Raman Verma MD, Presenter: Nothing to Disclose

Jean M. Seely MD, Abstract Co-Author: Nothing to Disclose

Karl Richard Smyth MD, Abstract Co-Author: Nothing to Disclose

Kalesha Hack MD, Abstract Co-Author: Nothing to Disclose

Ania Zofia Kielar MD, Abstract Co-Author: Nothing to Disclose

Denis Gravel, Abstract Co-Author: Nothing to Disclose

Management of papillary lesions of the breast is controversial. There is general agreement that surgical excision is appropriate for biopsy-proven atypical or malignant papillary lesions. However, appropriate management of benign papillomas is disputed. Some authors believe histologically benign papillary lesions can be safely managed conservatively with follow-up imaging while others advocate excision of all papillary lesions, citing an unacceptably high rate of “histologic underestimation” by percutaneous biopsy. The purpose of this study was to examine whether biopsy with a newer, larger bore vacuum-assisted biopsy device improves diagnostic accuracy when compared to the traditional, smaller bore spring-activated devices.

Databases at two institutions were reviewed to identify all ultrasound-guided biopsy proven papillary lesions from January 1, 2002 – October 31, 2009. Patients with subsequent surgical resection or minimum of 12 month imaging follow-up were included. Pathology slides of the percutaneous biopsy specimens were reviewed by two pathologists experienced in breast biopsy interpretation. Histologic underestimation rates for lesions biopsied with a 14-gauge core needle device were compared to those for the 10 and 11 gauge vacuum-assisted device.

Of the 226 papillary lesions included, 169 had surgical excision and 57 had imaging follow-up (mean of 30 months). In group A, 126/226 (55.8%, mean age = 58) were biopsied with a 14G needle while group B, 100/226 (44.2%, mean age = 61) utilized vacuum assistance (10-11G). There were cases in both groups that were subsequently upgraded in the surgical specimen to higher grade dysplasia or invasive carcinoma; 15 (12%) with the 14G needle and 6 (6%) with the 10-11G needle (p=0.12). Benign papillomas represented 53% of the lesions upgraded in the core group compared to 33% with vacuum-assistance.

Benign papillary lesions biopsied with a 10 or 11 G vacuum-assisted device have a lower upgrade rate of 6% than lesions biopsied with 14G core needle device with an upgrade rate of 12%. However, the rate of histologic underestimation for both devices still exceeds the BI-RADS 3 2% risk of malignancy that can be safely followed.

All papillary lesions biopsied with core 14G devices should be excised, even without atypia. Although vacuum biopsy demonstrated a lower upgrade rate, close monitoring / excision is recommended. 

Verma, R, Seely, J, Smyth, K, Hack, K, Kielar, A, Gravel, D, Papillary Lesions of the Breast: Diagnostic Accuracy of Ultrasound-guided 14-Gauge Core Needle Compared to 10- and 11-Gauge Vacuum-assisted Biopsy Devices.  Radiological Society of North America 2011 Scientific Assembly and Annual Meeting, November 26 - December 2, 2011 ,Chicago IL. http://archive.rsna.org/2011/11004628.html