Breast Cancer Research and Treatment

, Volume 178, Issue 1, pp 87–94 | Cite as

Risk of malignancy in papillary neoplasms of the breast

  • Claire Liu
  • Ravi Sidhu
  • Avi Ostry
  • Rebecca Warburton
  • Jin-Si Pao
  • Carol Dingee
  • Urve Kuusk
  • Elaine McKevittEmail author
Clinical trial



In recent years, routine excision of papillary neoplasms (PN) of the breast has been questioned and controversy exists over when excision is necessary. The aim of this study was to evaluate the upstage rate to malignancy of core needle biopsy (CNB) diagnosed PNs from multiple diagnostic centers in our area and to identify factors predictive of malignancy.


Patients presenting to our surgical center between 2013 and 2017 for excision of CNB PN were evaluated. The primary endpoint was upstage to malignancy. The association of age, diagnostic center where CNB performed, type of CNB, palpability, discharge, clinical exam size, imaging size, family history of breast cancer, and presence of atypia, as risk factors for upstaging to cancer were also evaluated.


Of the 317 PN cases, 83 upstaged to malignancy following surgical excision. 77% of patients with CNB of Atypical PN upstaged, 39% of PN with concurrent atypical ductal hyperplasia, and 0% of PN with concurrent atypical lobular hyperplasia/flat epithelial atypia. Of the 206 non-atypical PNs on CNB, 3.4% upstaged to malignancy, but further review demonstrated a 1% upstage rate when atypia excluded. Factors found to be associated with malignancy included: older patient age, larger size, and presence of atypia.


We recommend excision of PN with atypia, concurrent cancerous lesion, or radiologic–pathologic non-concordance, and serial imaging follow up may be considered for image detected PN, less than 1 cm, with no atypia.


Papillary neoplasms Core needle biopsy Breast cancer Surgery 



Atypical ductal hyperplasia


Atypical lobular hyperplasia


Atypical papillary neoplasms


Core needle biopsy


Ductal carcinoma in situ


Flat epithelial atypia


Myoepithelial cell layer


Papillary neoplasms



The authors would like to acknowledge the input of the physicians in the Departments of Pathology, Surgery, and Radiology in our area that contributed to the development of our clinical pathways. We would also like to acknowledge Guilaine Boyce who helped with manuscript preparation and Kaidi Liu, Leo Chen, and Amy Wang who helped with data analysis.

Compliance with ethical standards

Conflict of interest

The authors of this manuscript have no conflicts of interest to declare for this publication.

Ethical approval

This study was approved by the Research Ethics Board by the University of British Columbia and Providence Health Care. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained as appropriate from all participants in the study as per the Research Ethics Board Standards.


