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Wo m e n s I m a g i n g O r i g i n a l R e s e a r c h

Lam et al.
Papillary
Breast
Lesions

W O M E N S
IMAGING

W. W. M. Lam1
W. C. W. Chu1
A. P. Y. Tang2
G. Tse1
T. K. F. Ma2
Lam WWM, Chu WCW, Tang APY, Tse G, Ma
TKF

Keywords: breast, cancer, mammography, papillary


lesions, sonography
DOI:10.2214/AJR.04.1908
Received December 17, 2004; accepted after revision
March 22, 2005.
1Department

of Diagnostic Radiology and Organ Imaging,


Rm. 27029, Prince of Wales Hospital, Ngan Shing St.,
Shatin, Hong Kong. Address correspondence to
W. W. M. Lam (wynnie@cuhk.edu.hk).

2Department

of Radiology, Alice Ho Miu Ling Nethersole


Hospital, Hong Kong.
CME
This article is available for 1 CME credit. See supplemental
data for this article at www.ajronline.org or visit
www.arrs.org for more information.

AJR 2006; 186:13221327


0361803X/06/18651322
American Roentgen Ray Society

1322

Role of Radiologic Features in


the Management of Papillary
Lesions of the Breast
OBJECTIVE. The purpose of our study was to assess the role of imaging and core biopsy
in the management of patients with papillary lesions of the breast.
MATERIALS AND METHODS. Clinical records and mammographic and sonographic
findings of 40 women with papillary lesions in the breast were retrieved. The imaging features
and cytologic findings were correlated with histologic findings.
RESULTS. Fifty-six papillary lesions in 40 patients underwent either mastectomy, segmental duct resection, or excision biopsy. There were three papillary carcinomas, 13 papillaryal
lesions with carcinoma in situ, one atypical papilloma, four sclerosed papillomata, and 35 papillomata. Of these lesions, 37.5% (21/56) and 82.1% (46/56) could be detected on mammography and sonography, respectively. Galactography and dilated ducts helped to suggest the papillary nature of the lesions. However, mammography and sonography were not able to predict
malignancy (sensitivity, 69% and 56%, respectively; specificity, 25% and 90%; positive predictive value [PPV], 60% and 75%; and negative predictive value [NPV], 33% and 90%). Combined interpretation of mammography and sonography gave a sensitivity of 61%, specificity of
33%, PPV of 85%, and NPV of 13%. Fine-needle aspiration gave a sensitivity of 44%, specificity of 68%, PPV of 31%, and NPV of 79%, whereas core biopsy gave a sensitivity of 82%,
specificity of 100%, PPV of 100%, and NPV of 83% in the diagnosis of malignancy.
CONCLUSION. Radiologic features are not sufficiently sensitive or specific to differentiate benign from malignant papillary lesions. Fine-needle aspiration and core biopsy have pitfalls, and the need for surgical excision of all papillary lesions should be revisited.
he presentation of papillary lesions in the breast is quite varied, both clinically and radiologically. Clinically, a palpable
mass or nipple discharge may [1] or may not
[2] be present in papillary lesions. Mammographically, patients might have multiple bilateral lesions of varying sizes associated or
not associated with microcalcifications.
Sonographically, the lesion might present as
a complex intracystic lesion or a homogeneous solid lesion. The radiologic appearance cannot accurately predict the benignity
or the malignancy of the lesions. Known pitfalls also exist in differentiating benign
from malignant papillary lesions using fineneedle aspiration and core biopsy. It can be
difficult to cytologically differentiate sclerosed papilloma and atypical papilloma
from papillary carcinoma. Examination of
the entire lesion for accurate grading is necessary because small foci of carcinoma in
situ or an area of abruption of the myoepi-

thelial layer might not be targeted in fineneedle aspiration or even core biopsy. We
believe that surgical excision may be warranted in virtually all cases. We evaluated
the histologic finding, the clinical outcome,
and the radiologic features of patients with
histologically proven papillary lesions and
assessed the potential role of radiologic
findings and biopsy in the management of
these patients.
Materials and Methods
The histologic reports of all patients with papillary lesions in the breast from 1993 to 2000 were retrieved. The clinical presentation, outcome, and radiologic findings of 40 patients (age, 2780 years;
mean age, 51 years) were found and considered in
this study. All 40 patients had clinical follow-up
and serial imaging for 411 years. All mammographic and sonographic images of the patients
were retrieved for interpretation by two radiologists, each of whom had more than 7 years experience in breast imaging.

