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Received: 2 July 2019    Revised: 5 September 2019    Accepted: 6 September 2019

DOI: 10.1111/tbj.13642

ORIGINAL ARTICLE

Benign breast papilloma: Is surgical excision necessary?

Alice Moynihan MB, BCh, BAO, MRCSI1  | Edel M. Quinn MB, BCh, BAO, MD, FRCS1 |
Clare S. Smith MB, BCh, BAO, FRCR2 | Maurice Stokes MB, BCh, BAO, MCh, FRCSI1 |
Malcolm Kell MBChB, FRCSI, FRCS, MD1 | John Mitchel Barry MB, BCh, BAO, LRCP&SI, H
Dip, MD, FRCSI1 | Siun M. Walsh MB, FRCS1

1
Department of Breast Surgery, Breast
Health Unit, Mater Misericordiae University
Hospital, Dublin, Ireland
2
Department of Breast Radiology, Breast
Health Unit, Mater Misericordiae University
Hospital, Dublin, Ireland
Correspondence
Alice Moynihan, Department of Breast
Surgery, Breast Health Unit, Mater
Misericordiae University Hospital, Dublin,
Ireland.
Email: alice.moynihan@ucdconnect.ie
Abstract
In many centers internationally, current standard of care is to excise all papillomas
of the breast, despite recently reported low rates of upgrade to malignancy on final
excision. The objective of this study was to determine the upgrade rate to malignancy
in patients with papilloma without atypia. A retrospective review of a prospectively
maintained database of all cases of benign intraductal papilloma in a tertiary referral
symptomatic breast unit between July 2008 and July 2018 was performed. Patients
with evidence of malignancy or atypia on core biopsy and those with a history of
breast cancer or genetic mutations predisposing to breast cancer were excluded.
One hundred and seventy‐three cases of benign papilloma diagnosed on core biopsy
were identified. Following exclusions, the final cohort comprised of 138 patients.
Mean age at presentation was 51. Mean follow‐up time was 9.6 months. The most
common symptom was a lump (40%). Of the 124 patients who underwent excision,
three had ductal carcinoma in situ and there were no cases of invasive disease, giving
an upgrade rate to malignancy of 2.4%. Upgrade to other high‐risk lesions (atypical
lobular and ductal hyperplasia and lobular carcinoma in situ) was demonstrated in 15
cases (12.1%). Benign papilloma was confirmed in 100 cases (81.5%), and 6 (4.8%) had
no residual papilloma found on final excision. Twelve patients (8.7%) were managed
conservatively. Of those, one later went on to develop malignancy. Patients with a di‐
agnosis of benign papilloma without atypia on core biopsy have a low risk of upgrade
to malignancy on final pathology, suggesting that observation may be a safe alterna‐
tive to surgical excision. Further research is warranted to determine which patients
can be safely managed conservatively.

KEYWORDS
benign breast, breast papilloma, breast papilloma excision, breast papilloma management

1 |  I NTRO D U C TI O N increased screening and imaging in general, papillary lesions are
being detected more frequently. Papillary lesions with atypia always
Papillary lesions of the breast encompass a wide range of disease warrant excision due to the high risk of carcinoma on final histolog‐
from benign papillomas to invasive papillary carcinomas. Due to ical evaluation.1,2 However, in recent years there has been a trend

Breast J. 2019;00:1–6. © 2019 Wiley Periodicals, Inc. |  1

wileyonlinelibrary.com/journal/tbj  
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2       MOYNIHAN et al.

