Peripheral Papillomas Diagnosed by Core Biopsy: To Excise or Not Excise
I believe that it is fair to say that most surgeons excise peripheral papillary mass lesions diagnosed by core needle biopsy. This approach has been challenged in a number of papers most of which contain small numbers of patients. The largest cohort study, however, has been recently published by Kuehner et al from Kaiser Permanente Medical Group in the Annals of Surgical Oncology. Though this paper was recently mentioned and made available in the Breast Care Network Forum, I thought it worthwhile to unpack this paper and potentially impact papilloma management.
The cohort consisted of three groups, each managed differently. The largest group consisted of 327 patients (80%) managed by surgical excision. Sixty-one patients (15%) were managed by image surveillance and the final 19 patients (5%) had no radiologic follow-up during the study period. Though subjects generally well matched, surgical excision statistically more common in women with lesions greater than 1.5cm. This, of course, carries little importance since it is the surgical group that is of greatest interest.
Of those who underwent surgical excision, 9.5% were found to have a high-risk lesion (ADH 4.9%, ALH 1.2%, LCIS 0.9%, and atypical papilloma in 2.5%). The lesions were upgraded to DCIS in 3.4% and invasive cancer in 2.4%. Factors increasing the rate of upgrade included, lesions greater than 1 cm, a palpable mass, age greater than 50 and lesions greater than 5 cm from the nipple.
On the other hand, upgrade was less common amongst women with nipple discharge. One might assume that nipple discharge was most common among papillomas that involved large subareolar and lactiferous ducts which have a minimal risk of malignancy.
It should also be noted that those lesions that were upgraded to invasive cancer had favorable characteristics. Almost all women had T1a or T1b lesions that were low to intermediate grade. All but one patient was ER+.
Though there were only 61 patients who elected to undergo surveillance imaging, only 1 of the 61 was diagnosed with ADH during the 2-year followup period.
The authors suggest that the study supports that a conservative approach to the management of large papillomas is a reasonable alternative to surgical excision. However, prior to embarking on a imaging surveillance protocol with any patient, it is important to recognize that a little over 15% of lesions were upgraded to either a high-risk lesion, DCIS or invasive cancer.