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

Abstract

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.

Keywords

breast papillary upgrade papilloma carcinoma

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References

Tay

TKY

Tan

. Papillary neoplasms of the breast-reviewing the spectrum. Mod Pathol. 2021;34(6):1044-1061.

Jacobs

Connolly

Schnitt

. Nonmalignant lesions in breast core needle biopsies: to excise or not to excise? Am J Surg Pathol. 2002;26(9):1095-1110.

Pareja

Corben

Brennan

, et al. Breast intraductal papillomas without atypia in radiologic-pathologic concordant core-needle biopsies: rate of upgrade to carcinoma at excision. Cancer. 2016;122(18):2819-2827.

Tatarian

Sokas

Rufail

, et al.

Intraductal papilloma with benign pathology on breast core biopsy: to excise or not?

Ann Surg Oncol. 2016;23(8):2501-2507.

Tan

Chen

Chan

. Surgical excision of intraductal breast papilloma diagnosed on core biopsy. ANZ J Surg. 2012;82(3):168-172.

Chang

Moon

Cho

, et al. Risk of carcinoma after subsequent excision of benign papilloma initially diagnosed with an ultrasound (US)-guided 14-gauge core needle biopsy: a prospective observational study. Eur Radiol. 2010;20(5):1093-1100.

Jaffer

Nagi

Bleiweiss

. Excision is indicated for intraductal papilloma of the breast diagnosed on core needle biopsy. Cancer. 2009;115(13):2837-2843.

Rizzo

Lund

Oprea

Schniederjan

Wood

Mosunjac

. Surgical follow-up and clinical presentation of 142 breast papillary lesions diagnosed by ultrasound-guided core-needle biopsy. Ann Surg Oncol. 2008;15(4):1040-1047.

Sydnor

Wilson

Hijaz

Massey

de Paredes ES

. Underestimation of the presence of breast carcinoma in papillary lesions initially diagnosed at core-needle biopsy. Radiology. 2007;242(1):58-62.

10.

Mercado

Hamele-Bena

Oken

Singer

Cangiarella

. Papillary lesions of the breast at percutaneous core-needle biopsy. Radiology. 2006;238(3):801-808.

11.

Shiino

Tsuda

Yoshida

, et al. Intraductal papillomas on core biopsy can be upgraded to malignancy on subsequent excisional biopsy regardless of the presence of atypical features. Pathol Int. 2015;65(6):293-300.

12.

Tseng

Chen

, et al. The management of papillary lesion of the breast by core needle biopsy. Eur J Surg Oncol. 2009;35(1):21-24.

13.

Kang

Park

, et al. The management strategy of benign solitary intraductal papilloma on breast core biopsy. Clin Breast Cancer. 2017;17(5):367-372.

14.

Nasehi

Sturgis

Sharma

Turk

Calhoun

. Breast cancer risk associated with benign intraductal papillomas initially diagnosed on core needle biopsy. Clin Breast Cancer. 2018;18(6):468-473.

15.

Kiran

Jeong

Nelson

, et al.

Are we overtreating intraductal papillomas?

J Surg Res. 2018;231:387-394. doi:10.1016/j.jss.2018.06.008

16.

Ivan

Selinko

Sahin

Sneige

Middleton

. Accuracy of core needle biopsy diagnosis in assessing papillary breast lesions: histologic predictors of malignancy. Mod Pathol. 2004;17(2):165-171.

17.

Agoff

Lawton

. Papillary lesions of the breast with and without atypical ductal hyperplasia: Can we accurately predict benign behavior from core needle biopsy? Am J Clin Pathol. 2004;122(3):440-443.

18.

Grimm

Bookhout

Bentley

Jordan

Lawton

. Concordant, non-atypical breast papillomas do not require surgical excision: a 10-year multi-institution study and review of the literature. Clin Imaging. 2018;51:180-185. doi:10.1016/j.clinimag.2018.04.021

19.

Douglas-Jones

Verghese

. Diagnostic difficulty arising from displaced epithelium after core biopsy in intracystic papillary lesions of the breast. J Clin Pathol. 2002;55(10):780-783.

20.

Shamonki

Chung

Huynh

Sim

Kinnaird

Giuliano

. Management of papillary lesions of the breast: can larger core needle biopsy samples identify patients who may avoid surgical excision? Ann Surg Oncol. 2013;20(13):4137-4144.

21.