toward the conservative management of papillomas without atypia, most common presenting symptom was a lump, seen in 56 cases
given the low reported rates of upgrade to in situ or invasive can‐ (40.58%). Blood‐stained nipple discharge was reported by 33
cer. Recently published studies cite rates of upgrade to malignancy (23.91%) and nonbloody nipple discharge by 26 (18.84%). Mastalgia
ranging from 0% to 8.9%.1,3-8 Current standard of care in many in‐ was reported by 13 (9.42%), nipple changes by 6 (4.35%), and nodu‐
stitutions worldwide is to excise all benign papillomas of the breast larity by 5 (3.62%). Of the 59 women who presented with a palpable
detected on core biopsy. This is largely due to concern that percuta‐ abnormality (lump or nodularity), the area of clinical concern was
neous biopsy may not yield a representative sample. In recent years, concordant with the area of radiological and histological findings in
a number of studies have been published attempting to clarify the 53 cases (89.83%). Other methods of detection were through inci‐
most appropriate treatment action for these patients, producing dental finding on CT performed for an unrelated issue (1.45%), or
1,3-8
conflicting results and recommendations. finding on mammograms performed as employee health screening
The objective of this study was to determine the rate of upgrade (n = 1, 0.72%), family history surveillance (n = 1, 0.72%), or patient
to malignancy and potential role for nonoperative management in a concern (n = 1, 0.72%). Twenty‐nine patients (21%) had a normal
symptomatic population diagnosed with papilloma with no atypia on breast examination, while 99 (72%) had a palpable but nonsuspicious
core needle biopsy. lump. Ten (7.2%) had a palpable lump concerning for malignancy.
Following mammogram and/or ultrasound, 1 (0.72%) patient was
classified as BI‐RADS category 2, 16 (11.59%) were classified cat‐
2 |  M E TH O DS egory 4, 3 (2.17%) were classified category five with the remaining
118 (85.51%) being classified category 3. Overall, the radiographic/
We carried out a retrospective review of a prospectively maintained histological concordance was 86% (Table 1).
database of all core needle biopsies carried out on patients referred
by their general practitioner with concerning breast symptoms be‐
3.2 | Final pathology
tween July 2008 and July 2018. We selected all cases of benign in‐
traductal papilloma diagnosed by core needle biopsy and excluded Overall, 124 (89.8%) patients opted for excision in order to achieve
cases with evidence of malignancy or atypia on core biopsy. Patients a definitive diagnosis. Of these, 120 (96.77%) patients underwent
with a previous history of breast cancer and/or confirmed genetic surgical excision and 4 (3.23%) underwent vacuum‐assisted excision.
mutations predisposing to breast cancer were also excluded. Data The remaining 12 (8.70%) patients were managed conservatively.
on other previous cancers were not collected. Age at presentation,
presenting symptom, radiological findings, and final histopathologi‐ TA B L E 1   Patient characteristics
cal diagnosis were recorded. Upgrade to malignancy was defined
  n (%)
as the presence of in situ or invasive carcinoma on final excision.
a
Presenting symptom
Atypical ductal hyperplasia, atypical lobular hyperplasia, and lobular
carcinoma in situ were classified as upgrade to “high risk” lesions. Bloody discharge 33 (23.9)
Lump 56 (40.6)
Nipple changes 6 (4.4)
3 |   R E S U LT S Nodularity 5 (3.6)
Nonbloody discharge 26 (18.8)
We identified 173 cases of papilloma diagnosed by core needle bi‐ Pain 13 (9.4)
opsy between July 2008 and July 2018. Of these, five had evidence Incidental finding on imaging 5 (3.6)
of malignancy on initial core biopsy and a further 13 had evidence of
Physical findings
atypia on core biopsy, leaving 155 papillomas without atypia. Nine
Normal examination (S1) 11 (7.97)
of these cases were lost to follow‐up after their original biopsy, con‐
Benign variation (S2) 18 (13.04)
tinuing their care in alternative hospitals. Of the remaining cases,
Palpable lump, likely benign (S3) 99 (71.74)
five had a previous history of breast cancer occurring a mean of
Palpable lump suspicious for malignancy (S4) 10 (7.25)
21.2 years previously. One had a concurrent breast cancer of the
contralateral side. One case had a first degree relative confirmed to Imaging

carry the BRCA genetic mutation and another had a personal diag‐ Normal imaging (R1) 0 (0)

