathologic features of patients with a CNB diagnosis of IDP were correlated with an upgrade to carcinoma at EXC.

RESULTS

The study population consists of 189 women with 196 IDPs; 166 women (171 IDPs) underwent EXC. The upgrade rate was 2.3% (4 of 171). The upgraded lesions were 2 invasive lobular carcinomas and 2 cases of ductal carcinoma in situ (DCIS). One case of DCIS involved the residual IDP, whereas the other 3 carcinomas were ≥ 8 mm away. Twenty-four women (25 IDPs) did not undergo EXC and had stable imaging on follow-up (median, 23.5 months).

CONCLUSIONS

The upgrade rate at EXC for IDPs diagnosed at CNB with radiologic-pathologic concordance was 2.3%. These findings suggest that observation is appropriate for patients with radiologic-pathologic concordant CNB yielding IDP, regardless of its size. Cancer 2016. © 2016 American Cancer Society. Cancer 2016;122:2819-2827. © 2016 American Cancer Society.

A Molecular View of Pathological Microcalcification in Breast Cancer

Breast microcalcification is a potential diagnostic indicator for non-palpable breast cancers. Microcalcification type I (calcium oxalate) is restricted to benign tissue, whereas type II (calcium hydroxyapatite) occurs both in benign as well as in malignant lesions. Microcalcification is a pathological complication of the mammary gland. Over the past few decades, much attention has been paid to exploit this property, which forms the basis for advances in diagnostic procedures and imaging techniques. The mechanism of its formation is still poorly understood. Hence, in this paper, we have attempted to address the molecular mechanism of microcalcification in breast cancer. The central theme of this communication is "how a subpopulation of heterogeneous breast tumor cells attains an osteoblast-like phenotype, and what activities drive the process of pathophysiological microcalcification, especially at the invasive or infiltrating front of breast tumors". The role of bone morphogenetic proteins (BMPs) and tumor associated macrophages (TAMs) along with epithelial to mesenchymal transition (EMT) in manipulating this pathological process has been highlighted. Therefore, this review offers a novel insight into the mechanism underlying the development of microcalcification in breast carcinomas.

The Diagnostic Value of Micropure Imaging in Breast Suspicious Microcalcificaion

RATIONALE AND OBJECTIVES

The purpose of this study was to evaluate the diagnostic value of Micropure Imaging (MI) in breast lesions differentiation by comparison with B-mode ultrasonography (B-US) and Doppler ultrasonography (DU).

MATERIALS AND METHODS

A total of 135 consecutive patients (all females) with 135 suspicious lesions were examined and skin marked by MI before mammotome biopsies. All patients (age range, 20-86 years; mean age, 42.5 ± 15.6 years) were the first onset, not in the pregnancy or lactation and had no history of radiation or chemotherapy. The maximum diameter of lesions ranged from 0.2 to 9.6 cm (average 1.98 ± 1.3 cm). Their final diagnoses were obtained by histologic examination. The study protocol was approved by the hospital review board; each patient gave written informed consent.

RESULTS

One hundred thirty-five breast lesions were classified into 90 nonmalignant and 45 malignant types. To 86 breast lesions with microcalcification, MI showed more microcalcification and coincided better with pathology results than B-US did (P < .05). The specificity of MI was higher than that of B-US and DU; the sensitivity of DU was significantly higher than that of B-US and MI (P < .001). By combining B-US, DU, and MI, the detection accuracy was 86.7%. Receiver-operator characteristic curves showed the area under the curve of B-US, DU, and MI was 0.865, 0.934, and 0.923(P = .000), respectively. Moreover, the interobserver agreements of MI were the highest, 0.922 (observer 1 vs. observer 2), 0.866 (observer 1 vs. observer 3), and 0.916 (observer 2 vs. observer 3).

CONCLUSIONS

MI as an adjunct ultrasound modality holds some promise in locating and differentiating breast lesions.