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Papillary Breast Lesions


Mammographic Interpretation
Images were obtained in two standard planes
(mediolateral oblique and craniocaudal). Dedicated
film-screen equipment (Senographe DMR, GE
Healthcare) was used. The radiologists were informed of the study design but were blinded to the
clinical findings, full histologic diagnosis, and clinical outcome. The mammographic findings were
reported according to the American College of Radiology (ACR) Breast Imaging Reporting and Data
System (BI-RADS) [3]. The presence of a mass,
shape of the mass (round, oval, lobular, or irregular), calcification (benign, intermediate, or higher
probability of malignancy), and the margin characteristics (circumscribed, microlobulated, obscured,
indistinct, or spiculated) were noted.
Any lobular or irregular mass, any presence of
calcification of intermediate or high probability of
malignancy, and any mass showing microlobulation or an obscured, indistinct, or spiculated margin
was considered suspicious of malignancy. When
there was a single ductal opening with bloody or serous discharge on the day of examination, galactography was performed. Galactography was performed by cannulation of the ductal opening using
a 30-gauge Jabczenski cannula (Cook). Nonionic
iodinated contrast material (iopamirol 300) was injected until the patient felt discomfort or pain
(0.52 mL). Two mammographic views (craniocaudal and mediolateral oblique) were then obtained after the injection of the contrast material.

Sonographic Interpretation
All sonographic examinations were performed
with a 10-MHz linear array transducer in the VST
Masters Series (Logic 700, GE Healthcare). All examinations were performed by one of the six attending radiologists, each having had more than 2 years
experience in the interpretation of breast images. All
static and color Doppler images of the lesions and axillary lymph nodes identified were saved and filmed.
All hard-copy films were reviewed by two radiologists at least 2 days after mammography interpretation. Sonographic features were analyzed according
to the ACR BI-RADS US lexicon classification [3].
The presence of a mass, shape of the mass (oval,
round, irregular), orientation of the lesion (parallel or
not parallel to the skin line), margin (circumscribed
or not circumscribed, which was further divided into
indistinct, angular, spiculated, or microlobulated),
lesion boundary (abrupt interface or echogenic
halo), echo pattern (anechoic, hyperechoic, complex, hypoechoic, or isoechoic), posterior acoustic
features (no posterior acoustic features, shadowing,
enhancement, or a combination), surrounding tissue
changes (duct changes, Coopers ligament changes,
edema, architectural distortion, skin thickening, skin
retraction, or irregularity), calcification (macrocalci-

AJR:186, May 2006

fications, microcalcification within or outside the


mass), and vascularity (not present, present in lesion,
present immediately adjacent to lesion, or diffusely
increased in surrounding tissue) were all recorded.
The presence of any of the following was considered
suspicious of malignancy: an irregular mass, any lesion not parallel to the skin line, any noncircumscribed margin, a complex echo pattern, posterior
acoustic shadowing or a combined pattern, Coopers
ligament changes, skin thickening, edema, architectural distortion, or skin retraction or irregularity.
The presence and shape (oval or round) of axillary lymph nodes and suspicious features (loss of
echogenic hilum, presence of central necrosis)
were also recorded.

Ten mastectomies were performed in these


40 patients because of breast malignancy, although some of these patients had coexisting
benign and malignant breast lesions. A total of
three papillary carcinomas, 13 papillary lesions associated with carcinoma in situ, and
five papillomata were yielded. None of these
patients had histologic metastasis to axillary
lymph nodes. Thirty-seven excisional biopsies
or segmental duct resections were performed;
two excisional biopsies were performed before
mastectomy. The remaining 35 excisional biopsies yielded a total of one atypical papilloma, four sclerosed papillomata, and 30 papillomata. A total of 16 malignant and 40 benign
papillary lesions were analyzed.

Fine-Needle Aspiration or Core Biopsy


Aspirates and tissue cores obtained were retrieved. All specimens were reviewed by two experienced pathologists, each having more than 5
years experience in breast pathology. The findings
of cytologic specimens were classified into four
categories: insufficient to make a diagnosis, benign,
intermediate with atypia, and malignant. Lesions
with atypia were considered suspicious and the lesion was excised for further evaluation at our center. Lesions with atypia were categorized as malignant for the following analysis.
All fine-needle aspirations and core biopsies
were performed under sonographic guidance. A 21gauge hypodermic needle connected to a 20-mL syringe was used for fine-needle aspiration. Suction
was maintained until aspirate was noted in the needle hub. For all core biopsies, a16-gauge biopsy
needle was used. At least three good cores of tissue
were obtained for each lesion.

