Diagnostic pitfall in radiological imaging after vacuum-assisted excision of B3 breast lesion: A case report.

The management of B3 breast lesions using vacuum-assisted excision (VAE) is gaining increasing traction in clinical practice. However, it is infrequently reported in the literature how this technique may affect long-term imaging appearances. We present a challenging case in which the previous VAE site displayed a mass-like appearance that mimicked breast cancer. The purpose of this case report is to share our experience and illustrate the ultrasound and mammographic characteristics of the residual cavity after VAE, in order to contribute to expanding knowledge regarding radiological imaging post-VAE, which is currently still limited.

First vacuum-assisted excision of a breast intraductal papilloma in the pediatric age group: Case report.

Intraductal papillomas (IP) are benign breast tumors that can occur in adolescents and young women, but they are extremely rare in pediatric age group and their occurrence in pediatric patients is not well documented in the medical literature [1,2]. The standard approach for IPs in teenagers involves conservative management with careful monitoring and follow-up imaging. However, in select cases, surgical intervention may be warranted to confirm the diagnosis and prevent complications such as bleeding or infection [3,4]. A novel, less invasive alternative to surgical excision is ultrasound-guided vacuum-assisted excision (VAE), which uses ultrasound to accurately target and extract the lesion using a vacuum-assisted device [4,5]. Compared to surgical excision, VAE offers the advantage of being a less invasive procedure, which leads to a decrease in the number of complications. Over the past 10 years, this method has become increasingly popular due to its ability to specifically and efficiently remove intraductal papilloma while minimizing risks and preserving the structure of the breast [5,6]. To our knowledge, this is the first documented use of VAE in a pediatric patient, as demonstrated in our case of a 9-year-old with nipple discharge successfully managed with VAE, highlighting its potential as a viable treatment option for pediatric breast lesions. This case highlights the potential use and success of VAE as a management option for breast lesions in pediatric patients. Further research and additional case reports are needed to further establish the efficacy and safety of this technique in this specific age group.

Vacuum-assisted excision: a safe minimally invasive option for benign phyllodes tumor diagnosis and treatment-a systematic review and meta-analysis.

Synopsis: This is a systematic review and meta-analysis comparing surgical excision with percutaneous ultrasound-guided vacuum-assisted excision (US-VAE) for the treatment of benign phyllodes tumor (PT) using local recurrence (LR) as the endpoint. Objective: To determine the frequency of local recurrence (LR) of benign phyllodes tumor (PT) after ultrasound-guided vacuum-assisted excision (US-VAE) compared to the frequency of LR after surgical excision. Method: A systematic review and meta-analysis [following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) standard] was conducted by comparing LR in women older than 18 years treated for benign PT by US-VAE compared with local surgical excision with at least 12 months of follow-up. Studies were retrieved from PubMed, Scopus, Web of Science, and Embase. The pooled effect measure used was the odds ratio (OR) of recurrence. Results: Five comparative prospective or retrospective observational studies published between January 1, 1992, and January 10, 2022, comparing surgical excision with percutaneous US-VAE for LR of benign PT met the selection criteria. Four were retrospective observational cohorts, and one was a prospective observational cohort. A total of 778 women were followed up. Of them, 439 (56.4%) underwent local surgical excision, and 339 (43.6%) patients had US-VAE. The median age of patients in the five studies ranged from 33.7 to 39 years; the median size ranged from 1.5 cm to 3.0 cm, and the median follow-up ranged from 12 months to 46.6 months. The needle gauge ranged from 7G to 11G. LR rates were not statically significant between US-VAE and surgical excision (41 of 339 versus 34 of 439; OR 1.3; p = 0.29). Conclusion: This meta-analysis suggests that using US-VAE for the removal of benign PT does not increase local regional recurrence and is a safe minimally invasive therapeutic option. Systematic review registration: https://www.crd.york.ac.uk/prospero/, identifier CRD42022309782.

Nonsurgical Management of High-Risk Lesions.