nosis of Cowden syndrome. These cases were also excluded giving a Benign variation (R2) 1 (0.72)
total of 138 cases for analysis. Abnormal imaging likely benign (R3) 118 (85.51)
Abnormal imaging suspicious for malignancy (R4) 16 (11.59)
Abnormal imaging highly suggestive of malig‐ 3 (2.17)
3.1 | Patient characteristics
nancy (R5)
The mean age at presentation was 51.12, ranging from 20 to a
For patients presenting with more than one symptom, each symptom
94 years of age. There were no male cases in our study group. The was considered separately.
MOYNIHAN et al.
The decision for conservative management was a joint decision be‐
tween the patient and surgical team, with advanced age being the
most commonly cited reason patients opted for conservative man‐
agement. Of the 124 patients who underwent excision, none had
invasive carcinoma, but three were found to have DCIS on final his‐
tology giving an upgrade rate of 2.4%. Upgrade to high‐risk lesions
(ALH, ADH, LCIS) was seen in a further 15 patients (12.1%). One hun‐
dred and one (81.45%) were confirmed to have a benign papilloma
only, and in six cases, no residual papilloma was found. Imaging on
the day of planned surgery showed no residual corresponding lesion
in two patients. We did not find a significant association between
upgrade and nipple discharge, bloody nipple discharge, presence of a
palpable lump, or suspicious radiological findings (Table 2). The mean
age at diagnosis of those not upgraded was 49.66 years, and of those
upgraded was 51.5 years. This difference was not significant.
3.3 | Patient outcomes
Of those cases with DCIS on final histology, patient A had 28 mm
of DCIS, with a positive inferior margin and so proceeded to sur‐
gery to excise the original margins followed by adjuvant radiation.
She was followed with annual mammographic surveillance which
detected a lesion on the contralateral breast the following year. This
was ultimately found to be T1N0 ER PR positive grade II invasive
mucinous carcinoma following wide local excision and sentinel node
biopsy. She had adjuvant radiation and adjuvant tamoxifen therapy.
She is currently undergoing annual surveillance with mammography
and has no evidence of disease recurrence at follow‐up of 4 years.
Patient B was found to have 25 mm of low and intermediate grade
DCIS, present at the margin of excision. She had re‐excision of mar‐
gins which yielded further DCIS in all margins and also multifocal
invasive tubular carcinoma. She underwent completion mastectomy
with sentinel lymph node biopsy. A focus of T1a grade I invasive
ductal carcinoma was found in her mastectomy specimen. Sentinel
TA B L E 2   Association between patient characteristics and
upgrade to atypia or carcinoma
Characteristic Upgrade rate P‐value
Any nipple discharge
Yes 8/56 (14.3%, [95% CI 0.07‐0.25)] .947
No 10/68 (14.7% [95% CI 0.06‐0.23)]
Bloody nipple discharge
Yes 2/31 (6.5% [95% CI 0.01‐0.19)] .141
No 16/93 (17.2% [95% CI 0.11‐0.26)]
Lump
Yes 9/51 (17.6% [95% CI 0.09‐0.29)] .408
No 9/53 (12.3% [95% CI 0.06‐0.21)]
Suspicious radiological findings
Yes 4/17 (23.5% [95% CI 0.09‐0.47)] .256
No 14/107 (13.1% [95% CI 0.08‐0.2)]
Note: Chi‐square test used.
|
      3
lymph node biopsy was negative, and she is currently undergoing
annual mammographic surveillance and clinical review with no evi‐
dence of disease recurrence. Patient C had 30 mm of low grade DCIS,
with DCIS < 1 mm from the margin of excision. She had re‐excision of
margins followed by radiotherapy. It was planned that she would be
followed with annual mammogram; she elected to continue her care
in an alternative hospital (Table 3).
Of those cases who were upgraded to high‐risk lesions, planned
follow‐up was with annual mammogram and clinical review for
5 years in 13/14 cases. One patient was followed with mammogram
at 1 year and then discharged. Amongst these patients, 1 developed
DCIS in her contralateral breast several years after her diagnosis of
ADH. One other patient developed a second papilloma while on sur‐
veillance which was excised and also found to be benign. There were
no developments of DCIS or invasive carcinoma in the ipsilateral
breast in any of the patients on surveillance after a mean follow‐up
of 2.9 years.
3.4 | Conservative management
Of the patients who were managed conservatively, one went on
to develop malignancy. Of note, there was discordance between
this patient's biopsy result and radiographic features, having been
given an R5 grading radiographically. She was aged 94 at the time
of diagnosis and elected for conservative, and ultimately palliative,
management. She was seen in clinic at 6 months postdiagnosis and
died the following year. Follow‐up of the other patients was variable;
three patients were followed with annual mammograms for 5 years,
one patient had a single mammogram at 1 year while one patient
underwent US at 6 months. Two patients were referred to the family
history clinic where they are under annual mammographic surveil‐
lance. Four patients had no further follow‐up. None of these pa‐
tients developed further lesions or cancer. None have re‐presented
with in situ or invasive cancer to date. Two of the patients who
initially opted for conservative management subsequently chose to
have their papillomas excised due to troublesome symptoms. Both
were benign on final histology.
4 | D I S CU S S I O N
Intraductal papillary lesions may be subdivided into those without
atypia, those with atypia and those with features of malignancy.
While there is agreement that those with features of atypia or malig‐
nancy should undergo surgical excision,8 the recommendations for
lesions without atypia are much less clear. The standard of care in
Ireland is excision of these lesions.
In the current study, the upgrade rate of papillomas without atypia
to invasive or in situ cancer on final excision was 2.4%. Upgrade to
a high‐risk lesion was seen in 11.67%. This is consistent with similar
previous studies (Table 4). Jaffer et al8 performed a retrospective re‐
view of 104 cases of intraductal papilloma without atypia managed
at a single center from 2000 to 2004. The upgrade rate to atypia,
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4       MOYNIHAN et al.