Surgical Excision or Mastectomy


Decisions as to surgical excision or mastectomy
were made by the attending surgeon. Histology
from surgical excision of the mass or mastectomy
served as the gold standard.

Statistical Analysis
Imaging features and cytologic findings were
correlated with histologic findings. Imaging features and cytologic findings were also correlated
with clinical outcomes. All statistical analysis was
performed using SPSS version 11.0 software installed on a PC. All results with a p value of less
than 0.05 were considered significant.

Results
Of the 40 patients, 10 presented with nipple
discharge, which was bloody in four. Thirtyone patients presented with a lump. One patient presented with both bloody nipple discharge and a lump.

Correlation of Fine-Needle Aspirates and Core


Biopsy with Mastectomy or Surgical Excision
Of the 56 lesions, 41 lesions had sonographically guided fine-needle aspiration before excisional biopsy or mastectomy. Four aspirates
had insufficient material for diagnosis and were
excluded from the following analysis. Of these
37 lesions, nine lesions were malignant and 28
were benign. When the presence of cellular atypia was considered suspicious for malignancy,
fine-needle aspiration gave a sensitivity of 44%
(95% confidence interval [CI], 1277%), specificity of 68% (5185%), positive predictive
value of 31% (656%), and negative predictive
value of 79% (6395%).
Core biopsy was performed in a total of 21
lesions, of which 11 were malignant and 10
were benign. Three cores of tissue were obtained for each of 15 lesions, of which 10 lesions were malignant and five were benign.
Four cores of tissues were obtained for each
of the remaining one malignant and five
benign lesions. Papilloma with foci of sclerosis was diagnosed at core biopsy in two lesions in which histology showed papillary
lesion associated with carcinoma in situ.
Therefore, core biopsy had a sensitivity of
82% (95% CI, 59100%), specificity of
100% (100100%), positive predictive value
of 100% (100100%), and negative predictive
value of 83% (62100%) for the detection of
malignancy in papillary lesions (Table 1).
Correlation of Imaging Features with
Mastectomy or Excision Results
Only eight patients underwent galactography. Intraluminal filling defects were identified
in seven ductograms. One ductogram failed because of high pressure encountered during the
injection of contrast material, as a result of
which the duct could not be well delineated.

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Lam et al.
Thirty-five lesions (62.5%) were not detected on mammography. Of the 21 lesions
detected on mammography, 10 were ductal
carcinoma in situ, three were papillary carcinoma, six were papilloma, and two were sclerosed papilloma. The mammographic features of these lesions are listed in Table 2.
Using the characteristics of the mass shown
on mammography to differentiate malignant
from benign papillary lesions would therefore
give a sensitivity of 67%, positive predictive
value of 50%, and both specificity and negative predictive value of less than 10%. Characteristics of microcalcifications (Fig. 1) used
to predict malignancy gave a sensitivity of
75%, specificity of 50%, positive predictive
value of 75%, and negative predictive value of
25%. A total of nine malignant lesions
showed at least one or more suspicious mam-

mographic features; four of the malignant lesions did not show any suspicious malignant
features. Of the eight benign lesions, six
showed one or more suspicious malignant lesions. The overall sensitivity was therefore
69% (95% CI, 4494%); specificity, 25%
(5% to 55%); positive predictive value, 60%
(3585%); and negative predictive value,
33% (4% to 71%) (Table 2).
Sonography was more sensitive than mammography in the detection of abnormality in
papillary lesions in the breast. Abnormality in
sonography was detected in 46 lesions (82.1%).
Ten papillomata were not detected sonographically, of which five were coincident
histologic findings found in the mastectomy
specimens and five were diagnosed at segmental duct resection. The sonographic features of the 25 papillomata, one atypical pap-

TABLE 1: Cytologic and Histologic Results of Fine-Needle Aspiration (FNA) and


Core Biopsy
Histology

FNA

Core Biopsy

Sclerosed papilloma

Atypia (2)

Atypical papilloma

Benign (1)

Papilloma

Atypia (7)

Benign (1)

Benign papilloma (2)

Benign (17)

Benign papilloma (8)

Invasive papillary carcinoma

Benign (1)

Papillary lesion with

Atypia (3)

Ductal carcinoma in situ (9)

Malignant (1)

Benign papilloma (2)

