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Significance of Papillary Lesions at Percutaneous Breast Biopsy

¹ Department of Surgery, Comprehensive Breast Service, St. Luke’s Roosevelt Medical Center, 425 West 59th Street, Suite 7A, New York, New York 10019
² Department of Radiology, Comprehensive Breast Service, St. Luke’s Roosevelt Medical Center, 425 West 59th Street, Suite 7A, New York, New York 10019

Correspondence: Address correspondence and reprint requests to: Edna K. Valdes, MD; E-mail: edvaldes{at}chpnet.org.

	ABSTRACT

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Background: The management of nonpalpable papillary lesions found in specimens obtained by percutaneous breast biopsy is controversial. We reviewed the treatment of patients found to have papillary lesions by stereotactic, sonographic, or fine-needle aspiration breast biopsy to identify indications for surgical excision.

Methods: Consecutive patients with intraductal papilloma, atypical papilloma/papilloma with atypical ductal hyperplasia, papillary neoplasm, and papillomatosis according to percutaneous breast biopsy were identified from radiology records. The charts were reviewed to identify patients who had subsequent surgical excision, and the pathologic findings were correlated with the biopsy method and indications for surgery.

Results: Papillary lesions were found in 120 biopsy samples from 109 patients. Malignancy was found at operation in 19 (24%) of 80 lesions that underwent surgical excision: 12 (63%) were ductal carcinoma-in-situ, 4 (21%) were infiltrating ductal carcinoma, 2 (11%) were infiltrating papillary carcinoma, and 1 (5%) was intracystic papillary carcinoma. Malignancy was found in 9 (30%) of 30 fine-needle biopsy papillary lesions, 6 (35%) of 17 core biopsy papillary lesions, and 4 (12%) of 33 stereotactic biopsy papillary lesions. Malignancy was missed significantly less frequently with stereotactic biopsy (P < .05).

Conclusions: Malignancy is frequently found at surgical excision for papillary lesions found on percutaneous breast biopsy. Malignancy is missed significantly less frequently with stereotactic biopsy.

Key Words: Papillary lesion • Papillary neoplasm • Intraductal papilloma • Papillomatosis • Papillary carcinoma • Percutaneous breast biopsy

	INTRODUCTION

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Percutaneous breast biopsy is replacing surgical excision in the diagnosis of indeterminate mammographic densities and microcalcifications. Surgical excision for benign pathologic findings from percutaneous biopsy is recommended for discordance between the radiological appearance and the pathologic findings, if inadequate tissue is obtained, and for a variety of benign histological findings that have a high risk of associated malignancy.

Papillary breast lesions are found in up to 5% of breast biopsy specimens.¹ They account for <10% of all benign breast neoplasms and between .5% and 2% of malignant neoplasms. The term papillary lesion includes papilloma, papillomatosis, sclerosing papilloma, atypical papilloma, papilloma with atypical ductal hyperplasia, intraductal papillary carcinoma, and invasive papillary carcinoma.² To distinguish benign from malignant lesions can be quite challenging without surgical excision because of the lack of distinctive clinical and radiological signs. Consequently, the management of percutaneously identified nonpalpable papillary lesions is controversial. We examined our experience with papillary lesions identified by percutaneous biopsy to identify lesions that should be removed surgically.

	PATIENTS AND METHODS

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Records of percutaneous breast biopsies between February 1998 and April 2004 at St. Luke’s-Roosevelt Hospital Center were reviewed to identify patients with papillary lesions. The percutaneous biopsies included stereotactic, ultrasound-guided core, and fine-needle aspiration biopsies. The stereotactic biopsies were performed by using a directional vacuum-assisted biopsy device with an 11-gauge probe (Mammotome; Biopsys/Ethicon Endo-Surgery, Cincinnati, OH) while patients were placed in prone position on a dedicated table. The ultrasound-guided biopsies were performed with patients in the supine or supine oblique position by using a GE LOGIQ 400 PRO Series (Pewaukee, WI) with a high-resolution 9- to 12-MHz linear array transducer. The ultrasound-guided core biopsies were performed by using 14-gauge needles, and the fine-needle aspiration biopsies were performed by using 20- or 22-gauge needles. The number of samples taken was determined by the breast radiologist on the basis of specimen adequacy. In cases where calcifications were present, 14-gauge core biopsy specimens or 11-gauge vacuum-assisted biopsy specimens were obtained. The specimens were then radiographed to ensure the presence of the targeted microcalcifications. A metallic clip was then placed in the biopsy site.

Papillary lesions were identified in 120 specimens from image-guided biopsies performed in 109 patients. Seventy-one (65%) of the patients subsequently underwent surgical excision of 80 papillary lesions. Papillary lesions identified on image-guided biopsy included intraductal papilloma, atypical papilloma/papilloma with atypical ductal hyperplasia, papillary neoplasm, and papillomatosis. The pathologic findings from the percutaneous biopsies were correlated with the radiological appearance and the pathologic findings from the surgical excisions.