Collagen Type XI Alpha 1 Expression in Intraductal Papillomas Predicts Malignant Recurrence

Despite the progress achieved in the treatment of breast cancer, there are still many unsolved clinical issues, being the diagnosis, prognosis, and treatment of papillary diseases, one of the highest challenges. Because of its unpredictable clinical behavior, treatment of intraductal papilloma has generated a great controversy. Even though considered as a benign lesion, it presents high rate of malignant recurrence. This is the reason why there are clinicians supporting a complete excision of the lesion, while others support an only expectant follow-up. Previous results of our group suggested that procollagen 11 alpha 1 (pro-COL11A1) expression correlates with infiltrating phenotype in breast lesions. We analyzed the correlation between expression of pro-COL11A1 in intraductal papilloma and their risk of malignant recurrence. Immunohistochemistry of pro-COL11A1 was performed in 62 samples of intraductal papilloma. Ten out 11 cases relapsed as carcinoma presents positive staining for COL11A1, while just 17 out of 51 cases with benign behaviour present immunostaining. There were significant differences (P < 0.0001) when comparing patients with malignant recurrence versus nonmalignant relapse patients. These data suggest that pro-COL11A1 expression is a highly sensitive biomarker to predict malignant relapse of intraductal papilloma and it can be used as indicative factor for prevention programs.

Outcomes of benign breast papillomas diagnosed at image-guided vacuum-assisted core needle biopsy

PURPOSE

To determine the upgrade rate of benign papillomas diagnosed at image-guided vacuum-assisted core needle biopsy (VACNB) and to compare our results with the summarized literature.

MATERIALS AND METHODS

A database search was performed to identify patients older than 18 years of age with benign papillomas diagnosed at VACNB between 2004 and 2013. A total of 199 papillomas in 184 patients were identified. Clinical, imaging, and pathological features for each were analyzed. Patients who were subsequently diagnosed with malignancy at the site of papilloma, either at surgical excision or upon imaging follow-up, were compared with those not upgraded. Upgrade was defined as a diagnosis of invasive carcinoma or ductal carcinoma in situ (DCIS).

RESULTS

Of 199 papillomas, 110 (55.3%) were diagnosed at ultrasound-guided VACNB, 78 (39.2%) were diagnosed at stereotactic-guided VACNB, and 11 (5.5%) were diagnosed at magnetic resonance imaging-guided VACNB. Surgical excision was performed for 89 (44.7%), and the remaining 110 (55.3%) underwent imaging follow-up. Two patients were subsequently diagnosed with invasive carcinoma and 4 were found with DCIS. The upgrade rate across both groups was 3% (6 of 199). Masses with calcifications (P=.001) and smaller needle gauge at VACNB (P=.02) had a significant association with upgrade.

CONCLUSION

Benign papillomas diagnosed with VACNB demonstrated a 3% upgrade rate to malignancy, which is similar to the 2.9% upgrade rate calculated by compiling applicable published literature. Conservative management with imaging follow-up as opposed to surgical excision may be appropriate in cases where an initial diagnosis of benign papilloma is made with VACNB. Benign papillomas associated with calcifications on imaging should be considered for surgical excision given their increased association with malignancy.

Papillomas of the breast 15 mm or smaller: 4-year experience in a community-based dedicated breast imaging clinic

PURPOSE

To determine the significance of small, often mammographically occult and asymptomatic papillomas of the breast 15 mm and smaller.

METHODS

Four-year retrospective review of papillomas of the breast in a community-based dedicated breast imaging center, with a selected cohort of 179 papillomas 15 mm or smaller in 147 patients, all completing image-guided core biopsy followed by surgical excision.