Carcinoma in situ

illoma, four sclerosed papillomata, and 16


malignant lesions are presented in Table 3
and shown in Figures 2 and 3. Of all 16 malignant lesions, nine showed one or more
sonographically suspicious features and the
remaining seven were benign-appearing on
sonography. Of the 30 benign lesions, three
showed one or more suspicious sonographic
features and the remaining 27 appeared benign on sonography. Sonography had a sensitivity of 56% (95% CI, 3281%), specificity
of 90% (79100%), positive predictive value
of 75% (51100%), and negative predictive
value of 79% (6693%).
Twenty-one lesions were detected on
both mammography and sonography. When
the presence of any suspicious mammographic or sonographic feature was considered to indicate malignancy, interpretation
of both mammographic and sonographic
features gave a sensitivity of 61% (95% CI,
3984%), specificity of 33% (20% to
87%), positive predictive value of 85%
(65100%), and negative predictive value of
13% (10% to 35%) for the detection of malignancy in papillary lesions. The combined
interpretation of both mammography and
sonography therefore increased the positive
predictive value but the diagnosis became
less specific.

Benign (4)
Total

37

21

NoteData are numbers of lesions.

TABLE 2: Mammographic Features of Malignant Versus Benign Tissue Diagnosis


in 21 Papillary Lesions
Diagnosis
Feature
Mass

Malignant (n = 13)
6/13 (46)

Benign (n = 8)
4/8 (50)

Oval or round

2/6 (33)

0 (0)

Irregulara

4/6 (67)

4/4 (100)

Margins
Circumscribed

2/6 (33)

0/4 (0)

Not circumscribeda

4/6 (67)

4/4 (100)

8/13 (62)

4/8 (50)

Benign

2/8 (25)

2/4 (50)

Intermediate probability of malignancya

4/8 (50)

2/4 (50)

High probability of malignancya

2/8 (25)

0 (0)

Calcification

NoteNumbers in parentheses are percentages.


a Features suspicious for malignancy.

1324

Fig. 1Mammogram (magnified oblique view) in 51year-old woman shows irregular lesions associated
with microcalcifications having high probability of
malignancy (arrows). Microcalcifications are in a
ductal distribution. Mastectomy confirmed papillary
carcinoma.

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Papillary Breast Lesions


Correlation of Both Imaging Features and
Core Biopsy Results with Histologic Findings
Of all the 21 lesions having core biopsy, 13
had concordant imaging and biopsy findings.
Of these 13 lesions, seven were benign and six
were malignant. One of these lesions with
concordant imaging and core biopsy, which
suggested a benign abnormality, eventually
showed a malignant lesion on excision. The
histologic findings agreed with the biopsy and
imaging findings in the remaining 12 lesions.
Eight lesions had discordant imaging and biopsy findings. Four of these eight lesions were
malignant histologically. The imaging features
were suspicious of malignancy in only one of
these lesions. The remaining four histologically
proven benign lesions were all benign at core
biopsy but had suspicious imaging features.
Correlation of Both Imaging Features and
Fine-Needle Aspiration Biopsy Results with
Histologic Findings
Of all the 37 lesions having fine-needle aspiration biopsy, 22 had concordant imaging

and fine-needle aspiration findings. Of these


22 lesions, 20 were benign and two were malignant histologically. Three lesions with concordant imaging and fine-needle aspiration
findings suggestive of malignancy were
proven to be benign histologically. None of
the malignant lesions showed concordant benign imaging and fine-needle aspiration findings in this small series.
Fifteen lesions had discordant imaging
and fine-needle aspiration findings. Eight of
these lesions were benign and seven were
malignant.
Clinical Follow-Up
One patient developed a papilloma in the
contralateral breast 1 year after the excision
of the presenting papilloma. Another patient
developed carcinoma in situ in the ipsilateral
breast 1 year after the excision of the presenting papilloma. Three of 13 patients developed
papillary carcinoma in the ipsilateral breast
12 years after the initial diagnosis of carcinoma in situ by surgical excision.

