Papillary Lesions of the Breast

Background: Papillary breast lesions (PBL) include a wide spectrum of lesions and can be benign, with atypia or malignant. They correspond to up to 5% of breast biopsies, but their incidence has increased in recent years, mainly due to technical improvements in percutaneous biopsies and the greater use of breast ultrasound. Many studies have been published about the management of PBL identified in biopsies and underdiagnosis rates may vary in the literature. In the presence of atypia, a high rate of underdiagnosis is observed, therefore, complete excision of the lesion is recommended. On the other hand, papillary lesions without atypia identified on core needle biopsy (CNB) remain without consensus regarding management. Objective: To verify the underestimation (atypia and carcinoma) in ultrasound-guided CNB of papillary breast lesions, after undergoing surgical excision. Furthermore, to verify the clinical and radiological characteristics associated with upgrade. Method: Retrospective study, through analysis of medical records of 56 patients with papillary breast lesions identified on ultrasound-guided CNB and subsequently undergoing surgical excision of the lesion, between 2007 and 2020, in the Mastology service at Escola Paulista de Medicina - Unifesp (Sao Paulo - Brazil). Results: Among the 59 lesions considered for the study, of which 40.7% were cases of papillary lesions with atypia, 39% were papillary lesions without atypia and 20.3% were intraductal papillomas, we identified 52.5% (95%CI: 39.1% to 65.7%) of underdiagnosis without distinct percentages by biopsy classification (p=0.295), by characteristics (p>0.05), as well as differences in mean age (p=0.186) and size of the lesion (p=0.196). Univariate and multivariate logistic regression models were applied, but none of the characteristics proved to be significant, even after excluding the variables one by one in order of significance (backward method). Considering only the underdiagnosis of ductal carcinoma in situ (DCIS) or invasive carcinoma, a rate of 32.2% (95%CI: 20.6% to 45.6%) was observed, being 54.2% (95%CI: 32.8% to 74.4%) among papillary lesions with atypia, 26.2% (95%CI: 10.2% to 48.4%) among papillary lesions without atypia and no cases among pure intraductal papillomas. Univariate and multivariate logistic regression models were applied and remained in the final model, the variables age (p=0.022) and normal physical examination (p=0.049). Thus, a 1-year increase in age leads to an increase in 6% chance of underdiagnosis for cancer, adjusted by physical examination. In addition, patients with normal physical examination have an 83% lower chance of underdiagnosis for cancer than patients with changes in physical examination. Conclusions: This study showed a high rate of underdiagnosis among papillary lesions obtained on CNB and did not identify associated clinical or radiological characteristics. Considering only the underdiagnosis of DCIS or invasive carcinoma, it was identified that the patient's increasing age and the presence of changes in physical examination as predictive factors for underdiagnosis. Therefore, it is concluded that excision of papillary lesions identified in CNB should be considered, given the risk of underdiagnosis not only of carcinoma, but also of atypia. Citation Format: Renata Puccini, Vanessa Sanvido, Angela Waitzberg, Gil Facina, Afonso Nazario. Underestimation in core-needle biopsies of papillary breast lesions: a retrospective cohort from a university center [abstract]. In: Proceedings of the San Antonio Breast Cancer Symposium 2024; 2024 Dec 10-13; San Antonio, TX. Philadelphia (PA): AACR; Clin Cancer Res 2025;31(12 Suppl):Abstract nr P1-10-09.

We aimed to investigate the magnetic resonance imaging (MRI) features of benign, atypical, or malignant papillary breast lesions and to assess the additional value of diffusion-weighted imaging (DWI) and turbo inversion recovery magnitude (TIRM) sequences to routine breast MRI. 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. 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: 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. Benign papillary lesions were smaller in size (p=0.006 and p=0.005, for radiologists 1 and 2 respectively), closer to the 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 the 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). 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.

-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. -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. -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 ). -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.

