What is the recommended treatment for a breast papilloma?

Breast Papilloma Treatment

Surgical excision is recommended for all breast papillary lesions due to the significant risk of upgrade to malignancy (up to 21.4%) and the inability to reliably distinguish benign from malignant lesions on imaging or core biopsy alone. 1, 2

Initial Diagnostic Approach

When a breast papilloma is suspected or diagnosed on core needle biopsy, the following evaluation is mandatory:

• Obtain bilateral diagnostic mammography as the initial imaging study 1
• Perform targeted ultrasound of the affected breast, as it is more sensitive than mammography for detecting papillary lesions 1
• Core needle biopsy (CNB) is preferred over fine needle aspiration for tissue diagnosis prior to any surgical procedure 1

Management Based on Core Biopsy Results

Benign Papilloma on Core Biopsy

Surgical excision should still be performed despite a benign diagnosis on core biopsy 1, 3, 4. The rationale includes:

• The upgrade rate to malignancy ranges from 0-21.4% even when core biopsy shows benign papilloma 5, 2
• Imaging features cannot reliably differentiate benign from malignant papillary lesions 3
• Complete histopathological examination of the entire lesion is necessary to rule out focal atypia or carcinoma 4

Exception: Some recent evidence suggests that surgical excision may not be required for benign papillomas diagnosed on 11-gauge vacuum-assisted breast biopsy (upgrade rate 0%), but this remains controversial and excision is still generally recommended 5

Atypical Papilloma on Core Biopsy

Immediate surgical excision is mandatory 1, 5. Key considerations:

• Upgrade rate to malignancy is 18.2% for atypical papillomas 5
• These lesions fall into the B3 category (lesion of uncertain malignant potential) requiring excision 6
• The presence of atypia on core biopsy is significantly associated with malignancy at final excision (P = 0.031) 5

Papillary Lesions with DCIS, LCIS, or Other High-Risk Features

Surgical excision is required with the following specifications 1:

• Ensure negative margins on all resected tissue
• If margins are positive or close, re-excision is necessary
• Consider risk-reduction therapy according to breast cancer risk reduction guidelines 1
• Maintain regular breast cancer screening following treatment 1

Surgical Technique

The surgical approach should prioritize complete excision while preserving cosmesis:

• Use curvilinear skin incisions following Langer's lines for optimal cosmetic results 1
• Excise the lesion with a rim of grossly normal tissue without excessive sacrifice of breast tissue 1
• Close skin with subcuticular technique to minimize visible scarring 1
• Preserve subcutaneous tissue with separate closure to improve cosmetic outcome 1
• For non-palpable lesions, perform needle localization under ultrasound guidance prior to excision 2

Post-Excision Management

If Final Pathology Shows Benign Papilloma

• Return to routine breast cancer screening 1
• No additional follow-up is required beyond standard screening, as solitary benign papillomas do not significantly increase cancer risk 4

If Final Pathology Shows Atypical Hyperplasia or LCIS

• Consider risk-reduction therapy per breast cancer risk reduction guidelines 1
• Counsel patient to maintain regular breast screening with annual mammography 1
• For multiple papillomas, annual surveillance with digital mammography is recommended due to increased cancer risk 4

If Final Pathology Shows Malignancy

• Treat according to breast cancer treatment guidelines based on stage and tumor characteristics 1
• Ensure adequate margins were achieved; if not, re-excision or mastectomy may be required 1

Common Pitfalls to Avoid

• Do not rely on imaging alone to determine benignity—tissue diagnosis is essential 3
• Do not assume concordance between core biopsy and final pathology—upgrade rates are significant even for "benign" papillomas 5, 2
• Do not perform frozen section examination on papillary lesions, as distinguishing atypical hyperplasia from DCIS is impossible on frozen sections 1
• Do not observe papillary lesions without excision, even if they appear benign on imaging and core biopsy 1, 3