Risk factors of breast intraductal lesions in patients without pathological nipple discharge
- Authors:
- Published online on: August 10, 2020 https://doi.org/10.3892/mco.2020.2108
- Article Number: 38
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Copyright: © Shen et al. This is an open access article distributed under the terms of Creative Commons Attribution License.
Abstract
Introduction
Intraductal lesions of the breast, include usual ductal hyperplasia (UDH), atypical ductal hyperplasia (ADH), ductal carcinoma in situ (DCIS), benign intraductal papilloma (IDP) with or without atypia, and malignant papillary carcinoma (1). Intraductal lesions are often associated with pathological nipple discharge (PND), with papilloma being the most common cause (40-70%), followed by adenomatous or papillary epithelial proliferation (14%) (2,3). One to 23% of women with PND are diagnosed with invasive breast cancer or ductal carcinoma in situ worldwide (4-6). However, intraductal lesions may be asymptomatic and can be detected through routine mammography screening. Sometimes they can be found due to other symptoms such as palpable lump(s), or associated micro-calcification (7).
Fiber-optic ductoscopy is important for the diagnosis of patients with PND, and it is now becoming indispensable (8,9). Women without PND are usually diagnosed through ultrasound-guided core needle biopsy (CNB) (7,10). However, it has been reported that physicians fail to obtain the appropriate specimens from atypical or malignant lesions through CNB, due to histological heterogeneity. It has been demonstrated that CNB is not concordant with surgical excision due to high rates of upgrading of precursor lesions into carcinoma (7,10-16). For this reason, numerous authors have advocated surgical excision of intraductal lesions, such as benign papilloma (with or without atypia), but others conclude that CNB would remove all lesions (17,18). Increasingly, the focus of studies has been on patients with intraductal lesions without nipple discharge than with nipple discharge. However, in none of those studies have researchers drawn attention to the importance of PND. There is no consensus on whether such patients should undergo routine ductoscopy examination. Recent research has suggested that precursor lesions of cancer include IDPs and ADH (10,19). Therefore, it is important to identify intraductal lesions in women without PND at an early stage.
The objective of the present study was to retrospectively survey potential risk factors associated with intraductal lesions (IDPs, ADH and DCIS) in patients without PND and to provide recommendations for clinicians.
Materials and methods
Study design and patients' information
The histopathology and imaging databases were searched for patients who had been diagnosed with non- or intraductal lesions after post-operative histopathological examination in the 13 month-period from April 2016 to April 2017 at the Department of Breast Surgery within China-Japan Union hospital of Jilin University (Jilin, China). The patients presented in outpatient because of routine physical examination or breast palpable lump(s). The age range of the patients was 12-77 years of age, with a median age of 40 years.
Lesions with mastitis and invasive carcinoma as indicated through post-operative histopathological analysis and patients with PND were excluded. Patients were divided into the following study groups: Intraductal lesions (IDP, ADH and DCIS) and control group: Non-intraductal lesions (fibroadenoma, adenosis, cysts and lobular carcinoma in situ). In this study, intraductal papilloma included both central papilloma and peripheral papilloma. Intraductal papilloma with an atypical lesion was defined as ADH. DCIS was categorized as pure DCIS and intraductal papilloma with DCIS. As LCIS arises from the breast lobular epithelium of the breast rather than the breast ductal epithelium, so LCIS was placed under non-intraductal lesions in our study (20,21). Once eligibility was established based on histopathological diagnosis, we extracted data of clinical variables, such as patient age, course of disease (year), menopausal status, age at menarche, number of pregnancies and abortions, non-menstrual breast pain; and imaging features, such as tumor size, number, margin and shape of masses, distance from nipple, masses with or without blood flow, as well as duct ectasia indicated through ultrasound, and calcification indicated through mammography. Breast Imaging Reporting and Data System (BI-RADS) categories were measured using ultrasound.
The study was approved by the China-Japan Union Hospital of Jilin University (included all content related to the patient; project approval no. 201620218). Even though this was a retrospective study, the hospital Ethics Committee evaluated it carefully and suggested it could waive the informed consent (including the 12-year-old patient's guardians), based on our institutional policy of strict maintenance of anonymity.
Ultrasonography and pathology assessment
All patients were evaluated using a Philips IU22A Ultrasound Imaging system (line probe, probe frequency 9-15 MHZ) and all ultrasonography examinations were performed by two physicians with 5 years of experience in US diagnosis. Each surgically resected specimen was fixed in formalin and embedded in paraffin for histological analysis, which was performed by three pathologists specialized in breast diagnosis. The pathologists were blinded to the US reports. Diagnosis was made based on the 2012 WHO classification of tumors of the breast (22).
