Surgical pathology and upgrade following core biopsy of intraductal papillomas

Background: It has continued to be controversial regarding excision or observing intraductal papillomas (IPs) diagnosed on core needle biopsy (CNB) without other histopathological features. The risk of upgrading papillomas on excision has been quoted as high as 24.5%. Historical recommendations have been to excise all intraductal papillomas. However, this has become less controversial with a recent prospective study recommendation of excision only if atypia is present or the IP is palpable. The aim of this study is to determine if there are pathological features that may present in benign IPs that are indicative of high-risk disease and warrant complete surgical excision. Methods: In this retrospective study 133 patients with benign IPs were evaluated over the past 10 years from 2011 to 2021. One hundred and eleven patients underwent surgical excision. They were evaluated for upgrading to atypia, ductal carcinoma in situ (DCIS), or invasive carcinoma on final histopathology. Results: We found that a total of 12.6% of the patients were upgraded to atypia (8.1%) or malignancy (4.5%). Though multiple potential risk factors were studied, older patient age and peri- and post-menopause had a strong correlation, but were not statistically significant. The finding of microcalcifications in the CNB specimen correlated with upgrading. Eighty-six percent of papillomas that were upgraded to atypia or malignancy contained microcalcifications. Conclusions: All IPs having benign ductal epithelium on CNB and containing microcalcifications should be excised. When the patient is older and in the perimenopausal or postmenopausal age group, consideration should be given for excision. All other benign IPs on CNB can be safely observed.