What are the risks of an intraductal papilloma?

From the Guidelines

Intraductal papillomas carry a risk of upgrade to malignancy, with reported rates between 3% and 14%, and thus, management typically involves surgical removal through an excisional biopsy to exclude malignancy and alleviate symptoms. The symptoms of intraductal papillomas, such as nipple discharge and breast lumps, can mimic those of more serious conditions, potentially leading to delayed diagnosis of other breast diseases 1. Complications may include infection of the affected duct, causing pain and inflammation.

Risks and Complications

• Infection of the affected duct
• Pain and inflammation
• Delayed diagnosis of other breast diseases due to similar symptoms
• Risk of upgrade to malignancy, particularly in women with a family history of breast cancer or those with atypical cells or multiple papillomas 1

Management

• Surgical removal of the papilloma through an excisional biopsy, which serves both diagnostic and therapeutic purposes 1
• Regular breast cancer screening after removal to monitor for any changes, especially for those with atypical cells found in the removed tissue
• Image-guided core biopsy, particularly vacuum-assisted core biopsy, may be useful in diagnosing and managing intraductal papillomas, but may not be sufficient to exclude malignancy in all cases 1

Important Considerations

• The decision to perform percutaneous biopsy versus major duct excision should involve the patient and their health care provider 1
• Major duct excision remains the reference standard to exclude malignancy in patients with unremarkable imaging 1

From the Research

Risks of Intraductal Papilloma

The risks associated with intraductal papilloma include:

• Upgrade to malignancy: Studies have shown that intraductal papillomas can harbor occult carcinoma, and there is a risk of upgrade to malignancy after surgical excision 2, 3.
• Association with surrounding malignant pathology: Intraductal papillomas can be associated with surrounding malignant pathology, making it difficult to diagnose and treat 2.
• Recurrence: There is a risk of recurrence after surgical excision, especially if the lesion is not completely removed 4.
• Difficulty in diagnosis: Intraductal papillomas can be difficult to diagnose, and the diagnosis may not be accurate until after surgical excision 2, 3.

Upgrade Rates

The upgrade rates for intraductal papillomas vary depending on the study, but they range from 7.1% to 22.72% 2, 3.

• A study found that 2 out of 28 patients (7.1%) had an upgrade from benign intraductal papilloma to intraductal papilloma with atypia, and 1 patient (3.6%) had an upgrade to ductal carcinoma in situ 2.
• Another study found that the upgrade percentage was 22.72%, with 5 out of 22 patients having an in-situ or invasive component during surgical excision 3.

Management

The management of intraductal papillomas is controversial, but most studies recommend surgical excision to rule out malignancy 2, 3.

• A study recommends a more aggressive approach, including surgical excision of all benign intraductal papillary lesions 2.
• Another study suggests that vacuum excision is sufficient for lesions without atypia, but surgical excision with clearance of margins is advocated for lesions with atypia 3.