Management of BIRADS 3, 4A, and 4B Lesions Diagnosed as Pure Papilloma by Ultrasound-Guided Core Needle Biopsy: Is Surgical Excision Necessary?

Acad Radiol. 2019 Jul;26(7):909-914. doi: 10.1016/j.acra.2018.08.014. Epub 2018 Oct 6.


Rationale and objectives: There is lack of consensus on managing papillomas due to varied upgrade rates in the literature related to variability in the studied populations. We specifically studied upgrade rates of pure papilloma diagnosed with ultrasound core biopsy (UCB) using spring-loaded (SLB) and vacuum-assisted (VAB) biopsy devices in patients with low-to-intermediate pre-test probability for malignancy on imaging.

Materials & methods: From 01/01/2008 to 06/30/2016, 227 patients with 248 pure papillomas classified as BI-RADS 3, 4a, and 4b were diagnosed by UCB and underwent surgical excision or clinical and/or imaging follow-up. Imaging features, biopsy device, and final pathology were documented.

Results: 177 lesions were biopsied with SLB (14-gauge) and 71 lesions with VAB (9-13 gauges). At surgery, upgrade rates to high-risk lesions and malignancy for SLB were 14.3% (22/154) and 1.9% (3/154), and for VAB were 3.5% (2/57) and 0% (0/57), respectively (p < 0.05). The combined surgical upgrade rate to high-risk lesions and malignancy was 11.4% (24/211) and 1.4% (3/211), respectively. The overall upgrade rate (including surgical and clinical and/or imaging follow-up) to high-risk lesions and malignancy was 9.7% (24/248) and 1.2% (3/248), respectively. No ultrasound features were predictive of upgrade. Rates of complete excision were 7.1% (11/154) for SLB and 19.3% (11/57) for VAB (p < 0.05).

Conclusion: BI-RADS 3, 4a, or 4b masses biopsied with UCB revealed pure papilloma upgrade to malignancy in less than 2% of cases. SLB was associated with greater upgrades compared with VAB. Therefore, follow-up imaging is a reasonable alternative to excision, particular in those sampled by VAB. Excision could be considered if the diagnosis of a high-risk lesion would change clinical management.

Keywords: Papilloma; Ultrasound; Ultrasound guided core biopsy; Upgrade rates.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Aged
  • Aged, 80 and over
  • Biopsy, Large-Core Needle / instrumentation
  • Biopsy, Large-Core Needle / methods
  • Breast Neoplasms / classification
  • Breast Neoplasms / diagnostic imaging*
  • Breast Neoplasms / pathology*
  • Breast Neoplasms / surgery
  • Female
  • Humans
  • Image-Guided Biopsy / instrumentation
  • Image-Guided Biopsy / methods
  • Middle Aged
  • Needles
  • Papilloma / classification
  • Papilloma / diagnostic imaging*
  • Papilloma / pathology*
  • Papilloma / surgery
  • Ultrasonography, Mammary
  • Young Adult