TA B L E 3   Summary of outcomes for patients upgraded to malignancy

Presenting symptom Classification Pathology Treatment Long‐term outcome

Nonbloody discharge S3 R3 DCIS Re‐excision of margins + RTX Developed contralateral invasive cancer 1 y later
Lump S4 R3 DCIS Re‐excision of margins + RTX Margins clear, undergoing surveillance elsewhere
Bloody discharge S4 R3 DCIS Completion mastectomy—IDC in On surveillance with no disease recurrence
mastectomy specimen

TA B L E 4   Summary of literature review

Upgrade to Upgrade to Follow‐up duration of Patients who de-

Study N (excision) N (conservative) high risk malignancy conservative cases veloped cancer

Current study 124 – 11.7 2.4% – –

15
Nayak 30 50 – 3.8% >2 y 0
Parej4 166 24 ‐ 2.3% Mean 23.5 mo 0
5
Swapp 224 100 16% 3% Mean 36 mo 0
Jaffer6 14 24 0 0 >12 mo 0
7
Tatarian 75 44 21.3% 2.7% 31.4 mo 2.3%
Richter‐Ehrenstein1 132a 19 – 8.9%b 4 y 0
8
Jaffer 104 96 7.7% 8.7% – –
a
Includes 71 cases that underwent surgical excision alone without core biopsy.
b
Included atypia in overall upgrade rate.