This article highlights the recent publications and changing trends in practice regarding management of high-risk lesions of the breast. Traditional management has always been a surgical operation but this is recognized as overtreatment. It is recognized that overdiagnosis is inevitable but what we can control is overtreatment. Vacuum-assisted excision is now established as an alternative technique to surgery for further sampling of these high-risk lesions in the United Kingdom. Guidelines from the United Kingdom and Europe now recognize this alternative pathway, and data are available showing that vacuum-assisted excision is a safe alternative to surgery.

Ultrasound-guided vacuum-assisted excision for idiopathic granulomatous mastitis at the abscess stage.

BACKGROUND: Idiopathic granulomatous mastitis (IGM) is a rare inflammatory disease of the breast with clinical features that are often confused with those of breast cancer leading to delayed diagnosis and treatment. This retrospective study aimed to evaluate the therapeutic effectiveness and cosmetic results of drainage surgery using ultrasound-guided vacuum-assisted excision (VAE) for the treatment of IGM at the abscess stage. METHODS: The time of recovery, cases of further surgical intervention, and cosmetic results were retrospectively collected and analyzed from patients who underwent drainage with VAE or conventional drainage between October 2017 and August 2021. RESULTS: A total of 65 patients diagnosed with IGM at the abscess stage who underwent drainage surgery with VAE or conventional drainage surgery were enrolled. Overall, 38 (58.5%) underwent conventional drainage surgery and 27 (41.5%) underwent drainage with VAE. We found that patients who underwent VAE recovered much faster than those who underwent traditional drainage surgery (30.1 vs. 48.0 days). Nine (33.3%) patients in the VAE group required further surgical intervention after drainage, whereas 33 (86.8%) patients in the control group underwent another surgery to resect residual lesions. Additionally, patients in the VAE group were more satisfied with the breast appearance, mainly due to less influence of the scars and better symmetry of their breasts. CONCLUSION: Compared with conventional drainage surgery, drainage surgery using VAE for IGM patients at the abscess stage improved therapeutic and cosmetic outcomes. Furthermore, postoperative management of IGM is crucial.

Minimally invasive treatment of early, good prognosis breast cancer-is this feasible?

Breast cancer screening programmes frequently detect early, good prognosis breast cancers with significant treatment burden for patients, and associated health-cost implications. Emerging evidence suggests a role for minimally invasive techniques in the management of these patients enabling many women to avoid surgical intervention. Minimally invasive techniques include vacuum-assisted excision, cryoablation, and radiofrequency ablation. We review published evidence in relation to the risks and benefits of each technique and discuss ongoing trials. Data to date are promising, and we predict a trend towards minimally invasive treatment for early, good-prognosis breast cancer as technical skills, suitability criteria, and follow-up protocols are established.

Malignancy mimic: Suspicious mammographic and sonographic findings post-vacuum-assisted excision biopsy.

Vacuum-assisted excision biopsy (VAEB) provides a safe alternative to surgical excision for selected (low-risk) B3 breast lesions. We report a case of imaging findings that mimicked malignancy in a patient one year post-VAEB. Awareness of this entity is important to prevent misdiagnosis and unnecessary surgical excision.

Vacuum-assisted excision of small breast cancers under ultrasound guidance.

PURPOSE: The purpose of this study was to evaluate if it is possible to completely remove small breast cancer tumours with vacuum-assisted excision (VAE) under ultrasound guidance. METHODS: Women ≥ 50 years old with a biopsy proven invasive cancer ≤ 10 mm were selected between October 2021 and November 2021 based on referrals and enrolled in this prospective study. The patients underwent VAE within six weeks following biopsy to remove the tumour. After the tumour was excised and the biopsy cavities margins were shaved, a radioactive seed was inserted into the biopsy cavity. The VAE excision cavity and surrounding tissue were surgically excised. Preliminary VAE results were evaluated after ten patients. For the study to proceed at least 80 % of the breast cancer tumours had to be completely removed by VAE. RESULTS: The tumours median size in mammography was 8.5 mm (6-9 mm) and in ultrasound 6.5 mm (4-9 mm). The shape of the lesion was round in three (30 %), oval in two (20 %) and irregular in five (50 %) patients. None of the tumours were completely removed in the first VAE specimen, meaning that there was invasive cancer or ductal carcinoma in situ (DCIS) in the "shaved margins" and/or the surgical specimen. In five (50 %) cases, the surgical specimen was free of invasive cancer and DCIS. CONCLUSIONS: None of the small invasive breast cancers were completely excised with VAE under ultrasound guidance, therefore it is not a reliable method to remove small breast cancers.