TABLE 3: Sonographic Features in 46 Papillary Lesions


Tissue Diagnosis
Feature

Malignant (n = 16)

Benign (n = 30)

Shape
Oval or round

8 (50)

30 (100)

Irregulara

8 (50)

0 (0)

8 (50)

30 (100)

8 (50)

0 (0)

8 (50

29 (97)

Orientation to skin line


Parallel
Not

parallela

Margins
Circumscribed
circumscribeda

8 (50)

1 (3)

Abrupt lesion boundary

6 (38)

27 (90)

0 (0)

1 (3)

Not

Echo pattern
Anechoic
Hyperechoic

1 (6)

Hypoechoic

10 (63)

27 (90)

5 (31)

2 (7)

Complexa

Posterior acoustic shadowinga

1 (6)

0 (0)

Change in surrounding ducts

8 (50)

2 (7)

Microcalcification in lesion

1 (6)

0 (0)

Vascularity in lesiona

2 (13)

0 (0)

15 (94)

30 (100)

Axillary lymph nodes


Oval
Round
NoteNumbers in parentheses are percentages.
a Suspicious for malignancy.

AJR:186, May 2006

1 (6)

Discussion
Pathologically, a broad spectrum of papillary lesions of the breast is seen. The differential diagnosis includes papilloma, papillomatosis, sclerosing papilloma, atypical
papilloma, and papillary carcinoma. Distinguishing papillary carcinoma from other benign papillary lesions is important. Papillary
carcinoma accounts for fewer than 2% of all
breast cancers and can be further classified
into papillary carcinoma in situ and infiltrating papillary carcinoma [1, 4]. Absence of a
uniform layer of myoepithelial cells along the
intraluminal portion of the lesion suggests a
malignant process [1]. Therefore, making an
accurate diagnosis of the lesion is difficult unless the entire lesion is examined.
Solitary breast papillomata are potentially
malignant and are associated with a high risk
of breast cancer [5]. In our series, up to 12
patients (30%) who had carcinoma in situ or
carcinoma had papilloma before or after the
diagnosis of a presenting carcinoma. Such a
high association between papilloma and
breast cancer has also been reported previously [5]. Gutman et al. [5] reviewed 95
women with papilloma or papillomatosis
and found that in up to 10% of patients, solitary papillomata were associated with
breast carcinoma. An additional 9% of patients presented with invasive or noninvasive
carcinoma in the papilloma. Patients with
papilloma also have a high chance of developing a second papilloma. MacGrogan and
Tavassoli [6] found that the presence of epithelial hyperplasia, ductal hyperplasia, or
lobular neoplasia in the surrounding breast
as well as infarction of the papilloma were
significant predictive factors of recurrence.
Because only one patient in our series had
recurrent papilloma, we could not identify
any factors for the prediction of recurrence.
Radiologically, the lesion can be small and
can be mammographically and sonographically occult. The overall sensitivity for detection of papillary lesions on mammography is
low (37.5% in our series). In the series by
Woods et al. [7], abnormal mammographic
findings were seen in eight of 19 patients, and
the incidence of abnormal mammographic
findings was similar to that in our series. Even
when the lesion is detectable on mammography, such detection is neither sensitive nor
specific enough for accurate differentiation
between malignancy and benignancy. The
presence of calcification in papilloma was rare
in our series: only two lesions showed punctate
microcalcification [8, 9]. A higher proportion

1325

Lam et al.
of malignant lesions showed associated microcalcification (62.5%). When the lesion is
detectable on mammography, analysis of
the characteristics of microcalcifications is
slightly more sensitive than analysis of the
characteristics of the mass in differentiating
between benign and malignant lesions. When
patients present with nipple discharge, galactography is a sensitive [7, 9] but nonspecific
method [10] for the detection of intraductal lesions. A high incidence of abnormal findings
on galactography was also shown in our small
series. Unfortunately, many of our patients did
not present with nipple discharge so the role of
galactography was limited in our study.
The presence of dilated ducts is a common
sonographic finding that is often associated
with a visible intraluminal echo [8]. We also
found dilated ducts associated with 10 of our
sonographically detectable lesions (21.7%). A
dilated duct is a sonographic sign useful for differentiating intraductal lesions from other benign lesions such as fibroadenoma. Sonographically, papillomata usually present as a
circumscribed hypoechoic oval nodule. Vascularity identified in the fibrovascular core of the
papilloma might suggest the diagnosis. Color
Doppler images were unfortunately not available for all lesions and most of the papillomata
in our series were small; vascularity is therefore
not shown in our series. Differentiating sclerosed papilloma from papillary carcinoma is also