Context:Diagnosis of papillary lesions of the breast by fine needle aspiration cytology (FNAC) is problematic. For this reason, it is situated in the indeterminate zone in classification systems.Aims:To ascertain the accuracy of cytological diagnosis of papillary lesions in distinguishing papillary lesions from non-papillary lesions and to determine whether papillomas can be reliably distinguished from malignant papillary lesions by FNAC.Material and Methods:A total of 346 cases with the diagnoses of breast papillary lesions were selected among 5112 breast FNAC procedures performed in our center. One hundred and thirty-nine cases with excised lesions were included in this study, and their corresponding histology was reviewed.Results:Papillary lesion diagnosis was confirmed by histopathology in 103 (74.1%) of 139 patients. Cytology and histopathology results were not found to be compatible in 35 (25.2%) cases. The diagnostic accuracy of distinguishing papillary breast lesions as malignant or benign was assessed statistically. According to the cytology–histology comparison, one case was evaluated as false negative (FN) and twelve cases as false positive (FP). Overall accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of FNAC in distinguishing papillary lesions as benign or malignant were calculated as 87%, 97%, 83%, 72%, and 98%, respectively.Conclusions:The diagnostic accuracy of papillary breast lesions classified by FNAC might be improved by careful evaluation together with cytological, radiological, and clinical findings (triple test). Cell block may allow more accurate evaluation of the papillary lesion and can be applied to immunohistochemical examination. It may also facilitate the differentiation of benign/malignant papillary lesions.

Papillary breast lesions diagnosed by core biopsy require complete excision

IntroductionPapillary breast lesions are segregated into benign and malignant based on the presence or absence of myoepithelial cells in the papillary cores. Papillary breast lesions are further classified into: intraductal papilloma, papilloma with atypical ductal hyperplasia (ADH)/ductal carcinoma in situ (DCIS), papillary DCIS, solid papillary carcinoma in situ, solid papillary carcinoma with invasion, invasive solid papillary carcinoma, encapsulated papillary carcinoma and encapsulated papillary carcinoma with invasion. In this study, we evaluated the spectrum of papillary breast lesions in resection specimens of the breast according to the latest World Health Organization (WHO) classification of breast tumors.MethodsThis was a retrospective cross-sectional study, and was conducted at Liaquat National Hospital for a period of six years, from January 2012 till December 2017. Data of patients that underwent surgeries for breast tumors were included in the study. All specimens were grossed, according to defined protocols, and representative sections were taken after inking resection margins. Hematoxylin and eosin-stained sections were examined by experienced histopathologists, and myoepithelial stains (p63 and myosin) were done in selected sections of all tumors. Histopathological classification of papillary tumors was performed according to WHO classification of breast tumors.ResultsThe study involved 190 excision specimens of papillary breast lesions. Mean age of the patients was 45.6±17.1 years. Most of the lesions were between two and five centimetres (69.1%). For invasive carcinomas (n = 76), the most frequent grade was II (52.6%). For in situ and invasive carcinomas (n = 129), lymphovascular invasion and axillary metastasis were noted in 5.4% and 9.3% cases, respectively. Among papillary breast lesions, 36.8% were benign (intraductal papilloma, solitary or multiple) while 63.2% harbored ADH, DCIS, or invasive carcinoma. Invasive papillary carcinoma was the most frequent malignant papillary lesion (20%), followed by solid papillary carcinoma with invasion (12.6%). We found significant associations between patient’s age and tumor size with histological type of papillary lesion as benign papillary lesions had smaller size and younger age compared to malignant papillary lesions.ConclusionWe noted a high frequency of malignancy in papillary breast lesions. Moreover, malignant papillary lesions were significantly associated with higher age and larger tumor size.

Papillary breast tumors are rare breast tumors. Presentation of papillary breast lesions varies clinically and radiologically. Standard diagnostic work-up for papillary breast lesions includes various radiological modalities such as mammography, galactography, ultrasound and MRI. Papillary lesions often have a wide spectrum of appearance on different radiological modalities, so that optimal differentiation of papillary lesions is not easy with various imaging methods. The purpose of this review article is to describe the different imaging appearances of benign and malignant papillary lesions of the breast with special emphasis on atypical appearances. Keywords: Breast, magnetic resonance imaging, mammography, papillary lesions, ultrasound.