Efficacy and safety of vacuum-assisted excision (VAE) of fibroadenomas: experience in a tertiary centre.

PURPOSE: To evaluate the technical success and efficacy rates of US-guided percutaneous vacuum-assisted excision (VAE) of breast fibroadenomas, also assessing procedural complications and long-term patient satisfaction rates. MATERIALS AND METHODS: The institutional database of a tertiary breast cancer referral centre was retrospectively reviewed to retrieve all women with fibroadenomas who underwent US-guided VAE between May 2011 and September 2019. We subsequently included in this study all fibroadenomas with a maximum diameter of 3 cm at US and an available histological confirmation obtained by core-needle biopsy before VAE. Immediately after VAE, technical success (defined as the correct VAE execution) and the occurrence of procedural complications were evaluated. Imaging follow-up (US ± mammography) after 6, 12, 24 and 36 months was performed to evaluate technical efficacy (defined as the absence of fibroadenoma recurrence at 6-month follow-up). Long-term patient satisfaction was evaluated with telephonic interviews in October 2022. RESULTS: We retrospectively included 108 women (median age 46 years) with 110 fibroadenomas diagnosed at core-needle biopsy with a median lesion size at US of 12 mm. Technical success was obtained in 110/110 VAEs (100%). Minor procedural complications (haematomas) occurred in 7/110 VAEs (6%), whereas 8/110 patients had a fibroadenoma recurrence at 6-month follow-up, resulting in a 93% technical efficacy (102/110 VAEs). All patients available for telephonic follow-up (104/104, 100%) reported high satisfaction with VAE results. CONCLUSION: US-guided VAE is a safe and effective procedure for the excision of fibroadenomas, representing a viable alternative to surgery, with a low complication rate and high patient satisfaction.

Third International Consensus Conference on lesions of uncertain malignant potential in the breast (B3 lesions).

The heterogeneous group of B3 lesions in the breast harbors lesions with different malignant potential and progression risk. As several studies about B3 lesions have been published since the last Consensus in 2018, the 3rd International Consensus Conference discussed the six most relevant B3 lesions (atypical ductal hyperplasia (ADH), flat epithelial atypia (FEA), classical lobular neoplasia (LN), radial scar (RS), papillary lesions (PL) without atypia, and phyllodes tumors (PT)) and made recommendations for diagnostic and therapeutic approaches. Following a presentation of current data of each B3 lesion, the international and interdisciplinary panel of 33 specialists and key opinion leaders voted on the recommendations for further management after core-needle biopsy (CNB) and vacuum-assisted biopsy (VAB). In case of B3 lesion diagnosis on CNB, OE was recommended in ADH and PT, whereas in the other B3 lesions, vacuum-assisted excision was considered an equivalent alternative to OE. In ADH, most panelists (76%) recommended an open excision (OE) after diagnosis on VAB, whereas observation after a complete VAB-removal on imaging was accepted by 34%. In LN, the majority of the panel (90%) preferred observation following complete VAB-removal. Results were similar in RS (82%), PL (100%), and FEA (100%). In benign PT, a slim majority (55%) also recommended an observation after a complete VAB-removal. VAB with subsequent active surveillance can replace an open surgical intervention for most B3 lesions (RS, FEA, PL, PT, and LN). Compared to previous recommendations, there is an increasing trend to a de-escalating strategy in classical LN. Due to the higher risk of upgrade into malignancy, OE remains the preferred approach after the diagnosis of ADH.