Statistical analysis
Statistical analysis was performed using IBM SPSS Statistics for Windows (version 20.0; IBM Corp., Armonk). First, comparison of categorical data was conducted using the χ2 test. Then, a multivariate logistic regression analysis was used to determine risk factors that may be associated with intraductal lesions without PND. P<0.05 was considered statistically significant.
Results
Postoperative histopathology findings
A total of 370 lesions in 255 patients without PND, and with a postoperative histopathology diagnosis of intraductal lesions (IDP or IDPs, ADH and DCIS) or non-intraductal lesions (fibroadenoma, adenosis, cysts and lobular carcinoma in situ), were included in the study. Of the 255 patients, 115 patients had bilateral lesions, while 140 patients had unilateral lesions. ADH was found in 29 cases and DCIS was found in 16 cases. The distribution of the histopathological diagnoses is summarized in Table I.
Univariate analyses (characteristics of patients)
The clinicopathological parameters of the surgical histopathological diagnosis data of 370 lesions were compared based on the presence or absence of intraductal lesions (Table II). The average age of these patients was 43 years (range, 12-77 years), with an average of 54 years in the study group, and 41 years in the control group. We confirmed that there was only one 12-year old patient in the present study, her information was not removed prior to the statistical analysis, and this case did not affect the results. The data in our study demonstrated that age was associated with intraductal lesions (P<0.001). In addition, we found that age at first menstruation was statistically different among patients of each group (P=0.047). In terms of menopausal status, no significant difference was found between the two groups (P=0.186). Regarding the number of pregnancies and abortions, there was a statistically significant difference between the two groups (P=0.009; P<0.001, respectively). Similarly, there was a difference between the groups with regard to the course of disease (P=0.033). We also evaluated non-menstrual breast pain, and the difference was statistically significant between the two groups (P=0.003) (Table II).
 | Table IIUnivariate analysis of characteristics of intraductal lesions patients compared with non-intraductal lesions patients. |
Univariate analyses (characteristics of imaging)
Table III shows the imaging characteristics of intraductal lesions, compared with non-intraductal lesions, in patients without PND. In terms of breast duct ectasia, lesion size, and distance from nipple, significant differences (all P<0.01) were found. In the 156 samples without PND that were confirmed positive for intraductal lesions, 26 of the samples were found to contain duct ectasia (Fig. 1). However, only 6 samples were found to have duct ectasia in the control group. The lesion size (>1 cm) in the control group was more than that of the study group (68.9 vs. 31.1%), while the distance from nipple (>2 cm) was the same (68.7 vs. 31.3%).
| Table IIIUnivariate analysis of imaging (mammography and ultrasonography) characteristics of the patients without PND. |
For the other imaging characteristics, BI-RADS, calcification, blood flow, the number of nodules, margin and shape of masses, no significant difference was found between the study and control groups (P>0.05) (Table III).
Risk factors for intraductal lesions
Nine out of 14 factors were found to be statistically different as shown by the univariate analyses (Tables II and III). Five factors were identified as relative risk factors through multivariate logistic regression analysis (Table IV). The predominant relative risk of intraductal lesions for women without PND but with duct ectasia of breast was found to be 9.455 times higher than that for women without duct ectasia of the breast (95% CI=3.194-27.987, P<0.001). The second highest relative risk for intraductal lesions was found to be patients aged over 50 years (OR=6.207, 95% CI=2.587-14.891, P<0.001). Age between 35 and 50 years also constituted a risk factor. The data confirm that the relative risk for older patients was higher than that of younger patients. The relative risk of having intraductal lesions ≤2 cm (Fig. 2) from the nipple was 2.745-fold higher than that of patients who have intraductal lesions at a distance >2 cm from the nipple (95% CI=1.668-4.526, P<0.001). The multivariate analysis also shows that non-menstrual breast pain (OR=1.922, 95% CI=1.037-3.564, P=0.038), and a lesion size of ≤1 cm (Fig. 3) (OR=1.903, 95% CI=1.155-3.136, P=0.012) were more highly associated with intraductal lesions than non-intraductal lesions (Table IV).
| Table IVMultivariate analysis of characteristics of intraductal lesions compared with non-intraductal lesions. |
Discussion
Along with the increase in the knowledge of breast cancer, it is a generally accepted consensus that early detection and early treatment is of great benefit to patients. To the best of our knowledge, DCIS is considered a true precursor lesion for invasive cancer (19), as well as ADH. In addition, all IDPs are considered cancer precursor lesions (10), so all precursor lesions are intraductal lesions (10,19). However, there is no generally accepted consensus regarding criteria used to distinguish between intraductal and non-intraductal lesions.
