Histologic Uncertainty to Surgical Clarity: Institutional Insights Into Malignancy Risk in Papillary Breast Lesions

BackgroundPapillary lesions of the breast pose a diagnostic and management challenge.Although these lesions have been discussed in the international literature, local data remain limited.This study provides targeted insights to support informed surgical decision-making and improve patient outcomes. MethodsA retrospective review of a prospectively maintained pathology database was conducted from January 2023 to December 2025, and cases of papillary breast lesions diagnosed on core needle biopsy were extracted.Papillary cancers and incidental papillary lesions identified in surgical specimens were excluded.Patients who underwent subsequent diagnostic surgical excision were included in the final database, and their medical notes, radiology reports, and histology reports were reviewed.The rate of upgrade to DCIS or invasive cancer was recorded, and clinical or radiological predictors of upgrade were explored. ResultsA total of 132 patients were identified with isolated papillary breast lesions.Five patients underwent surveillance and were excluded from the analysis.The final cohort comprised 127 patients who underwent diagnostic surgical excision.The mean age was 52 ± 12.8 years.Overall, malignant upgrade was identified in 14/127 lesions (11.0%).Papillomas with atypia (B3b) demonstrated a significantly higher upgrade rate than papillomas without atypia (B3a) (20.5% vs 6.8%, p = 0.032).On multivariable analysis, the presence of atypia remained an independent predictor of malignant upgrade (adjusted OR 3.99, 95% CI 1.22-13.00,p = 0.022), while increasing age was significantly associated with upgrade. ConclusionPapillary lesions with atypia on core biopsy have significant potential to harbour malignant disease, supporting further diagnostic excision, particularly in patients aged over 50 years.The low upgrade rates observed in younger patients without atypia, warrant future studies evaluating the safety of surveillance in a similar large cohort.