  1. 1.
    Rakha EA, Ellis IO (2018) Diagnostic challenges in papillary lesions of the breast. Pathology 50:100–110. CrossRefPubMedGoogle Scholar
  2. 2.
    Menes TS, Rosenberg R, Balch S, Jaffer S, Kerlikowske K, Miglioretti DL (2014) Upgrade of high-risk breast lesions detected on mammography in the breast cancer surveillance consortium. Am J Surg 207:24–31. CrossRefPubMedGoogle Scholar
  3. 3.
    Shiino S, Tsuda H, Yoshida M et al (2015) Intraductal papillomas on core biopsy can be upgraded to malignancy on subsequent excisional biopsy regardless of the presence of atypical features. Pathol Int 65:293–300. CrossRefPubMedGoogle Scholar
  4. 4.
    Khan S, Diaz A, Archer KJ et al (2018) Papillary lesions of the breast: to excise or observe? Breast J 24:350–355. CrossRefPubMedGoogle Scholar
  5. 5.
    Hong YR, Song BJ, Jung SS et al (2016) Predictive factors for upgrading patients with benign breast papillary lesions using a core needle biopsy. J Breast Cancer 19:410–416. CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Han SH, Chung YR, Yun BL et al (2018) Benign Intraductal Papilloma without atypia on core needle biopsy has a low rate of upgrading to malignancy after excision. J Breast Cancer 21:80–86. CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Pareja F, Corben A, Brennan S et al (2016) Breast intraductal papilloma without atypia in radiologic-pathologic concordant core needle biopsies: rate of upgrade to carcinoma at excision. Cancer 122:2819–2827. CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Padilla-Thornton A, Farrell J, Gordon P et al (2018) Current evaluation of breast health concerns and diagnosis of breast cancer. BCMJ 60:27–32Google Scholar
  9. 9.
    Wen X, Cheng W (2013) Nonmalignant breast papillary lesions at core-needle biopsy: a meta analysis of underestimation and influencing factors. Ann Surg Oncol 20:94–101. CrossRefPubMedGoogle Scholar
  10. 10.
    Boin DP, Baez JJ, Guajardo MP et al (2014) Breast papillary lesions: an analysis of 70 cases. Ecancermedicalscience 8:461. CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Rizzo M, Lund MJ, Opera G, Schniederjan M, Wood WC, Mosunjac M (2008) Surgical follow-up and clinical presentation of 142, breast papillary lesions diagnosed by ultrasound-guided core-needle biopsy. Ann Surg Oncol 15:1040–1047. CrossRefPubMedGoogle Scholar
  12. 12.
    Ashkenazi I, Ferrer K, Sekosan M et al (2007) Papillary leisons of thebreast discovered on percutaneous large core vacuum-assisted biopsies: reliability of clinical and pathological parameters in identifying benign lesions. Am J Surg 194:183–188. CrossRefPubMedGoogle Scholar
  13. 13.
    Cyr AE, Novack D, Trinkaus K et al (2011) Are we overtreating papillomas diagnosed on core needle biopsy? Ann Surg Oncol 18:946–951. CrossRefPubMedGoogle Scholar
  14. 14.
    Sidhu R, MacKay E, Warburton R, Pao J, Kuusk U, Dingee C, McKevitt E (2018) Upstage to breast cancer after excision of atypical ductal hyperplasia on core needle of the breast-a regional experience. Ann Surg Oncol 25(2_suppl):341–342Google Scholar
  15. 15.
    The American Society of Breast Surgeons (2016) Consensus guidelines on concordance assessment of image-guided breast biopsies and management of borderline or high-risk lesions. The American Society of Breast Surgeons. Accessed Mar 2019
  16. 16.
    Becker AK, Gordon PB, Harrison DA, Hassell PR, Hayes MM, Niekerk D, Wilson CM (2013) Flat ductal intraepithelial neoplasia IA diagnosed at stereotactic core needle biopsy: is excisional biopsy indicated? AJR Am J Roentgenol 200:682–688. CrossRefPubMedGoogle Scholar
  17. 17.
    Agoumi M, Giambattista J, Hayes MM (2016) Practical considerations in breast papillary lesions: a review of the literature. Arch Pathol Lab Med 140:770–790. CrossRefPubMedGoogle Scholar
  18. 18.
    Tse GM, Tan PH, Lui PC et al (2007) The role of immunohistochemistry for smooth-muscle actin, p63, CD10, and cytokeratin 14 in the differential diagnosis of papillary lesions of the breast. J Clin Pathol 60:315–320. CrossRefPubMedGoogle Scholar
  19. 19.
    Zhang H, Xiong Y, Zhang S, Zhang Y, Wang YH, Li T (2011) Clinicopathologic and immunohistochemical study of 187 cases of intraductal papillary neoplasm of breast [in Chinese]. Zhonghua Bing Li Xue Za Zhi 40:726–731. CrossRefPubMedGoogle Scholar
  20. 20.
    Omi Y, Yamamoto T, Okamoto T, Obara T, Kobayashi M (2011) A useful immunohistochemical approach to evaluate intraductal proliferative lesions of the breast and to predict their prognosis. Histol Histopathol 26:79–86. CrossRefPubMedGoogle Scholar
  21. 21.
    Tse GM, Tan PH, Moriya T (2009) The role of immunohistochemistry in the differential diagnosis of papillary lesions of the breast. J Clin Pathol 62:407–413. CrossRefPubMedGoogle Scholar
  22. 22.
    Tan PH, Aw MY, Yip G et al (2005) 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 29:625–632. CrossRefPubMedGoogle Scholar
  23. 23.
    Grin A, O’Malley FP, Mulligan AM (2009) Cytokeratin 5 and estrogen receptor immunohistochemistry as a useful adjunct in identifying atypical papillary lesions on breast needle core biopsy. Am J Surg Pathol 33:1615–1623. CrossRefPubMedGoogle Scholar
  24. 24.
    Schnitt S, Collins L (2008) Papillary lesions. In: Epstein JI (ed) Biopsy interpretation of the breast. Wolters Kluwer, Philadelphia, pp 205–235Google Scholar
  25. 25.
    Tavassoli F, Devilee P (1999) Papillary lesions. In: Tavassoli F (ed) Pathology of the Breast, 2nd edn. McGraw-Hill, New York, pp 325–372Google Scholar
  26. 26.
    Tan PH, Schnitt SJ, van der Vijver MJ, Ellis IO, Lakhani SR (2015) Papillary and neuroendocrine breast lesions: the WHO stance. Histopathology 66:761–770. CrossRefPubMedGoogle Scholar
  27. 27.
    Page DL, Salhany KE, Jensen RA, Dupont WD (1996) Subsequent breast carcinoma risk after biopsy with atypia in a breast papilloma. Cancer 78:258–266.;2-V CrossRefPubMedGoogle Scholar
  28. 28.
    Lewis JT, Hartmann LC, Vierkant RA et al (2006) An analysis of breast cancer risk in women with single, multiple, and atypical papilloma. Am J Surg Pathol 30:665–672CrossRefGoogle Scholar
  29. 29.
    Putti TC, Pinder SE, Elston CW, Lee AH, Ellis IO (2005) Breast pathology practice: most common problems in a consultation service. Histopathology 47:445–457. CrossRefPubMedGoogle Scholar
  30. 30.
    McKevitt E, Warburton R, Pao J, Kuusk U, Dingee C, Brown C (2017) Breast cancer surgery wait times exceeding targets with current OR allocation methodology. Meeting of the British Columbia Surgical Society, Parksville, BC, May 2017Google Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of SurgeryProvidence Health Care Breast Centre & University of British ColumbiaVancouverCanada
  2. 2.Department of Pathology and Laboratory MedicineSt. Paul’s HospitalVancouverCanada
  3. 3.Providence Breast CentreMount Saint Joseph HospitalVancouverCanada

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