Management Of Intraductal Papilloma Research Articles

Intraductal Papilloma on Breast Biopsy: Upstaging Rate and Implications for Practice Guidelines

The recommendation for management of intraductal papilloma has not been clearly established and its surgical excision criteria remain controversial. This study determines the institutional malignancy upstage rate of benign intraductal papillomas and identifies risk factors for upstage. Retrospective review was conducted on female patients who were diagnosed with intraductal papillomas without atypia on core needle biopsy at Atrium Health Wake Forest Baptist Hospital between 1/2012 and 6/2021. Patients were excluded if there was a concomitant malignancy or atypia or deemed to be discordant with imaging. Features associated with upstage on imaging and histopathology were obtained from the electronic medical record. This study included 245 intraductal papillomas without atypia in 231 women (mean age, 59.1 ± 12.3 [SD] years). Approximately 31% (76/245) of the papillomas were excised, whereas 69% (169/245) of the papillomas underwent surveillance. Of the patients who underwent excisional biopsy, upstage rate for DCIS was 1.3% (1/76) and 5.3% (4/76) for atypia. All of the papillomas upstaged to DCIS or atypia had lesion size ≥10mm on imaging. Out of the 139 intraductal papillomas that underwent radiologic surveillance, two (1.4%) developed malignancy and three (2.2%) developed atypia. The risk of upstaging of intraductal papilloma without atypia to malignancy remains extremely low. Therefore, routine surgical excision may not be necessary. While the papillomas upstaged to either malignancy or atypia have size abnormality ≥10mm, other potential selective excision criteria should be explored to further decrease the risk of an upstage.

Multidisciplinary Review of Intraductal Papilloma of the Breast can Identify Patients who may Omit Surgical Excision.

The purpose of this study was to define contemporary management recommendations regarding who would benefit from surgical excision of intraductal papilloma (IDP). A prospective database from a single institution identified patients with IDP on percutaneous biopsy from February 2015 to September 2020. Categorical patient demographic, biopsy, and pathologic variables were analyzed using Fisher's exact test and continuous demographic and imaging variables using the Mann-Whitney U test. IDP was present in 416 biopsies, at a median age of 56 years. The median size was 0.9cm, and the majority had greater than 50% of the target excised by biopsy. Surgical excision was performed for 124 of 416 biopsies (29.8%). Upgrade to malignancy was identified in 14 (11.3%): 8 to ductal carcinoma in situ (DCIS) and 6 to invasive cancer. Upgrade was significantly associated with concurrent ipsilateral breast cancer (p = 0.027), larger imaging size (p = 0.045), <50% excised with biopsy (p = 0.02), and atypia involving IDP (p = 0.045). Age, clinical presentation, and concurrent contralateral cancer were not significantly associated with upgrade. Lowest upgrade risk (0%) was in pure IDP ≤1 cm with >50% removed by biopsy. Of 401 biopsies that either did not upgrade or undergo excision, 7 (1.7%) developed subsequent breast cancer over a median follow-up of 23.5 months (interquartile range [IQR] 11,41), none at IDP site. After multidisciplinary review, the management of IDP can be stratified into low- and high-risk for upgrade groups using key criteria. Low-risk group may omit surgical excision, because those patients have 0% risk of upgrade over the limited short-term follow-up.

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.

Abstract P5-02-16: Is surgical excision of intraductal papillomas justified by the rate of upstaging to breast cancer?

