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The risk of intraductal papillomas relates mostly to the risk of undersampling.
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Multiple factors increase the risk of finding malignancy, including the presence of atypia, size, symptoms, and personal risk factors.
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Personalized decision-making is important. Papillomas that are not excised should be observed.
Intraductal Papillomas
Section snippets
Key points
The most common manifestation of papillary breast disease is intraductal papilloma (IDP), which is usually characterized by a pedunculated intraductal mass on a fibrovascular stalk, usually
Presence of atypia
The presence of atypia is one of the most significant risk factors for upstaging in most studies. One study evaluated only IDPs without atypia, reviewing 383 lesions that were reviewed again by pathology, showed a very small upgrade risk, with 4.4% upgrading to high-risk atypia and only 0.8% upgrading to malignancy.11 Another evaluated 500 patients with 206 undergoing surgical excision, and the malignant upgrade rate was only 1.8%.(Choi) In a study of 259 patients comparing IDPs without atypia
Palpable mass and/or nipple discharge
Multiple studies have demonstrated a link between presentation with symptoms and upstaging to malignancy. A Chinese retrospective study of 4450 intraductal papillomas in which 51% presented with a palpable mass and 16% presented with both a palpable mass and nipple discharge showed a statistically significant association, with 32% of palpable papillomas showing malignancy on excision compared to 3.4% of nonpalpable papillomas, and 35% of palpable papillomas with discharge showing malignancy
History of cancer
Several articles looked at the risk of upstaging in patients with a prior history of breast cancer. One article from Mt. Sinai, reviewing a total of 490 IDPs showed an overall upgrade rate of 12.3% for atypia and 1.1% for cancer.18 The subgroup of 40 patients with prior breast cancer had a significantly higher risk of upgrade, with 27.5% to atypia (though this would be unlikely to change management) and 5% to new cancer. In MSKCC study of 166 patients where 34.9% had a prior history of breast
Older age
The Alberty-Oller study from Mt. Sinai of 490 cases of intraductal papilloma showed a 1.81 prevalence ratio in patients 55 or older, compared with younger patients. Another study of 327 patients showed age greater than 50 was statistically significant.16 One older study evaluating 205 patients showed that age over 45 was statistically significant.20
Race
While much outcomes data on racial disparities can be attributed to systemic racism, there are some clinical and biological differences among ethnic groups associated with breast cancer, such as ER negativity, high S-phase fraction, and so forth.21 Few studies have directly examined the effect of race on upgrading of IDPs, but one small study of 29 patients undergoing excision where 25 were African American showed a higher-than-average malignant upgrade rate of 25%, with 2 of 3 patients with
Size of papilloma
Most studies have shown an association between the size of the IDP and risk of upgrade, with 1 cm tending to be the cut-off. A study of 147 patients in Malaysia showed a statistically significant difference in average sonographic size, with benign lesions being a median of 1.0 cm, atypical lesions being a median of 1.1 cm, and malignant lesions being a median of 1.9 cm, though there was overlap with benign lesions as large at 1.35 cm and malignant lesions as small as 0.7 cm.23 The recent
Location in breast
Several studies have suggested that the risk of upgrade to invasive cancer increases with more peripheral locations within the breast, though this is more difficult to characterize. In 327 patients undergoing surgical excision of IDPs demonstrated a significantly increased risk if the lesion was > 5 cm from nipple.16 Peripheral location was also significant in a study of 250 cases.17 It has been noted that intraductal papillomas in the axillary tail should also undergo pathological
Number of papillomas
While the entity of papillomatosis is known to be associated with increased risk for breast cancer, the presence of multiple papillomas in a single patient is also associated with an increased likelihood of upgrading at excision. In Alberty-Oller and colleagues, each additional IDP was associated with a prevalence ratio of 1.51 for overall upgrade and 2.23 PR for malignant upgrade. In the study of 383 IDPs without atypia, multifocality was one of the statistically significant factors for
Vascularity
Intralesional vascularity has been shown in some studies to be associated with malignant upgrade, though vascularity is not uncommon due to the fibrovascular core within the feeding pedicle. One study showed vascularity was present in 7/39 cases of benign papillary lesions, and 9/17 cases of malignant papillary lesions, showing overlap.23
Overall high risk
A study of 278 patients showed an overall upgrade risk of 14.6%, with a 3.9% upgrade to DCIS.28 A subgroup of high risk patients, with > 20% lifetime risk of developing breast cancer, was 2.5 times more likely to upgrade.
Other
Characteristics that have been evaluated without much statistical association with upgrade include morphology and ductal dilation. Various factors, including margins, echogenicity, posterior features, orientation, echogenic halo, associated calcifications, and architectural distortion have been evaluated, without consistency in statistical significance among studies.
Management decisions for intraductal papillomas remain challenging, with some contradictory recommendations and lack of clear
Clinics care points
When discussing excision versus observation of IDPs, it is crucial to balance the risks of undersampling with the risks of surgery. In patients where upstaging to atypia may not change management and the likelihood of cancer is low, observation may be preferred. As atypia can be the strongest predictor for upstaging to cancer, most IDPs with atypia should be excised.
Disclaimer
The author has nothing to disclose.
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