Histopathological Upgrade in Papillary Breast Lesions Diagnosed on Core Needle Biopsy: Predictors and Clinical Implications from a Tertiary Care Cohort
Abstract
Background: Papillary breast lesions encompass a heterogeneous spectrum, and core needle biopsy (CNB) may underestimate in situ or invasive malignancy. We evaluated malignant upgrade and preoperative factors associated with upgrade after surgical excision.
Methods: This retrospective cohort study identified 298 patient records with papillary breast lesions. Eight patients without a preceding CNB, five without subsequent surgical excision, and one whose index papillary diagnosis and surgery occurred before the January 2019–December 2025 study period were excluded, leaving 284 patients for analysis. Malignant upgrade was defined as ductal carcinoma in situ or invasive malignancy on excision after a benign or atypical papillary lesion on CNB; atypical ductal hyperplasia alone was not considered malignant upgrade. Firth penalized logistic regression was used to obtain adjusted estimates in the presence of a highly predictive atypia variable.
Results: Malignant upgrade occurred in 137 of 284 patients (48.2%). Upgrade was observed in 130 of 150 lesions with atypia (86.7%) and 7 of 134 lesions without atypia (5.2%). In adjusted analysis (n=273 complete cases), atypia on CNB was the strongest independent predictor (adjusted odds ratio [aOR] 71.49, 95% CI 25.96–196.84; p<0.001). Increasing age (aOR 1.039 per year, 95% CI 1.006–1.072; p=0.021) and manual rather than ultrasound-guided core biopsy (aOR 5.01, 95% CI 1.46–17.20; p=0.010) also remained associated. Ultrasound lesion size, palpability, peripheral location, and BI-RADS ≥4 were not independently associated after adjustment.
Conclusion: Atypia on CNB was associated with a very high probability of malignant upgrade and supports surgical excision. The low upgrade rate among lesions without atypia is hypothesis-generating but cannot establish the safety of surveillance because only surgically excised lesions were analyzed.
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Copyright (c) 2026 Maleeha Khan Lodhi, Rufina Soomro
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