Abstract Introduction: The management of intraductal papilloma (IDP) diagnosed on core needle biopsy (CNB) is controversial. Some investigators advocate surgical excision based on an upgrade risk of as high as 24%. Others contend that after adjusting for confounders, including size, clinical presentation, presence of other accompanying high-risk lesions and radiologic correlation, the upgrade risk may be as low as 2.3%. The implications for patient care would be the avoidance of invasive surgical procedures. The purpose of our study was to investigate the upgrade rate of IDP diagnosed on CNB to ductal carcinoma in situ (DCIS) and invasive carcinoma on subsequent surgical excision and the impact of associated high-risk borderline lesions and other clinicopathologic and radiologic variables. Methods: Our institutional pathology database was queried for all women who had a CNB with a diagnosis of intraductal papilloma between 2005-2018. Two independent pathologists reviewed all the core biopsy slides and excisional biopsy slides. Variables of interest included clinical, imaging and pathologic characteristics. Statistical analyses included Pearson’s chi-square, Wilcoxon rank-sum and logistic regression. Results: Out of 216 women, 19 (8.8%) upgraded to breast cancer (BC), including 14 (74%) DCIS and 5 (26%) invasive carcinoma. Out of 161 pure IDP without any atypia, 5 (3.1%) upgraded to BC and out of 45 IDP with atypical ductal hyperplasia (ADH), 13 (28.9%) upgraded to BC. Only one patient who upgraded to BC from IDP with ADH had a discordant finding on imaging. When we evaluated the clinicopathologic and radiologic variables associated with upgrading from pure IDP to BC on final pathology, we found that older age (&amp;gt;53 years) at time of biopsy (OR=1.05, 95%CI 1.01-1.09, p=0.027) and concomitant ipsilateral atypical ductal hyperplasia (ADH) (OR=9.69, 95%CI 3.37-27.81, p&amp;lt;0.0001) were associated with a BC upgrade. There was no significant association of upgrading to BC after having a concomitant ipsilateral or contralateral breast cancer. Conclusions: Our results support surgical excision of IDP on CNB when associated with ADH or diagnosed in women older than 53 years of age. The upgrade rate of 3.1% for IDP without atypia on CNB in younger women does not justify a universal recommendation for routine surgical excision. Citation Format: Paolo Cotzia, Ugur Ozerdem, Jiyon Lee, Jennifer Chun, Elianna Kaplowitz, Freya Schnabel, Farbod Darvishian. Is surgical excision of intraductal papillomas justified by the rate of upstaging to breast cancer? [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P5-02-16.

Can we now reach a consensus on the management of benign papillary breast lesions?

Management of benign breast lesions diagnosed by core needle biopsy (CNB) remains a controversial topic. Specifically, there is no consensus on the management of intraductal papillomas, despite multiple studies to determine whether excision or observation should be the next best step (1-5). When CNB yields a diagnosis of intraductal papilloma with atypia, excisional biopsy of the lesion is generally performed. For intraductal papillomas without atypia, however, a large retrospective study recently published in the Annals of Surgical Oncology suggests that observation without excision is likely a safe alternative (6). This is based on a low rate of malignancy found on surgical excision of 327 lesions diagnosed as benign papillomas on CNB, as well as no incidence of cancer found on follow-up for those (n=61) who did not undergo excision.

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.

Management of intraductal papilloma without atypia of the breast diagnosed on core biopsy: Size and sampling matter.

Due to the potential for atypia (atypical ductal or lobular hyperplasia) or carcinoma (in situ or invasive) on excision, aggressive reflex surgical excision protocols following core biopsy diagnosis of papillary lesions of the breast (ie, intraductal papilloma) are commonplace. Concepts in risk stratification, including radiologic-pathologic correlation, are emerging in an effort to curb unnecessary surgeries. To this end, we examined all excised intraductal papillomas diagnosed at our institution from 2010-2015 (N = 336) and found an overall atypia rate of 20%. To investigate further, we stratified all excised papillomas according to total lesion size (range = 1-40 mm) and found that the atypia rate for lesions ≤1.2 cm (16% with atypia) was statistically significantly lower (P = .008) than the atypia rate for lesions >1.2 cm (36% with atypia). To explore to effects of radiologic-pathologic correlation on the ability of the core biopsy to accurately predict nonatypical lesions we assessed thirteen consecutive paired nonatypical core biopsy/follow-up surgical excision specimens for the percent of the total lesion (on imaging) sampled by the core biopsy (measured histologically). None of the thirteen paired specimens showed upgrade on excision (0/13); the percent of total lesion sampled by biopsy in this cohort averaged 59%. We propose that in the absence of discordant clinical/radiological findings, small lesions (≤1.2 cm) with radiologic-pathologic concordance (>50% sampling of total lesion by core biopsy) may safely forego surgery for close clinical and radiographic follow-up.