Learning curve in ultrasound-guided vacuum-assisted excision of breast lesions for surgeons and ultrasound physicians.

Background: The varying experience of surgeons and ultrasound physicians, and their collaboration with physicians, may affect operation time and efficiency. We evaluated the learning curve of ultrasound-guided vacuum-assisted excision (VAE) of breast lesion with collaboration between different physicians, and assessed characteristics associated with operation time. Methods: The sample population of this retrospective study was divided into two groups: 49 consecutive patient surgeries completed by skilled surgeons and novice ultrasound physicians (U group); and 30 consecutive patient surgeries completed by skilled ultrasound physicians and novice surgeons (S group). Cumulative summation graphs were used to evaluate operation time and calculate the turning point of the learning curve. Patients in the U and S groups were divided into exploration stage and proficiency stage according to the turning point, and the differences in influencing factors were compared. A total of 548 patients who underwent vacuum-assisted breast excision performed by a combination of skilled surgeons and skilled ultrasound physicians were selected as the reference group (R group). The differences among the three groups were compared. The relationship between the operation time and other factors in the different groups was analyzed using linear regression. Results: The best learning curve of the sample population was the quadratic fitting equation, and the turning point was the 19th case in the U group and the 14th case in the S group. The total operation times in the proficiency stage were significantly shorter than those in the exploration stage in the U and S groups (P=0.012 and P=0.003, separately). Patient age, long diameter, short diameter, and depth of masses related to the operation time. Conclusions: Our data suggest the existence of different learning curves in ultrasound-guided vacuum-assisted excision for the collaborations of different stages surgeons and ultrasound physicians. Through the accumulation of experience, it is feasible to safely perform ultrasound-guided VAE of breast lesions.

Unexpected breast cancer mimicking benign lesions on ultrasound-guided vacuum-assisted excision biopsy: A retrospective cross-sectional study over a 20-year period.

Objectives: This study investigated the occurrence rate of unexpected breast cancer (UEBC) mimicking benign lesions [Breast Imaging Reporting and Data System (BI-RADS) category 3 or 4a] using ultrasound-guided vacuum-assisted excision biopsy (US-VAEB), and explored the factors responsible for late diagnosis of T2 stage UEBC. Materials and methods: We collected clinicopathologic data and preoperative US imaging features within 3 months before US-VAEB of patients who were diagnosed with UEBC from January 2002 to September 2022. The UEBC were divided into T1 and T2 stageUEBC. The US imaging features as well as clinical and pathological information of T1 and T2 stage UEBC were compared to explore the factors responsible for late diagnosis of T2 stage UEBC. Results: Breast cancer was diagnosed in 91 of 19 306 patients who underwent US-VAEB. We excluded eight patients with breast cancer assigned to BI-RADS 4b category by preoperative US, and two for whom US imaging records were unavailable. Finally, we enrolled 81 patients. The occurrence rate of UEBC after US-VAEB was 0.42%(81/19296). Of the 81 cases of UEBC, 22 were at T2 stage. The ratio of T2 stage UEBC was 27.2%. The differences in risk factor of breast cancer and routine breast US screening between T1 and T2 stage UEBC were significant[96.6% (57/59) vs 81.8% (18/22), 44.1% (26/59) vs 13.6% (3/22), respectively, P<0.05). Conclusion: UEBC was rarely detected by US-VAEB. Most cases of T2 stage UEBC were diagnosed late because of the absence of routine US screening and risk factors for breast cancer. Stricter clinical management regulations for breast lesions and performing regular US screening may be helpful to reduce T2 stage UEBC.

Comparison of ultrasound-guided microwave ablation and ultrasound-guided vacuum-assisted excision for treating breast lesions of uncertain malignant potential (B3 lesions): A retrospective study.