To analyze the multi-parametric ultrasonographic (MpUS) features of atypical/malignant papillary lesions of the breast with clinical information, identify independent risk factors, and construct a nomogram to improve the diagnostic accuracy. This retrospective study analyzed consecutively hospitalized patients diagnosed with pathologically confirmed papillary breast lesions from January 2017 to June 2023. Preoperative sonographic examinations, including gray-scale ultrasound (G-US), color Doppler flow imaging (CDFI), and contrast-enhanced ultrasound (CEUS), were conducted. Sonographic scans were retrospectively reviewed alongside clinicopathological data. Binary logistic regression identified independent risk factors for screening atypical/malignant papillary lesions. The receiver operating characteristic curve evaluated the predictive accuracy of these lesions, resulting in the development of a nomogram for assessing risk. The study involved 176 female patients with breast papillary lesions, identifying key predictors for atypical or malignant outcomes: age 57 or order, US diameter ≥13.95 mm, resistive index ≥0.70, enlarged enhancement on CEUS, and contrast agent retention, with respective odds ratios of 6.279, 8.078, 9.246, 9.401, and 5.047. The integrated use of G-US, CDFI, and CEUS in the MpUS approach offered higher diagnostic accuracy (area under the curve [AUC]: 0.966) than G-US or CDFI alone (0.869/0.918). CEUS particularly enhanced prediction for non-mass-like lesions, with a positive predictive value of 83.3%. A nomogram incorporating MpUS and patient age achieved an AUC of 0.956 for predicting atypical or malignant papillary lesions. MpUS imaging is highly effective for predicting malignant breast papillary lesions, especially considering patient age. The nomogram offers an intuitive framework for assessing malignant risk in these lesions. Ultrasound excels in identifying papillary lesions, and integrating diverse data and multi-parametric imaging enhances malignant risk evaluation. This study establishes a predictive risk model using the nomogram method, demonstrating heightened diagnostic efficacy in breast papillary lesions.

We aimed to estimate the upgrading rate of core-needle biopsy (CNB)-diagnosed papillary breast lesions to atypical or malignant papillary lesions on subsequent surgery. We performed a retrospective review of medical records and imaging findings of patients diagnosed by CNB as having papillary lesions from January 1, 2005 to May 31, 2011. Outcomes were determined by pathology findings from surgical excision or by imaging findings at 12 months follow-up. Of 130 papillary lesions in 127 patients, the upgrading rates were 0% for benign papillary lesion to malignancy, 19% for benign papillary lesion to atypical papillary lesion, and 31% for atypical lesion to malignancy. Most of the malignancies were ductal carcinoma in situ. The presence of malignant lesions was related to specific symptoms (palpable mass or nipple discharge; P = 0.020) and to a higher Breast Imaging Reporting and Data System (BIRADS) category (P = 0.017). CNB is accurate in the diagnosis of benign papillary lesions. If no atypical cells are present, no malignancy is found. The presence of atypia on CNB strongly indicates a need for surgical excision.

Biopsia percutánea con aguja gruesa en lesiones papilares mamarias: impacto en el manejo de pacientes

Papillary lesions of the breast diagnosed by core needle biopsy: 71 cases with surgical follow-up

Lesiones papilares intraductales mamarias: nuestra experiencia 2007-2017

Objective: The purpose of this study was to determine the accuracy of the pathologic diagnosis of papillary breast lesions when evaluated by percutaneous biopsy. Materials and Methods: A total of 2307 consecutive breast lesions, diagnosed by percutaneous biopsy, were retrospectively reviewed. Of these, 45 lesions were papillary lesions; 15 of the 45 cases were lost to follow-up or had not had imaging follow-up and were excluded. The remaining 30 papillary lesions constituted the study population. Subsequent surgical excision or imaging follow-up (a minimum of 6 months) was performed and correlated with the initial diagnoses. Results: Of the 30 lesions, 11 intraductal papillomas were diagnosed with stereotactic vacuum assisted biopsy (SVAB). Surgical excision was performed on four lesions (36.4%). Pathologic findings in all four lesions (100%) were benign. Of the 13 papillary lesions diagnosed with ultrasound-guided core needle biopsy, three (23.1%) demonstrated papillomatosis. Subsequent surgical excision was performed on 11 (84.6%) of the 13 papillary lesions, including two of the three papillomatosis. Pathology was benign in all. The two (18.2%) other lesions, initially diagnosed as papillomatosis and benign papilloma, were a fibroadenoma and organizing papillomatosis, respectively, at surgery. The six lesions that were sampled with fine needle aspiration (FNA) demonstrated intraductal papillary lesions, two (33.3%) of which had cytologic atypia. Surgical excision was performed on all six (100%) with benign breast tissue in four (66.7%) including one of the lesions demonstrating atypia. The two (33.3%) other lesions demonstrated high-grade invasive papillary carcinoma with in-situ components. Conclusion: Surgical excision is warranted when a percutaneous breast biopsy demonstrates a papillary lesion with atypia or when there is radiologic-pathologic discordance. Otherwise, these lesions can be followed conservatively. Furthermore, for improved diagnostic accuracy, indeterminate intraductal lesions should undergo biopsy with CNB or stereotactic vacuum assisted biopsy and not fine needle aspiration. The cytologic diagnosis of papillary lesions is considered only preliminary by fine needle aspiration, and should await surgical resection and histologic examination to further classify these lesions.

