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Breast Imaging

E3211. Intraductal Papillomas Diagnosed on Core Needle Biopsy: Is Excision the Decision?

Russell T1,  Foerter J1,2,  Kirkpatrick A.1 1. San Antonio Uniformed Services Health Education Consortium, Fort Sam Houston, TX; 2. Womack Army Medical Center, Fort Bragg, NC

Address correspondence to T. Russell (timothy.g.russell16.mil@mail.mil)

Objective: The need for surgical excision of benign papillomas discovered at core needle biopsy remains controversial. Upgrade rates within the literature vary widely, with many studies limited by small sample size and insufficient statistical power. We sought to determine the upgrade rate of benign papillomas to atypia or malignancy at our institution.

Materials and Methods: A retrospective analysis of pathology results for all percutaneous breast biopsies performed at our institution between May 2009 and May 2015 was completed. There were 192 patients who had benign papillomas without atypia or other high-risk lesions. Additional inclusion criteria included either surgical excision of the initial papilloma site or at least 12 months of follow-up imaging. Exclusion criteria included patients with biopsy indicating malignancy or atypia. Correlation of pathology results from surgical excision was performed to identify those patients requiring subsequent upgrade to atypia or malignancy.

Results: There were 176 patients who met the inclusion criteria. Of those, 129 patients (73%) underwent surgical excision (surgical group), and 47 patients (27%) underwent imaging follow-up (imaging group). Four patients (0.3%) in the surgical group had low- or intermediate-grade ductal carcinoma in situ (DCIS) on surgical excision, yielding a malignancy upgrade rate of 3.1% (95% CI, 0.1–6.1%). Ten patients (7.8%) in the surgery group had atypia or another high-risk lesion. None of the 47 patients in the imaging group went on to biopsy at the papilloma site, and all demonstrated stable imaging over a follow-up period of 1–5 years. There were no incidents of invasive carcinoma in either group.

Conclusion: In our patient population, no cases of benign papillomas were upgraded to invasive malignancy or high-grade DCIS, and only a small percentage (3.1%) were upgraded to low- or intermediate-grade DCIS. An additional subgroup of patients had atypia or another nonmalignant high risk lesion on surgical excision, which would likely prompt discussion of additional risk reduction interventions. These results suggest that the malignancy upgrade rate of benign papillomas identified at core needle biopsy may be low enough to allow for discussion of more conservative follow-up in select patients. In particular, imaging follow-up may be a safe alternative to surgical excision for management of patients with average or below-average baseline risk for whom reliable follow-up can be assured. Alternatively, surgical excision may be a better strategy in patients with higher than average baseline risks, who are more likely to benefit from risk-reduction interventions.