AIMS: To compare the safety and therapeutic effect of ultrasound (US)-guided microwave ablation (MWA) and US-guided vacuum-assisted excision (VAE) for patients with B3 lesions of the breast. METHODS: Patients who underwent US-guided MWA or US-guided VAE at Sichuan Tumor Hospital from January 2016 to December 2021 were retrospectively analyzed. The technical success rate and residual rate of the two minimally invasive surgeries were recorded. During follow-up, differences in symptom relief, recurrence or progression, re-intervention, incidence of adverse events, or personal satisfaction were observed between the two groups. RESULTS: The follow-up time was comparable between the two groups. The technical success rate was similar between the two groups; no residue was found in the US-guided MWA group, and the residue rate in the US-guided VAE group was 3.4%. The symptoms of the two groups were improved after the operation. The incidence of postoperative adverse events in the US-guided MWA group was significantly lower than that in the US-guided VAE group. Additionally, the MWA group had a lower incidence of adverse events when the tumor diameter was >2.5 cm. Compared to the US-guided VAE group, the US-guided MWA group had a lower rate of tumor recurrence or progression, re-intervention rate, and higher personal satisfaction. CONCLUSIONS: The technical success rate of US-guided MWA for B3 lesions was comparable to that of US-guided VAE, but US-guided MWA had a lower incidence of adverse events and a higher degree of personal satisfaction compared with US-guided VAE.

The positive predictive value of vacuum assisted biopsy (VAB) in predicting final histological diagnosis for breast lesions of uncertain malignancy (B3 lesions): A systematic review & meta-analysis.

INTRODUCTION: High-risk or B3 breast lesions are considered lesions of uncertain malignant potential and comprise between 5 and 12% of initial biopsy results. We sought to perform a systematic review and meta-analysis of studies published within the last twenty years to determine the pooled Positive Predictive Value (PPV) of VAB in selected B3 lesions. METHODS: The study report is based on the guidelines of PRISMA and Meta-Analysis of Observational Studies in Epidemiology. OUTCOMES: The primary outcome of this study was to determine the PPV of VAB in determining final histological diagnosis in B3 breast lesions using pooled estimates. The secondary outcomes were to determine if needle gauge or the re-classification of Lobular Carcinoma in Situ(LCIS) introduced in 2012 influenced pooled estimates. RESULTS: 78 studies incorporating 6,377 B3 lesions were included in this review, 1214 of which were upgraded to DCIS or invasive malignancy following surgical excision(19%). The pooled PPV of VAB in Atypical Ductal Hyperplasia(ADH) and Lobular Neoplasia(LN) were 0.79(CI 0.76-0.83) and 0.84(CI 0.8-0.88). VAB of Flat Epithelial Atypia(FEA), radial scar and papillary lesions with/without atypia all had a pooled PPV >90% (underestimation rates 7%, 1%, 5% and 3% respectively). Needle gauge size and the change in LCIS classification did not appear to influence underestimation rates on subgroup analysis. CONCLUSION: Results from this meta-analysis suggests it is reasonable to perform VAB as definitive treatment for certain B3 lesions, specifically LN, FEA, radial scar, and papillary lesions when specific criteria are fulfilled. Surgical excision should continue as the mainstay of treatment for ADH.

Efficacy and safety of percutaneous ultrasound-guided vacuum-assisted excision for the treatment of clinical benign breast lesions larger than 3 cm: a retrospective cohort study.