	RESULTS

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The data analysis was based on the 71 patients who underwent surgical excision. Thirty-three (41%) of the 80 papillary lesions were found with stereotactic vacuum-assisted biopsy with an 11-gauge probe; 30 (38%), with fine-needle aspiration biopsy with a 20-or 22-gauge needle; and 17 (21%), with core needle biopsy with a 14-gauge needle. Thirty-six (45%) were papilloma or papillomatosis, 28 (35%) were papillary lesions without further specification, 9 (11%) were papillary lesions with atypia, and 7 (9%) were atypical papillomatosis or papilloma with atypical duct hyperplasia. Malignancy was found in 19 (24%) of the 80 specimens from needle localization excisional biopsy: 12 (63%) were ductal carcinoma-in-situ, 4 (21%) were infiltrating ductal carcinoma, 2 (11%) were infiltrating papillary carcinoma, and 1 (5%) was an intracystic papillary carcinoma.

The characteristics of the papillary lesions were not predictive of malignancy (Table 1). Malignancy was found in 6 (17%) of the 36 papilloma or papillomatosis, 9 (32%) of the 28 papillary lesions without further specification, 2 (22%) of the 9 papillary lesions with atypia, and 2 (29%) of the 7 atypical papillomatosis or papilloma with atypical duct hyperplasia.

	DISCUSSION

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The incidence of malignancy at surgical excision for papillary lesions found on percutaneous biopsy ranges from 17% to 34%.^1–5 Agoff and Lawton² and Renshaw et al.⁶ claim that benign papillary lesions can be distinguished from those associated with malignancy by the presence or absence of atypia. In both studies, no papillary lesions without atypia were associated with carcinoma. However, in our study, 15 (23%) of the 64 papillary lesions without atypia were associated with malignancy at surgical excision.

Tan et al.⁷ used immunohistochemical expression of cytokeratins to distinguish papillary lesions associated with malignancy from those associated with benign processes. Although high cytokeratin levels were commonly associated with benignity, some papillary lesions associated with malignancy also had high levels.

We found that papillary lesions diagnosed by stereotactic biopsy were significantly less likely to be associated with malignancy than papillary lesions found by core needle biopsy or fine-needle aspiration. Masood et al.⁸ and Gendler et al.³ found that core biopsy and fine-needle aspiration were comparable. Mercado et al.⁵ reported that one of six papillary lesions diagnosed by stereotactic biopsy was associated with malignancy. Our finding that stereotactic papillary lesions were significantly less frequently associated with malignancy than core biopsy or fine-needle aspiration is attributable to sampling error. The volume of tissue removed by stereotactic biopsy is orders of magnitude higher than with three passes of a core biopsy needle or with fine-needle aspiration. As a consequence, malignancy associated with papillary lesions is less frequently identified in the stereotactic biopsy specimen.

We agree with Hoda and Rosen⁹ that all papillary lesions, regardless of the presence or the degree of architectural and cytological atypia, diagnosed by percutaneous biopsy should be excised surgically. Papillary lesions without atypia and those diagnosed by stereotactic biopsy are less frequently associated with malignancy, but the absence of atypia and generous sampling of the lesion cannot be used to identify patients who can be followed up without surgery.

Received for publication August 1, 2005. Accepted for publication October 18, 2005.

	REFERENCES

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1. Rosen EL, Bentley RC, Baker JA, Soo MS. Imaging-guided core needle biopsy of papillary lesions of the breast. AJR Am J Roentgenol 2002; 179:1185–92.[Abstract/Free Full Text]
2. Agoff SN, Lawton TJ. Papillary lesions of the breast with and without atypical ductal hyperplasia. Am J Clin Pathol 2004; 122:440–3.[CrossRef][Medline]
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6. Renshaw AA, Derhagopian RP, Tizol-Blanco DM, Gould EW. Papillomas and atypical papillomas in breast core needle biopsy specimens. Am J Clin Pathol 2002; 122:217–21.
7. Tan PH, Aw MY, Yip G, et al. Cytokeratins in papillary lesions of the breast: is there a role in distinguishing intraductal papilloma from papillary ductal carcinoma in situ? Am J Surg Pathol 2005; 29:625–32.[CrossRef][Medline]
8. Masood S, Loya A, Khalbuss W. Is core needle biopsy superior to fine-needle aspiration biopsy in the diagnosis of papillary breast lesions? Diagn Cytopathol 2003; 28:329–34.[CrossRef][Medline]
9. Hoda SA, Rosen PP. Observations on the pathologic diagnosis of selected unusual lesions in needle core biopsies of the breast. Breast J 2004; 10:522–7.[Medline]

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