difficult. In our series, one of four sclerosed


papillomata had a microlobulated border and
another one was complex in echogenicity.
The margin of the lesion and the echo pattern appeared to be useful sonographic signs
for differentiating benign and malignant lesions. Although these signs are fairly specific,
the low sensitivity suggests that a number of
malignant lesions might be missed if one relies
only on imaging features to identify these lesions. Combining the sonographic and mammographic findings does not make the diagnosis more sensitive or specific. As a result, one
cannot reliably diagnose a papillary lesion as
benign or malignant simply on the basis of imaging features, nor could one use this assessment to decide whether to perform biopsy.
Michael and Buschmann [11] reviewed 22
fine-needle aspirations from histologically
proven papillary neoplasms (10 papillary carcinomas and 12 intraductal papillomata) and
concluded that papillary breast neoplasms can
be accurately classified by cytology. GomezAracil et al. [12] also suggested that papillary
carcinoma of the breast can be diagnosed on
cytology and differentiated from papilloma.
However, the diagnosis of papillary carcinoma
can be difficult by fine-needle aspiration. Fineneedle aspiration might miss the small foci of
carcinoma in situ or that are invasive.
A similar limitation might be encountered
at core biopsy [2, 13, 14]. Some authors have

Fig. 2Sonogram in 68-year-old woman shows complex lesion with both solid and
cystic components. Sonographic features are suggestive of malignant lesion. Both
excisional biopsy and mastectomy confirmed papillary carcinoma.

1326

suggested that benign papillomata diagnosed


at core biopsy can be followed up clinically
and radiologically so that surgical excision is
not necessary [14]. That a papillary carcinoma in situ diagnosed at core biopsy might
be upgraded to invasive carcinoma when the
entire lesion is examined is a significant limitation of core biopsy in the management of
papillary lesions [1517]. In our series, again
both fine-needle aspiration and core biopsy
showed their limitations for the diagnosis of
papillary lesions.
Considering these limitations, one might
question whether all papillary lesions, including benign papillomata diagnosed at
core biopsy or fine-needle aspiration,
should be surgically excised. The current
practice is not to excise benign papillomata
diagnosed at needle biopsy if there is no atypia and no discordance between imaging
and histologic findings. In our small series,
one lesion showing both benign radiologic
features and benign core biopsy results was
found to be ductal carcinoma in situ at histology. Our results also showed that a significant proportion of malignant papillary lesions did not show any malignant features
mammographically or sonographically. Our
small sample size suggests that even concordance between imaging and biopsy findings might fail to detect malignant papillary
lesions.

Fig. 3Sonogram in 48-year-old woman shows irregular lesion with indistinct


border and microcalcification (arrows) inside lesion. Mastectomy confirmed
papilloma with foci of carcinoma in situ.

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Papillary Breast Lesions


The use of larger-gauge needles would allow larger cores of tissue and more accurate
histologic assessment. Recent studies recommended the use of stereotactic vacuumassisted biopsy for the diagnosis of papillary
lesions [18]. We were not able to analyze the
role of stereotactic vacuum-assisted biopsy
in our study because that procedure has been
used in our center for only the past 2 years.
A significant limitation of our study is that
most of our core biopsies consisted of three
cores obtained with a 16-gauge needle,
which is considered undersampling by
present standards. The small gauge of the
needle may have a significant impact on the
results. However, even when stereotactic
vacuum-assisted biopsy is used, it is not
100% accurate in the histologic diagnosis of
papillary lesions [19]. Mercado et al. [19]
therefore suggested that the follow-up period for patients with papillary breast lesions
should be extended to more than 2 years
[19]. Excision biopsy to rule out malignancy
was also recommended when atypical hyperplasia of the lesion was shown at stereotactic vacuum-assisted biopsy [19].
In conclusion, we analyzed the imaging
features of papillary lesions according to the
BI-RADS and BI-RADS US lexicon classifications, and we found imaging features
such as positive findings on galactography
and associated ductal dilatation to be useful
signs in establishing the diagnosis of papillary lesion. However, neither mammographic nor sonographic features are sensitive and specific enough to allow accurate
differentiation between benign and malignant lesions. The limitations of fine-needle
aspiration and core biopsy should be kept in
mind. Papillary lesions, with their high asso-

ciation with breast cancer, should be closely


monitored in all patients. Excisional biopsy
or stereotactic vacuum-assisted biopsy
should be used to evaluate these lesions.
Multiple lesions found in both breasts might
create difficulty in management. If excisional biopsy or stereotactic vacuum-assisted biopsy of all papillary lesions is not
feasible, serial follow-up and intense scrutiny are prudent.

10.

11.

12.

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F O R YO U R I N F O R M AT I O N

This article is available for CME credit. See supplemental data for this
article at www.ajronline.org or visit www.arrs.org for more information.

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