Background: Breast ultrasound-guided vacuum-assisted excision (US-VAE) has become a scarless solution for the removal of benign breast lesions. This procedure is now favored by more and more female patients for its satisfactory cosmetic outcome and few postoperative complications. However, controversy have been raised regarding its efficacy and safety in treating larger benign breast lesions. This study aimed to evaluate whether US-VAE is sufficient for the treatment of clinical benign breast lesions larger than 3 cm and to investigate the lesion features that affect the complete excision rate and hematoma occurrence rate. Methods: From January 2018 to July 2021, a total of 1,812 lesions in 1,367 patients underwent US-VAE at the Chinese People's Liberation Army General Hospital. A total of 89 benign breast lesions in 87 patients enrolled in this retrospective cohort study. The baseline clinical characteristics and ultrasonographic features of the lesions were recorded. Patients were followed up by US to record if there are any serious issues and the occurrence of hematoma and the recurrence of the lesions within 3 days and 6-12 months later, then at 1-year intervals. Lesions were classified to analyze the possible factors associated with complete excision rate and hematoma occurrence rate. Results: The mean age was 35.9±9.5 years (range, 18-54 years), and the median maximum size of benign breast lesions was 3.5 cm (range, 3.1-5.0 cm). The complete excision rate was 91.0% (81/89). Histopathology (P=0.002) and vascularity (P=0.032) of lesions showed statistically significant differences in groups with or without recurrent lesions. A total of 17 cases (17/89, 19.1%) presented with hematoma after the procedure. The maximum lesion size in patients with hematoma was significantly larger than that in those without hematoma (P<0.001). Conclusions: US-VAE is an effective and safe alternative method for the treatment of benign breast lesions larger than 3 cm, especially for fibroadenoma, adenosis, hamartoma. For benign phyllodes tumors and intraductal papillomas larger than 3 cm and lesions with hypervascularity, the possibility of recurrence after US-VAE should be noted. The size of lesions needs to be considered when evaluating the occurrence of hematoma after US-VAE.

Comparison of vacuum-assisted excision (VAE) and breast lesion excision system (BLES) in the treatment of intraductal papillomas.

PURPOSE: This study aims to compare the feasibility of VAE and BLES in the treatment of intraductal papillomas. MATERIAL AND METHODS: Patients with a suspected intraductal papilloma who underwent a BLES or a VAE procedure were included in this retrospective study. The BLES procedures were performed between November 2011 and June 2016 and the VAE procedures between May 2018 and September 2020 at the Department of Radiology of Helsinki University Hospital (HUH). The procedures were performed with an intent of complete removal of the lesions. RESULTS: In total, 72 patients underwent 78 BLES procedures and 95 patients underwent 99 VAE procedures. Altogether 52 (60%) papillomas with or without atypia were completely removed with VAE, whereas 24 (46%) were completely removed with BLES, p = 0.115. The median radiological size of the high-risk lesions completely removed with BLES was 6 mm (4-12 mm), whereas with VAE it was 8 mm (3-22 mm), p = 0.016. Surgery was omitted in 90 (94.7%) non-malignant breast lesions treated with VAE and in 66 (90.4%) treated with BLES, p = 0.368. CONCLUSION: Both VAE and BLES were feasible in the treatment of intraductal papillomas. In most non-malignant lesions surgery was avoided, but VAE was feasible in larger lesions than BLES. However, follow-up ultrasound was needed more often after VAE. The histopathologic assessment is more reliable after BLES, as the lesion is removed as a single sample.

Ultrasound-guided 8-Gauge vacuum-assisted excision for selected B3 breast lesions: a preliminary experience.

PURPOSE: Nowadays, surgical excision is no longer justified for all B3 lesions and a minimally-invasive therapeutic treatment has been encouraged. The aim of this study was to evaluate the feasibility and the therapeutic efficacy of ultrasound-guided vacuum-assisted excision (US-VAE) for the treatment of selected breast lesions of uncertain malignant potential (B3). MATERIAL AND METHODS: From July 2018 to December 2019, 11/48 breast lesions classified as B3 after ultrasound-guided core needle biopsy were treated with US-VAE in our Institution. Inclusion criteria were: B3 nodules ultrasonographically detectable for which VAE is recommended by international guidelines2, size ranging between 5 and 25 mm, circumscribed margins, and lesion position at least 5 mm from the skin and the nipple. A radiological follow-up to evaluate the completeness of excision, the presence of post-procedural hematoma or of residual disease/recurrence was performed after 10 and 30 days and 6 and 12 months. 12-month ultrasound was considered the gold standard. All patients were asked to complete a satisfaction survey and a full assessment of the costs of US-VAE was performed. RESULTS: Complete excision was achieved in 81.8% of US-VAE. No lesions were upgraded to carcinoma and no patients had to undergo surgery. No complications occurred during or after US-VAE. All patients were satisfied with the procedure and the cosmetic result (100%). US-VAE cost approximately 422 Euros per procedure. CONCLUSION: US-VAE has proven to be an optimal tool for the therapeutic excision of selected B3 lesions, with high success rate, good patient compliance and considerable money savings compared to surgery. This technique has the potential to reduce unnecessary surgery and healthcare costs.