Ahmadiyeh

Stoleru

Raza

Lester

Golshan

. Management of intraductal papillomas of the breast: an analysis of 129 cases and their outcome. Ann Surg Oncol. 2009;16(8):2264-2269.

22.

Arora

Hill

Hoda

Rosenblatt

Pigalarga

Tousimis

. Clinicopathologic features of papillary lesions on core needle biopsy of the breast predictive of malignancy. Am J Surg. 2007;194(4):444-449.

23.

Cheng

Chen

Lee

, et al. Risk factors associated with conversion from nonmalignant to malignant diagnosis after surgical excision of breast papillary lesions. Ann Surg Oncol. 2009;16(12):3375-3379.

24.

Lin

Ozerdem

Cotzia

, et al. Upgrade rate of intraductal papilloma diagnosed on core needle biopsy in a single institution. Hum Pathol. 2021;110:43-49. doi:10.1016/j.humpath.2020.10.012

25.

Park

Yoon

Lee

Kang

Hur

. Factors associated with disease upgrading in patients with papillary breast lesion in core-needle biopsy. Gland Surg. 2020;9(4):919-924.

26.

Ahn

Han

Moon

, et al. Management of benign papilloma without atypia diagnosed at ultrasound-guided core needle biopsy: scoring system for predicting malignancy. Eur J Surg Oncol. 2018;44(1):53-58.

27.

Moseley

Desai

Whitman

, et al.

Benign breast intraductal papillomas without atypia at core needle biopsies: is surgical excision necessary?

Ann Surg Oncol. 2021;28(3):1347-1355.

28.

Kil

Cho

Kim

Nam

Yang

. Is surgical excision necessary in benign papillary lesions initially diagnosed at core biopsy? Breast. 2008;17(3):258-262.

29.

Glenn

Throckmorton

Thomison

3rd Bienkowski

. Papillomas of the breast 15 mm or smaller: 4-year experience in a community-based dedicated breast imaging clinic. Ann Surg Oncol. 2015;22(4):1133-1139.

30.

Nakhlis

Ahmadiyeh

Lester

Raza

Lotfi

Golshan

. Papilloma on core biopsy: excision vs. Observation. Ann Surg Oncol. 2015;22(5):1479-1482.

31.

Chen

Hong

, et al. Papillary breast lesions diagnosed by core biopsy require complete excision. Eur J Surg Oncol. 2012;38(11):1029-1035.

32.

Lewis

Hartmann

Vierkant

, et al. An analysis of breast cancer risk in women with single, multiple, and atypical papilloma. Am J Surg Pathol. 2006;30(6):665-672.

33.

MacGrogan

Tavassoli

. Central atypical papillomas of the breast: a clinicopathological study of 119 cases. Virchows Arch. 2003;443(5):609-617.

34.

Kim

Lee

, et al.

Asymptomatic benign papilloma without atypia diagnosed at ultrasonography-guided 14-gauge core needle biopsy: which subgroup can be managed by observation?

Ann Surg Oncol. 2016;23(6):1860-1866.

35.

Youk

Kim

Kwak

Son

Park

Kim

. Benign papilloma without atypia diagnosed at US-guided 14-gauge core-needle biopsy: clinical and US features predictive of upgrade to malignancy. Radiology. 2011;258(1):81-88.

36.

Chang

Han

Moon

, et al. Papillary lesions initially diagnosed at ultrasound-guided vacuum-assisted breast biopsy: rate of malignancy based on subsequent surgical excision. Ann Surg Oncol. 2011;18(9):2506-2514.

37.

Shin

Kim

, et al. Papillary lesions of the breast diagnosed at percutaneous sonographically guided biopsy: comparison of sonographic features and biopsy methods. AJR Am J Roentgenol. 2008;190(3):630-636.

38.

Holley

Appleton

Farria

, et al. Pathologic outcomes of nonmalignant papillary breast lesions diagnosed at imaging-guided core needle biopsy. Radiology. 2012;265(2):379-384.

39.

Jung

Kang

Kwon

, et al. Risk factors for malignancy in benign papillomas of the breast on core needle biopsy. World J Surg. 2010;34(2):261-265.

40.

Chen

Zhou

Wang

Pan

Zhu

. Treatment and outcome of 341 papillary breast lesions. World J Surg. 2019;43(10):2477-2482.

41.

Kuehner

Darbinian

Habel

, et al. Benign papillary breast mass lesions: favorable outcomes with surgical excision or imaging surveillance. Ann Surg Oncol. 2019;26(6):1695-1703.