Intraductal Papilloma with Benign Pathology on Breast Core Biopsy: To Excise or Not?

The management of intraductal papillomas on core biopsy continues to be controversial. Papillomas with atypia are typically excised. However, it is unclear whether surgical excision is warranted for benign lesions. A retrospective review of our institution's pathology and radiology databases from January 2009 through May 2014 identified 119 patients with a diagnosis of benign papilloma without atypia on core biopsy. We determined the rate of carcinoma identification on surgical excision. The average patient age was 52.8years (range 24-84years). Indication for core biopsy included: abnormal imaging (n=106), nipple discharge (n=21), or palpable mass (n=24). Seventy-five patients underwent surgical excision after core biopsy. Sixteen patients (21.3%) had atypia in the excision specimen (combination atypical ductal hyperplasia, n=11; atypical lobular hyperplasia, n=8; lobular carcinoma-in situ, n=3), 15 (93.8%) of which were in the surrounding breast tissue. Two patients (2.7%) had malignancy (ductal carcinoma-in situ and micropapillary carcinoma-in situ). As a result of surgical findings, 12% of patients had a change in management. In comparing those with benign findings on surgical pathology and those whose disease was upstaged, there was no statistically significant difference in family history of breast cancer, indication for core biopsy, mammographic findings, or location of papilloma. Benign papillomas diagnosed on core biopsy are rarely upstaged to malignancy on surgical excision. However, at least 21% of patients may have atypical findings in the surrounding tissue, which could change clinical management. Surgical excision should be considered in patients with benign papillomas.

Abstract P5-08-37: Intraductal papillomas: Risk of cancer, immediate and delayed

Abstract Introduction The management of Intraductal papillomas (IP) of the breast diagnosed on core needle biopsy (CNBx) is still controversial. For IP with atypia, excision is generally recommended. For IP w/o atypia, data for excision vs. observation are variable. A clearer understanding of the risk of the presence of invasive or in situ malignancy (IDC or DCIS) coincident with IP, as well as the long-term risk for cancer would be helpful in managing these patients. The aim of this study is to evaluate the rate of malignancy on immediate excision or with prolonged follow-up. We hypothesized that IP w/o atypia do not require excision, as the risk of malignancy is low. Conversely, we hypothesized that IP w/ atypia should be excised because of a significant rate of concomitant malignancy. We also evaluated the long-term risk of malignancy in either breast with excision or observation of women with IP. Methods 266 women who underwent a CNbx between 1995 and 2010 were identified from surgical pathology and breast imaging records. Four groups were defined based on the CNBx diagnosis (IP w/o atypia, IP with atypia, IP + ADH/ALH and Papillomatosis) and were also separated on the basis of immediate excision versus observation. For the 15-year period, it was generally the policy to excise IP lesions with atypia or ADH/ALH. Management of IP w/o atypia was more variable, but in the most recent 5 years, patients with IP w/o atypia were usually observed. For those who underwent immediate excision, the proportions with IDC or DCIS were calculated and compared using Fisher's exact test. Kaplan Meier curves were determined for each group's estimated time to cancer diagnosis, and significance was evaluated by the log-rank test. Results When surgical excision was performed for IP w/ atypia or IP + ADH/ALH on CNBx, cancer was found in 32% and 38.5% respectively. Of the 109 excisions for IP w/o atypia, cancer was found in 8.3%, significantly different from IP w/ atypia (p=0.004) and IP + ADH/ALH (p=0.007). For patients without atypia or ADH/ALH at the time of biopsy and no cancer on excision, the probability of remaining cancer-free was not significantly different for patients who had immediate surgical excision versus those that were observed (93.8% and 91.5% cancer-free at 10 years, p= 0.773). For patients with atypia or ADH/ALH at the time of biopsy but no cancer on excision, the probability of remaining cancer-free in both breasts was 85.9% at 10 years, and did not differ between patients who were excised or observed (p= 0.518). However, those w/atypia or ADH/ALH were significantly less likely to remain cancer-free than those w/o atypia (85.9% versus 92.8% at 10 years, respectively, p=0.008). Conclusions After a CNBx showing IP w/ atypia or IP + ADH/ALH, surgical excision is clearly justified, based on a 30-40% risk of concomitant invasive or in situ cancer. For IP w/o atypia, the likelihood of cancer is much lower. Moreover, even with excision, the finding of IP with atypia carries a significant risk of developing cancer long-term, and such patients should be followed carefully and perhaps should be considered for chemoprevention. Citation Format: Khan S, Diaz A, Archer KJ, Lehman RR, Mullins TC, Cardenosa G, Bear HD. Intraductal papillomas: Risk of cancer, immediate and delayed. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P5-08-37.