Efficacy and Safety of Vacuum-Assisted Excision for Benign Breast Mass Lesion: A Meta-Analysis.

Background and Objective: Breast mass lesions are common; however, determining the malignant potential of the lesion can be ambiguous. Recently, to evaluate breast mass lesions, vacuum-assisted excision (VAE) biopsy has been widely used for both diagnostic and therapeutic purposes. This study aimed to investigate the therapeutic role of VAE. Materials and Methods: Relevant articles were obtained by searching PubMed and EMBASE on 3 September 2021. Meta-analyses were performed using odds ratios and proportions. To assess heterogeneity, we conducted a subgroup analysis and meta-regression tests. Results: Finally, 26 studies comprising 18,170 patients were included. All of these were observational studies. The meta-analysis showed that the complete resection rate of VAE was 0.930. In the meta-regression test, there was no significant difference. The meta-analysis showed a recurrence rate of 0.039 in the VAE group. The meta-regression test showed no statistical significance. Postoperative hematoma, pain, and ecchymosis after VAE were 0.092, 0.082, and 0.075, respectively. Conclusion: VAE for benign breast lesions showed favorable outcomes with respect to complete resection and complications. This meta-analysis suggested that VAE for low-risk benign breast lesions is a reasonable option for both diagnostic and therapeutic purposes.

Audit on Intraductal Papilloma of the Breast: Upgrade Rate, Management Pitfalls, and Updated Guidelines in a Tertiary Health Care Center.

Background Intraductal papillomas (IDPs) are typically classified as B3 lesions in histology as they may show intralesional heterogeneity with a potential upgrade to malignancy. On core needle biopsy (CNB), a distinction between papilloma versus papillary ductal carcinoma in situ (DCIS) may be difficult. It is well known that otherwise benign papillomas may harbor foci of atypical ductal hyperplasia or DCIS. In this study, we aimed to calculate the radiological (mammogram and ultrasound) accuracy of IDP and to analyze the accuracy of CNB to diagnose IDP. Furthermore, we calculated the percentage of upgrade to malignancy after surgical excision. Any case that had a co-existing in-situ or invasive carcinoma during surgical excision was considered as an "upgrade" to malignancy. Finally, we analyzed the current management protocol for IDP in the institution and suggested changes, if needed. Methodology This is a retrospective cross-sectional study. A total of 112 cases diagnosed as IDP radiologically and/or by histopathology over a one-year time frame were included. A retrospective analysis of the accuracy of the radiological diagnosis was done by comparing it with CNB and/or surgical excision biopsy reports. The number of cases diagnosed with a co-existing in-situ or invasive carcinoma was calculated. This was considered as an "upgrade" from a B3 lesion in CNB to carcinoma in surgical excision. Current institutional management protocols were evaluated and compared with international benchmarks. Results Out of the 112 cases, 91 were suspected to be papilloma by imaging. The remaining 21 cases who were positive for papilloma on biopsy but were not diagnosed radiologically were also studied separately. Among the biopsied patients, eight were positive for IDP with atypia in CNB. Five out of these eight cases had an in-situ or invasive component during the surgical excision, with one invasive lobular carcinoma, three lobular carcinomas in situ, and one DCIS on surgical excision histopathology. The upgrade percentage was calculated to be 22.72%. Conclusions Due to the large upgrade potential of IDP, it is recommended to biopsy every radiologically suspected lesion and excise pathology-proved lesions. If the biopsy shows papilloma without atypia, vacuum excision is sufficient; otherwise, surgical excision with a clearance of margins is advocated. Annual mammograms/surveillance is recommended for biopsy-proven cases. IDP has a high upgrade potential, and, hence, care should be taken to biopsy suspicious lesions. An excision of biopsy-proven lesions must be done.