Role of Mammography, Ultrasound and Large Core Biopsy in the Diagnostic Evaluation of Papillary Breast Lesions

Abstract

Background: It is well recognized that distinguishing benign from malignant papillary lesions of the breast may pose challenging diagnostic problems. To prospectively evaluate the potential role of mammography, ultrasound and image-guided core biopsy in the diagnosis of papillary lesions of the breast. Methods: 1,442 women consecutively underwent 14-gauge core biopsy and in 51 cases (3.5%) a diagnosis of papillary lesion was formulated. Both radiologists and pathologists independently expressed their degree of suspicion of malignancy (not suspicious, low, moderate, high) on the basis of radiological and core biopsy findings, respectively. Surgical excision of the lesion was used as gold standard and diagnostic agreement was assessed by the kappa statistic. Results: At surgery, 19 of the 49 (38.7%) resected cases had a diagnosis of malignancy. A poor agreement was found between mammography and core biopsy results in the categorization of suspicion of malignancy (k = 0.03). Similar data were obtained between ultrasound and core biopsy (k = 0.07). A poor agreement was also observed between radiological and surgical results (k < 0.20). In contrast, a good agreement was found between core biopsy and surgical samples (k > 0.70). However, 5 (26%) out of the 19 malignant cases at surgery were judged as benign or probably benign on core biopsy. Depending on how the categories of suspicion on core biopsy were set up, the range of sensitivity was 74–89%, whereas specificity ranged from 91 to 97%. Conclusions: Image-guided large core biopsy allows for a correct diagnosis in the majority of papillary lesions. However, its sensitivity is not good enough for surgical excision to be avoided.

Excision is indicated for intraductal papilloma of the breast diagnosed on core needle biopsy

“…Of the 104 cases, 30 were mammotome core needle biopsies, all done for calcifications (14-gauge) and 74 were ultrasound-guided (16-, 18-, or 20-gauge). The average number of ultrasound-guided core cylinders obtained per patient was 5 (range, [3][4][5][6][7][8][9][10][11][12]; for mammotome core needle biopsy it was 15 (range, [10][11][12][13][14][15][16][17][18][19][20]. The diagnoses on the excision specimens were as follows: no residual intraductal papillomas, 16 (15.3%); residual intraductal papillomas, 71 (68.3%); atypical duct hyperplasia, 8 (7.7%); ductal carcinoma in situ, 6 (5.8%); and invasive carcinoma, 3 (2.9%).…”

“…Regardless of the gauge of the biopsy instrument or the number of cores obtained, this sampling error persisted in our series. Whereas the use of larger gauge needles may decrease the risk of sampling error, it can never be eliminated or achieve the same sensitivity as excision as documented by Puglisi et al 17 Nevertheless, suction-assisted vacuum biopsy is currently being considered in an attempt to entirely remove intraductal papillomas in a relatively noninvasive manner. Although this method may be suitable for uncomplicated intraductal papillomas, generous sampling of the surrounding tissue is probably indicated in intraductal papillomas with atypia or malignancy, because atypia or malignancy may extend outside of the intraductal papillomas, as seen in approximately one-third of our cases.…”

Papillary lesions of the breast diagnosed using core needle biopsies

“…The presence or absence of a myoepithelial cell layer in the papillary component of the lesion is the most important feature for differentiating a benign papilloma from a papillary carcinoma. We reviewed 21 studies (including ours); 10 studies supported the need for surgical excision and 10 did not (Table IV) (3)(4)(5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22). There were 643 cases in these studies; 424 cases (65.9%) underwent excisional biopsies: 334 cases (78.8%) were diagnosed as benign; 27 were diagnosed as atypical ductal hyperplasia; 21 were non-invasive ductal carcinoma; and 27 were invasive ductal carcinoma.…”

Benign breast lesions: Ultrasound

“…US is also used as a guide for needle biopsy with vacuum-assisted devices, which is preferred to core biopsies because a greater amount of tissue is obtained (sometimes the entire lesion) with the possibility to make a more accurate histological diagnosis and often definitively stop the secretion [3,57].…”