What is the recommended management for breast papilloma?

Management of Breast Papillomas

Surgical excision is recommended for breast papillomas with atypical features, while benign papillomas without atypia may be managed conservatively with adequate follow-up. 1, 2

Diagnostic Approach

Initial Evaluation

• Bilateral mammography with or without ultrasound is the first-line imaging approach
• Ultrasound can detect small intraductal lesions but cannot reliably distinguish between benign and malignant pathology 3
• Ductography may be performed to localize the affected duct before excision, especially for patients with pathologic nipple discharge 1

Tissue Diagnosis

• Core needle biopsy (CNB) is preferred over fine needle aspiration (FNA) for histologic diagnosis 3
• Vacuum-assisted CNB is particularly useful for small intraductal papillary lesions 3, 1
• Place a tissue marker at the biopsy site if the lesion is likely to be completely removed during biopsy 1

Management Algorithm

For Papillomas with Atypia:

1. Surgical excision is mandatory due to high upgrade rates to malignancy:
   • 22.5% upgrade rate to carcinoma in surgically excised specimens 2
   • 37.5% false-negative rate for atypical papillomas initially diagnosed at core needle biopsy 4
   • 18.2% upgrade rate for atypical papillomas diagnosed at US-guided vacuum-assisted breast biopsy 5

For Benign Papillomas without Atypia:

1. Conservative management may be appropriate with adequate follow-up:
   • Only 3% upgrade rate to carcinoma in surgically excised specimens 2
   • 0% upgrade rate (0 of 49 cases) for benign papillomas diagnosed at US-guided vacuum-assisted breast biopsy 5
   • Non-mass-associated benign papillomas showed no upgrades (0/37) in one study 6

Special Considerations for Surgical Excision:

• Large papillomas (>1.5 cm) or peripherally located papillomas should undergo surgical excision regardless of atypia status 4
• Multiple papillomas have a higher risk of malignancy than solitary ones 1

Treatment Options

Vacuum-Assisted Excisional Biopsy

• Can be both diagnostic and therapeutic
• Results in cessation of nipple discharge in 90-97.2% of patients 3, 1
• Less invasive alternative to traditional surgical excision

Ductal Excision

• Standard treatment for pathological nipple discharge 1
• Ductography-guided vacuum-assisted stereotactic biopsy should not replace surgical duct excision due to:
  • High underestimation rate (50%) for high-risk lesions and DCIS
  • False-negative rate (7%)
  • Histopathological detection of lesion remnants in every case 3

Follow-up Recommendations

• Patients with solitary benign papillomas have insufficient increase in risk of subsequent malignancy to justify routine follow-up 7
• Patients with multiple papillomas have an increased risk of developing cancer and should be kept under annual review with regular mammography 7
• Digital mammography or MRI may be used for surveillance due to their high sensitivity 7

Clinical Pitfalls and Caveats

• Approximately 20% of DCIS cases diagnosed by percutaneous core-needle biopsy will have areas of invasive carcinoma found at the time of surgical excision 3
• Removal of lesions in multiple fragments should be avoided as this precludes margin assessment and size determination 3
• Meticulous hemostasis is critical as hematoma formation produces changes that are difficult to interpret on physical examination and mammography 3
• Periareolar incisions are not appropriate for lesions in the periphery of the breast 3

By following this evidence-based approach to breast papilloma management, clinicians can minimize unnecessary surgeries while ensuring appropriate treatment for lesions with higher malignancy potential.