Scientific Session 28 — Breast - Screening/PathologyFriday, May 5, 2017
2714. Do Intraductal Papillomas Diagnosed After Image-Guided Core Needle Biopsy Need to Be Excised?
Alenezi S*, Falomo E, Kieger A, Panigrahi B, Harvey S. Johns Hopkins University, Baltimore, MD
Address correspondence to E. Falomo (firstname.lastname@example.org)
Objective: Currently at our institution, as well as many other institutions in the United States, excision of all papillomas identified at core needle biopsy (CNB) is the standard of care. This is based on data suggesting that papillomas, with and without atypia, are associated with malignancy at a rate that necessitates excision (estimated to be greater than 10% in multiple studies). Our hypothesis is that, papillomas without atypia may be associated with a very low rate of malignancy and thus, may not require surgical excision. The purpose of this study was to determine the rate of malignancy associated with papillomas without atypia at our institution. Based on this data, we postulate that this information would help us to make suggestions regarding the need for surgical excision of intraductal papillomas without atypia identified at CNB.
Materials and Methods: Following institutional review board approval, we performed a chart review in a retrospective cohort consisting of women over the age of 18 years diagnosed with papilloma upon image-guided CNB from January 2012 to December 2014. The cases with associated atypia or cancer were excluded. For patients who underwent surgical excision, excisional biopsy pathology reports were reviewed and the rates of atypia and upgrade to malignancy were calculated. Additionally, the modality of CNB was recorded and upgrade rates for the different CNB modalities were compared.
Results: We identified 117 patients with papillomas detected at image-guided CNB. Five cases were excluded due to associated atypia found on the CNB pathology report (two focal atypical papillomas, one atypical lobular hyperplasia, one atypical papillary neoplasm, and one lobular carcinoma in situ). Of the remaining 112 women, 17 (15%) were lost to follow-up, and 10 (9%) chose not to undergo surgical excision with stable imaging findings seen at follow-up (mean, 22.8 months; range, 12–36 months;). Eighty-five patients (76%) underwent surgical excision, 71 (84%) of whom had their papillomas diagnosed via ultrasound-guided CNB, five (6%) via stereotactic-guided CNB and the remaining nine (11%) via MRI-guided CNB. Following surgical excision, seven (8%) of the 85 patients were found to have malignancy and two (2%) of the patients were found to have atypical ductal hyperplasia. The upgrade rates to malignancy were 6% for the patients with papillomas detected via ultrasound-guided biopsy, 0% for stereotactic-guided biopsy, and 33% for MRI-guided biopsy, which were found to be statistically different (p < 0.05).
Conclusion: In our study, we found that the upgrade rate to malignancy following surgical excision of intraductal papillomas without atypia diagnosed on image-guided CNB is moderately high (8%) and may justify excisional biopsy. Additionally, our results show that papillomas diagnosed by MRI-guided CNB are significantly more likely to upgrade to malignancy (33%). This information can be used to guide us towards more precise stratification of papillomas at higher risk for associated malignancy.