To identify features which determine the papillary nature of breast lesions by contrast-enhanced ultrasound (CEUS) based on morphological and pathological correlations, and predict which papillomas are malignant. A retrospective review of 47 papillary lesions and 51 hypervascular benign abnormalities was performed. Enhancement patterns and diagnostic performance of CEUS were assessed. The most frequent finding in papillary lesions was perilesional linear ductal enhancement (87.2%) followed by heterogeneous enhancement (80.9%), and the presence of perfusion defects (66%). Among all CEUS morphological descriptors, a perilesional linear ductal enhancement pattern was the most effective feature to discriminate between papillary and hypervascular benign lesions. Using this criterion, the positive and negative predictive value for papilloma were 100% and 89.5%, respectively. A perilesional linear ductal pattern correlated with a ductal origin. The distinctive features associated with atypical or malignant papillomas were non-confluent enhancement, late overall wash-out, the presence of regional perfusion defect, clumped vascular pattern, and the presence of peripheral radial or penetrating vessels. The sensitivity, specificity, and positive and negative predictive values for predicting malignancy were 91.7%, 82.6%, 84.6% and 90.5%, respectively. CEUS provided characteristic enhancement patterns which could be helpful for identifying papillary lesions and for predicting potentially malignant papillomas. Papillary breast lesions display a characteristic appearance on CEUS. Adding CEUS to conventional US helps identify the papillary nature of papillomas. CEUS may be helpful for predicting potential malignancies among papillomas.

Introduction: The management of benign intraductal papillary (IDP) lesions is controversial. Radiological and clinical findings alone cannot distinguish benign or malignant IDPs. Surgical excision of IDPs diagnosed by core or vacuum assisted biopsies was the standard of practice. There is an increasing body of literature suggesting that observation may suffice. Design: This study investigated upgrade rates of benign IDPs on surgical excision. A listing of all cases where the pathology report included Papillary or papilloma was obtained after IRB approval. The upgrade rate on excised lesions and the association of IDPs with atypia and malignancy were assessed. Clinical and radiological presentations of papillary lesions was obtained from the medical records. We also reviewed recently published data on the subject for comparison. Results: We reviewed 65 pathology reports of IDPs diagnosed at our institution between 2011-2014. Papillary lesions were stratified in to three categories: benign, associated with atypia and associated with malignancy. Upgrade rates on surgical excision of benign IDPs diagnosed with core biopsy was calculated. Of the 65 papillary lesions 67.7% were benign, 10.8% were associated with atypia, and 21.5% were associated with malignancy. The upgrade rate on 28 excised benign IDPs was 7.14%. A review of 15 studies published between 2011-14 on IDPs shows an average upgrade rate of 17% in the routine excision group versus 2% in the observation group. Intraductal Papillomas and upgrade rates on excision Upgrade rate(%) in the routine excision studiesUpgrade rates(%) in the observation group 190 68.9 390 191.6 230 3.10 11.53.8 0 Numb of studies78Average rate17.231.79 Clinical presentation included: Palpable mass, nipple discharge, itching, mammographic mass/asymmetry or calcifications. This study found 69.3% of papillary lesions presented as mammographic findings including nodules/asymmetry (28%), calcifications (24%), masses (16.7%). The remaining 29.3% of the papillary lesions presented as palpable masses(14.7%), discharge (4%), itching (2.67%), and pain/tenderness(1.3%). Conclusion: IDPs present as a radiologic finding in 2/3 of the cases and a clinical complaint in the remaining patients. A review of the upgrade rates in the literature shows a range of 0-39%. Although larger cores from vacuum assisted biopsies may lower the upgrade rates, a good number of studies show rates that do not justify observation only. As concerning is the association of papillary lesions with atypia and malignancy in 32.3% of our patients indicating a possible causal relation. Our data and review of the literature indicate that short of a prospective randomized trial to settle this question, IDPs should be routinely excised. Citation Format: Asma Mursleen, Hanh Tam Tran, Omar M Ghanem, Maen Farha. Papillary breast lesions: Association with malignancy and upgrade rates on surgical excision [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P2-13-19.