RESULTS

Of 179 papillomas 15 mm or smaller, 36 % were abnormal (24 % atypia; 12 % cancer). Twenty-one percent had a surgical upgrade diagnosis. One hundred forty-six benign papillomas by core biopsy yielded 7 (4.7 %) cancers and 25 (17 %) atypias (atypical ductal hyperplasia (ADH), atypical lobular hyperplasia (ALH), or lobular carcinoma-in situ) at surgical excision. Seven of 34 (14 %) of very small papillomas (5 mm or smaller) showed cancer. Twelve of 72 (11 %) and 8 of 36 (13 %) papillomas showed cancer in normal-risk and high-risk patients, respectively. Increasing age (70+ years) associated strongly with increasing risk of papillomas with cancer (10 of 35, 29 %). Thirteen unsuspected papillomas in 10 patients with new nonpapillary breast cancers yielded 3 atypias and 3 additional cancers, changing surgical management in half of these patients. Breast ultrasound identified 44 % of papillomas as incidental findings, all mammographically occult and asymptomatic.

CONCLUSIONS

There is no size threshold below which a papilloma of the breast can be safely watched or ignored without risking a missed diagnosis of atypia or cancer. Identification of papillomas in patients with new nonpapillary breast cancers can change patient management in up to half of these patients. Finally, breast ultrasound significantly enhances identification of unsuspected papillomas.

Completely removing solitary intraductal papillomas using the Mammotome system guided by ultrasonography is feasible and safe

BACKGROUND

Because of the potential for an intraductal papilloma to progress to malignancy and the likelihood of detecting unexpected coexisting malignant disease, complete removal of the intraductal papilloma is safer than merely sampling it. The purpose of this study was to estimate the feasibility and safety of excising a solitary intraductal papilloma using the Mammotome system guided by ultrasonography (US).

METHODS

We retrospectively reviewed the clinical information of 136 patients who underwent excision of solitary intraductal papillomas using the 8-gauge probe with the US-guided Mammotome system between December 2005 and December 2011 at our institution. Their lesions had been suspected preoperatively or were occasionally diagnosed postoperatively.

RESULTS

There were no local recurrences during the follow-up period. Of the patients who showed atypia and underwent re-excision, only 2 (6.1 %) had local ductal atypia. The patients with atypia were significantly older than the patients without atypia (p < 0.05).

CONCLUSIONS

Using the US-guided 8-gauge probe Mammotome system to completely remove a solitary intraductal papilloma is feasible and safe. Close follow-up may be considered for those whose lesions exhibit atypia.

Follow-up of breast papillary lesion on core needle biopsy: experience in African-American population

Background

The optimal course of clinical follow-up after a diagnosis of breast papillary lesion on a core needle biopsy (CNB) remains elusive. In particular, no reports in literature have addressed this question in African-American population. We describe our experience with breast papillary lesions in a primarily African-American population.

Methods

A search of our database for breast papillary lesions diagnosed on CNB between September 2002 and September 2012 was conducted. Cases were categorized into benign, atypical, and malignant. CK5/6 and CK903 stains were performed when necessary.

Results

A total of 64 breast papillary lesions were diagnosed on CNB, including 55 (86%) benign papillary lesions, 6 (9%) atypical lesions, and 3 (5%) intraductal papillary carcinomas. Of these 64 patients, 29 patients (25 African-Americans, 3 Hispanics, 1 Asian American) underwent lumpectomy within 6 months after CNB. Pathology of the lumpectomy showed: five of the 25 (20%) benign papillary lesions on needle biopsy were upgraded to intraductal or invasive papillary carcinoma; 2 of the 3 atypical papillary lesion cases on core biopsy were upgraded (67%), one into intraductal papillary carcinoma, the other invasive papillary carcinoma; the only case of malignant papillary lesion on CNB remained as intraductal papillary carcinoma on lumpectomy. The rate of upgrade in lumpectomy/mastectomy was 25%. CK5/6 and CK903 immunostains were performed on all seven core needle biopsies that were later upgraded.

Conclusions

In our predominantly African-American urban population, 25% of benign or atypical papillary lesions diagnosed on CNB was upgraded in the final excisional examination. Early excision of all papillary lesions diagnosed on CNB may be justified in this patient population.

Virtual Slides

The virtual slide(s) for this article can be found here: http://www.diagnosticpathology.diagnomx.eu/vs/7950117821177201

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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