It has been demonstrated that clinical parameters, such as age, estrogen levels, a history of family genetics, including HER-2 overexpression and BRCA1/2 mutations, increase the risk of breast cancer. Although technology used for gene mutation detection is highly advanced, it is very expensive. Therefore, it is important to identify relative risk factors for precursor lesions, which may provide guidance for clinicians. Although many investigators have assessed risk factors for malignancies in benign papilloma of breast in CNB, the results remain conflicting (7,10-13,23-27).
PND is an important common symptom seen in intraductal lesions and has been confirmed as a risk factor for breast cancer in many studies (4-6). However, a recent study confirmed that the frequency of intraductal lesions without PND is much higher than that with PND (28). Pareja et al reported that only 8 out of 166 women with nipple discharge in their study were diagnosed with IDP (29). A number of cases have reported similar findings (Table V). Our findings confirm that the number of intraductal lesions is similar to that of non-intraductal lesions (156 vs. 214), which indicates that there may be many intraductal lesions in patients without PND. Although many studies have investigated risk factors associated with malignant changes in intraductal lesions, they have not specifically separated patients with PND from those without PND. Therefore, we studied risk factors associated with intraductal lesions in patients without PND, whose diagnosis was confirmed through histopathological methods. In addition, in our study, non-intraductal lesions were considered as the control group, and their characteristics were compared with precursor lesions.
We studied clinical and imaging variables to analyze risk factors of intraductal lesions. We found clinical parameters, including age, non-menstrual breast pain, breast duct ectasia, distance from nipple and lesion size to be related to the risk of intraductal lesions.
Clinically, intraductal papilloma could occur at any age, but the majority of patients are 40-50 years of age when it occurs (23). We reported that a more advanced age is associated with a higher risk of intraductal lesions. Some studies have indicated that age is correlated with the severity of intraductal lesions (12,14,17,28,30,31). Those studies have demonstrated that the older the patient, the higher the degree of severity of the intraductal lesions. In contrast to that, another study reported that age is not significantly related to the severity of intraductal lesions, but they found that all patients with carcinoma were aged over 50, and 34.9% of the patients in their study had prior or concurrent breast carcinoma (29). Therefore, their research, to a certain extent, does not provide clinical guidance for the early detection of intraductal lesions.
We also observed that the occurrence rate of both pregnancies and abortions, but not menopausal state was associated with intraductal lesions in the univariate analysis. However, in the multivariate logistic regression analysis, they were found to be confounding factors. Unlike in this study, a previous study by Shiino et al (10) founded that menopausal status (menopause) is a relative risk factor for precursors and carcinoma. One major reason for menopausal state not reaching statistical significance (P=0.186) in our study is that most patients were diagnosed with benign lesions at a younger age, at which they were still menstruating. Another reason is that the age factor may be more important when compared with menstrual and reproductive history. Although in this study menstrual and reproductive history was found to have no statistical significance, they should be taken into consideration when evaluating clinical cases, since many recent studies have shown that these factors are associated with an increased risk of breast cancer (32-35). Therefore, further investigations are required to explore the mechanisms that underlie the association between menstrual and reproductive histories and the risk of breast cancer.
Over half of the patients with intraductal lesions in our study (57.7%), had suffered non-menstrual breast pain, a statistically significant difference was found among clinical characteristics between lesions with and those without intraductal lesions. A recent study reported that breast pain may be associated with breast cancer and it has been suggested that clinicians and radiologists should remain attentive to female patients who complain of breast pain (36). Similarly, Preece et al (37) cautioned that focally isolated pain can be a presenting symptom of cancer. When the symptom of breast pain is present, further imaging examinations should be suggested.