Intraductal papillomas of the breast: Diagnosis and management of 151 patients

Introduction The assessment of papillary lesions continues to be a challenging area in breast radiology and pathology. The management of intraductal papillomas without atypia of the breast remains controversial. The purpose of the present study was to determine diagnostic accuracy of radiographical diagnosis, core biopsy, and surgical excision in papillary breast lesions. Material and methods By using files from 1995 to 2010, 151 cases of intraductal papilloma with or without atypia were identified. Patients were stratified as follows: core biopsy followed by surgical excision ( n = 61), core biopsy alone ( n = 19), and surgical excision alone ( n = 71). Results The upstage rate of intraductal papillomas without atypia on core biopsy to atypia or malignancy on excision was 8.9%. Excision specimens revealed intraductal papillomas without atypia in 68 out of 71 cases, and atypical papillomas in 3 cases. Conclusion Our findings suggest that radiographic and histopathological diagnosis of intraductal papillomas show high accuracy and good concordance. In cases where the radiographic diagnosis reveals suspicious lesions core biopsy represents the first choice.

The operative management of intraductal papilloma of the breast

Intraductal papillary tumors of the breast exhibit bloody nipple discharge with often no evidence of a palpable tumor, making discrimination between benign and malignant lesions sometimes difficult for pathologists and surgeons. However, appropriate surgical management requires correct differentiation between these lesions. According to previously reported 3-dimensional analyses of intraductal papillary lesions, solitary papilloma originates in the large ducts while multiple papilloma originates in the peripheral ducts and often coexists with intraductal carcinoma. We performed selected ductolobular segmentectomy on both solitary and multiple intraductal papilloma, and even on small foci of intraductal carcinoma which were found inadvertently. The favorable results of this surgery include a fine cosmetic appearance, functional breast feeding and no recurrence of papilloma during the 2 to 7 year follow-up period. In this article, the operative method of selected ductolobular segmentectomy is described.

Management of intraductal papilloma: Its relationship to cancer of the breast

Summary o 1. The study of 159 cases of intraductal papilloma has been made; seventy-six cases were from Good Samaritan Hospital and eighty-three cases from St. Vincent's Hospital. 2. Intraductal papilloma accompanied bynipple discharge is a confusing and frequently a poorly managed problem. 3. Carcinoma as well as benign breast diseasecan produce many different types of nipple discharge. 4. Only one patient's condition was diagnosedas carcinoma in situ in the intraductal papilloma. 5. One patient had atypical cellular changes predisposing toward carcinoma. 6. Segmental removal and simple mastectomy were the procedures carried out.