in situ, or invasive carcinoma was found to be 16.4%, leading to the
recommendation that papillomas without atypia should be excised
completely. Tatarian et al7 also retrospectively reviewed 119 cases
of intraductal papilloma without atypia, of which 63% underwent
surgical excision. Upgrade to in situ or invasive carcinoma was seen
in 2.7% of patients and 21% were found to have atypia, leading again
to a recommendation that all intraductal papillary lesions be excised.
Rizzo et al also advocated for the surgical excision of all papillary
lesions following their retrospective review of 276 patients.9 Of
those patients without atypia on core biopsy, 26.9% were upgraded
on final histology to ADH (17.9%), DCIS (8.1%), or invasive ductal
carcinoma (0.9%).
Conversely, there have also been several studies reporting low
upgrade rates, in which conservative management has been advo‐
cated. Han et al10 published a study of 511 cases of IDP without
atypia of which 398 were treated with surgical excision. Only 0.8%
were upgraded to a diagnosis of malignancy and 4.4% to a high‐risk
5
lesion. Similarly, Swapp et al retrospectively reviewed 299 papillo‐
mas, of which 77 patients were managed surgically, and reported no
upgrades in either the excision or surveillance cohort after a mean
surveillance period of 36 months. It is important to note however
that 32% of patients were lost to follow‐up. These findings are sup‐
ported by a similar study by Nayak et al3 who reported an upgrade
rate of 3.8% among their study group. They advised that for small
asymptomatic lesions  <  1.5  cm or those that had been sampled
with vacuum assistance, surgical excision was not required. This is
similar to the recommendation of Richter Ehrenstein et al1 who ad‐
vised that, for small lesions without evidence of atypia that have
been completely excised by core needle biopsy, it is acceptable to
follow‐up radiologically without surgical excision. Both of these
studies recommend surgical excision for lesions with atypia. Several
other similar studies with upgrade rates ranging from 2% to 3% con‐
curred with these findings.11,12 A study by Wang et al 13
published
in 2019 looked at the suitability of vacuum‐assisted excision as both
a diagnostic and therapeutic tool in the management of these le‐
sions. This group looked at 101 findings of intraductal papilloma on
7‐gauge VAE. All patients were subsequently followed with either
surgical excision or follow‐up ultrasound. The overall upgrade rate
was 18% with a diagnostic accuracy of 99%. They concluded that,
for papillomas excised via 7‐gauge VAE and confirmed as benign
on histology, no further intervention was warranted. However, for
those showing moderate to severe atypical hyperplasia, surgical ex‐
cision was recommended.
Researchers have endeavored to identify predictors of upgrade
in order to select patients who may be suitable for conservative man‐
agement. In our study, we did not find any association between pre‐
senting complaint or radiological findings and upgrade rate. Jaffer et
al8 found no correlation between radiological features, core biopsy
needle size or histological features and subsequent malignancy or
atypia on excision. Consistent with our findings, the clinical pres‐
ence of a mass or nipple discharge was not found to be predictors
of upgrade. Rizzo et al noted, as expected, that those patients with
atypia in the original core biopsy sample had a statistically significant
higher rate of upgrade to a lesion of more clinical significance—38%
overall (P < .0001). In our study, we excluded patients with atypia on
CNB. Rizzo at al, however, found age to be a statistically significant
risk factor for upgrade. No other risk factor was found to be predic‐
tive. In contrast, we did not find age to be a predictor of upgrade.
MOYNIHAN et al.
Han et al10 found that after excluding patients with a clinically
concerning palpable mass, no patients were upgraded to malignancy.
The presence of a symptom, concurrent contralateral breast cancer,
and multifocal lesions was all predictive of upgrade to malignancy.
Size of the lesion did not correlate with upgrade. These findings led
the group to recommend conservative management of IDP without
atypia for patients without clinically concerning symptoms or con‐
current contralateral breast cancer.
Pareja et al4 also attempted to identify predictors of upgrade at
excision. Amongst 189 cases of intraductal papilloma without atypia
diagnosed, four lesions (2.3%) were upgraded to either DCIS or inva‐
sive carcinoma following excision. IPD fragmentation in core needle
biopsy and concurrent ipsilateral breast carcinoma were both found
to be predictive of upgrade.
Historically, bloody nipple discharge has been a cause of sig‐
nificant concern to both patients and clinicians alike. However, as
discussed, there has been very little evidence in the literature to sup‐
port this association. In addition to the perceived association with
increased risk of malignancy, nipple discharge commonly causes dis‐
tress to patients. Two patients in our study who had initially been
managed conservatively later opted for excision due to the distress‐
ing nature of their discharge.
There are few studies which have studied the natural history of
papillomas without atypia which have not been surgically excised.
Tatarian et al7 followed 119 conservatively managed patients for a
mean of 32 months, one (2.3%) developed invasive disease at a sep‐
arate site in the same breast 6 months later. Swapp et al5 managed
