Diagnosis of Papillary Breast Lesions on Core Needle Biopsy: Upgrade Rates and Interobserver Variability

Abstract

The histologic distinction between papillary breast lesions remains challenging, especially with core biopsy (CB) specimens. A retrospective review of the clinical, imaging, and histologic findings was performed for patients with papillary breast lesions on CB from 2013 to 2017. The interpretation accuracy was expressed as upgrade rate relative to the excision diagnosis. Diagnostic reproducibility with and without immunohistochemistry was analyzed as interobserver variability among 3 board-certified pathologists. Among 57 papillary lesions with biopsies and excisions available for review, the upgrade rates were 0% for benign papilloma, 30% for papilloma with atypical ductal hyperplasia, and 25% for papilloma with ductal carcinoma in situ, resulting in an overall upgrade rate of 11.1%. There were no statistical differences between patients in an upgrade group and others, when comparing the patient age, clinical presentation, BI-RADS (Breast Imaging Reporting and Database System) category, location, and histologic grade. The overall interobserver variability of the 60 consecutive core biopsies of papillary breast lesions by morphology alone was in the “substantial” agreement range (κ = 0.79, 86% agreement), with an excellent κ score of 0.88 for papilloma (92% agreement). “Substantial” and “fair” κ values were seen for papilloma with atypical ductal hyperplasia/ductal carcinoma in situ (0.74, 84% agreement) and invasive carcinoma (0.40, 60% agreement). Use of immunohistochemical stains improved the κ values into “excellent” range (0.92, 94% agreement). Our study favors a conservative approach in the management of benign papillomas, at least in cases of good radiologic-pathologic concordance. Papillary breast lesions with atypia/malignancy show lower diagnostic reproducibility on CB, and utility of immunohistochemistry is recommended in challenging cases.

A multicenter study of interobserver variability in pathologic diagnosis of papillary breast lesions on core needle biopsy with WHO classification

“…Our study was performed to assess interobserver variability within 10 diagnostic categories among 20 pathologists. The number of pathologists and diagnostic categories is greater than those of other studies conducted with three pathologists with seven categories [11] and four pathologists with five categories [12].…”

Papillary lesions of the breast: A systematic evaluation of cytologic parameters

“…Even the diagnosis of papillary lesions by core needle biopsy is difficult, and this technique has failed to demonstrate much higher diagnostic accuracy in comparison with fine‐needle aspiration cytology (FNAC) 3,9 . Indeed, in core needle biopsy, there is significant underdiagnosis because the upgrade rate from benign/atypical papillary lesions to atypical/malignant lesions at excisions has been reported to be as high as 35% 10‐15 …”

“…3,9 Indeed, in core needle biopsy, there is significant underdiagnosis because the upgrade rate from benign/atypical papillary lesions to atypical/malignant lesions at excisions has been reported to be as high as 35%. [10][11][12][13][14][15] Cancer Cytopathology August 2021 Different cytologic criteria have been suggested [2][3][4][5][6][16][17][18][19][20][21] for diagnosing and grading papillary lesions, and this lack of uniformity highlights the difficulties encountered in routine practice.…”

Artefactual Epithelial Displacement in a Papilloma with Extensive Usual Duct Hyperplasia Mimics a Solid Papillary Carcinoma with Invasive Growth

“…Surgical excision was undertaken since papillomas are regarded as “B3 lesions,” ie, benign lesions with uncertain malignant potential. Although upgrade towards invasive carcinoma is more frequently observed in intraductal papillomas containing atypical ductal hyperplasia or ductal carcinoma in situ, 7 the institutional treatment guidelines in our hospital recommend the surgical excision of all intraductal papillomas.…”