147 patients with papilloma conservatively, and followed them for a
mean of 36 months. There was no progression reported and so they
recommended conservative management of papillomas without
features of atypia in patients with concordant imaging and biopsy
findings, who do not have concurrent breast disease in the same
quadrant as the papilloma. They highlighted that their recommen‐
dations are only applicable to cancer institutions where all imaging
and biopsy results are reviewed by specialist breast radiologists and
pathologists.
Weisman et al14 theorized that one of the reasons for the wide
variability in upgrade rates across the literature is the failure of other
authors to consider the different histological subtypes as different en‐
tities. In their retrospective review published in 2013, they stratified
IDPs into three histological subgroups: micropapilloma, fragmented
intraductal papilloma, and atypical papilloma. Amongst micropapil‐
loma and fragmented intraductal papilloma groups, there were no up‐
grades on surgical excision, nor was there any radiological evidence
of progression for those managed conservatively at a follow‐up of
50‐61 months. The authors recommended conservative management
for patients without evidence of atypia, while those with atypia or ma‐
lignancy in core biopsy should proceed to surgical excision. In the study
by Pareja et al,4 24 women underwent radiological surveillance alone,
with a mean follow‐up time of 23 months. There was no radiological
progression found in any of these women.
Of note in our patient cohort, the three cases that were upgraded
to malignancy had DCIS rather than invasive disease. Of these, one
|
      5
was intermediate nuclear grade, one low grade with the third being
mixed low and intermediate grade, giving USC/VNPI15 of 8, 8, and 9,
respectively, warranting radiotherapy treatment. However, smaller
lesions with adequate margins might be suitable for management
with excision alone, rather than adjuvant radiotherapy, as per the
USC/VNPI.
Our study differs from many of those published previously in
that it focuses purely on a symptomatic cohort. These patients
are often the cases which cause most clinical concern in spite of
a lack of evidence associating symptoms with higher risk of malig‐
nancy. Our study is limited by its retrospective observational na‐
ture, leaving it open to selection and loss to follow‐up bias. While
the overall study numbers are small, limiting the statistical analyses
available, they are comparable to similar studies previously pub‐
lished. We minimized confounding bias by excluding patients with
previous history of breast cancer or genetic mutations associated
with increased cancer risk. However, we did not assess previous gy‐
necological cancer history as part of our data collection. Previous
studies have discussed the association between gynecological can‐
cers and breast cancer.16-18Of the patients managed conservatively,
long‐term follow‐up was variable, with 4 (33.3%) having no further
follow‐up in our institution. In order to consider the long‐term suc‐
cess of conservative management, far greater numbers of conserva‐
tively managed patients with consistent long‐term follow‐up would
be required in order to assess suitability of conservative manage‐
ment of these lesions. It is important to note that our cases were
all discussed at a breast cancer multidisciplinary meeting involving
specialized breast radiologists, histopathologists, and surgeons be‐
fore a course of treatment was advised. As such, our results are
only applicable to centers who have similar specialized resources
available. The importance of specialized radiologists and histopa‐
thologists when managing these lesions has also been highlighted
by other studies.4,5
Given these limitations, we cannot advise conservative manage‐
ment for all intraductal lesions without atypia. However, our study
further adds to the available evidence on this topic that this may be
a beneficial treatment option for certain patient groups. While, as
mentioned, numbers in these studies have been small, ranging from
14 to 224, they suggest that there may be a role for conservative
management with strict surveillance for selected papillomas without
atypia. However, criteria for selection of these patients remain un‐
clear, and longer follow‐up is needed. In particular, a large prospec‐
tive study or randomised control trial is warranted.
5 | CO N C LU S I O N S
Patients with a diagnosis of benign papilloma with no atypia on core
biopsy have a low risk of upgrade to malignancy on final pathology,
suggesting that observation may be a safe alternative to surgical
excision in selected cases. However, the available literature is re‐
stricted to small retrospective studies. There is currently no consen‐
sus regarding patient selection for conservative follow‐up, or mode,
 |
6       MOYNIHAN et al.

frequency or duration of follow‐up. Further study is warranted to and radiologic analysis of 276 cases with surgical follow‐up. J Am
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10. Han SH, Kim M, Chung YR, et al. Benign intraductal papilloma with‐
out atypia on core needle biopsy has a low rate of upgrading to
malignancy after excision. J Breast Cancer. 2018;21(1):80‐86.
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11. Sydnor MK, Wilson JD, Hijaz TA, Massey HD, Shaw, . de Paredes
Alice Moynihan  https://orcid.org/0000-0002-4513-936X ES. Underestimation of the presence of breast carcinoma in pap‐
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