Furthermore, there are clear trends towards an increased risk of intraductal lesions with duct ectasia, as shown through ultrasound in the present study. In our study, duct ectasia has been demonstrated to be a predominant risk factor for intraductal lesions in women without PND (OR=9.455, P<0.01). Hsu et al (38) studied 172 patients with duct ectasia through ultrasound and found that there is a relationship between ductal ectasia and intraductal lesions, especially non-invasive cancerous lesions. However, they did not categorize the lesions as with or without nipple discharge. Therefore, it is not possible to determine the relationships between nipple discharge, duct ectasia and intraductal lesions using this study. Since our study was a preliminary study on risk factors for intraductal lesions in patients without PND, no categorization of the specific types of duct ectasia was made and further analysis of categories is required in future studies. Intraductal lesions originate from the ductal epithelium, therefore, regardless of the presence of PND, it is commonly accepted that ductal ectasia indicates intraductal lesions, which was confirmed by the results of our study, in which ductal ectasia was found to be statistically significant. Duct ectasia with a well-defined hypoechoic solid mass is a typical sonographic characteristic of intraductal tumors (23,39,40). Therefore, these findings support the results of our study.
Central intraductal lesions arise in the large mammary duct, typically at a distance of less than 2 cm from the nipple. By contrast, peripheral intraductal lesions arise in the terminal duct lobular units, typically at a distance of more than 2 cm from the nipple (12). Some authors argue that the distance from the nipple is not associated with intraductal breast lesions (12,13,23,29,30,41). However, the results of our study indicate that a distance of ≤2 cm from the nipple increases the relative risk of intraductal lesions. However, other authors have concluded that lesions 3 cm or more away from the nipple are more likely to be atypical. The differences between patient groups may account for these conflicting results.
Most intraductal papilloma are small (<5 mm). Zhu et al (23) reported that 32 of 44 intraductal papilloma analyzed were <1.0 cm in diameter. Similarly, we found that a higher number (52.4%) of intraductal lesion were <1.0 cm in diameter. Chang et al (13) demonstrated that a size >1.5 cm appears to be significantly associated with malignancy, which is consistent with our results (lesion ≤1 cm is a risk factor for intraductal lesions). Although sizes larger than 3-4 cm have been reported by Wang et al (24), no clinical significance has been found based on larger diameter tumors, both benign and malignant, which indicate that surgery may be required.
Our study found that calcification is not significantly related to a risk of intraductal lesions because we excluded invasive breast cancer patients and only examined characteristics of mammography, with or without calcification. Similarly, in the study by Pareja et al (29), the authors confirmed that there is no statistically significant difference in radiological characteristics of intraductal lesions. However, Li et al (12) confirmed that micro-calcification is a risk factor for the degree of severity of tumors (P=0.002). Maxwell et al (7) and Sakr et al (14) have reported similar results. Therefore, further studies are required to determine whether micro-calcifications or calcifications can be used as an indication of the relative risk of intraductal lesions.
To the best of our knowledge, one of the strengths of the present study is that it is the first to study risk factors of patients without PND but diagnosed with intraductal lesions, and all lesions were removed through surgical excision, assuring the accuracy of their pathological diagnosis.
However, our study also has some limitations. First, our study is a purely retrospective study with selection bias. Second, the number of cases included in the current study is limited, and a majority of cases in the control contained lesions that were not clear precursors. Furthermore, our observations of the associated risk factors of intraductal lesions should be regarded as preliminary, since no relevant studies exist to confirm that these factors can help clinicians to improve the early detection rate of breast cancer. Furthermore, large samples of a variety of population studies are needed to confirm our results. We are currently conducting this scale of research with intraductal lesions that have PND, non-intraductal lesions that have PND, intraductal lesions that do not have PND and non-intraductal lesions that do not have PND.
Our study results demonstrate that there is a statistically significant difference in clinical features and imaging between intraductal and non-intraductal lesions in patients without PND. Our data indicate that an age >35 years, non-menstrual breast pain, breast duct ectasia, distance from nipple of ≤2 cm and lesion size of ≤1 cm are risk factors of intraductal lesions in patients without PND. Since the vast majority of intraductal lesions are associated with PND, and usually only in the presence of this symptom do clinicians and imaging physicians attach more importance to a lesion, we suggest that patients without PND but with the above-mentioned risk factors require investigation, in order to prevent misdiagnosis and improve early detection rates of breast cancer.
Acknowledgements
The authors would like to thank Dr Enqi Chen and Dr Yuanqiang Lin (Department of Ultrasonography, China-Japan Union Hospital of Jilin University, Changchun, China) for their assistance of evaluating the breast ultrasound. The authors would also like to thank the other pathologist, Dr Chengwei Jiang.
Funding
Authors are grateful to the Science and Technology of Jilin Province Health and Family Planning Commission 2017Q035 (to ZYY).
Availability of data and materials
The datasets used and analyzed during the current study are available from the corresponding author on reasonable request.
Authors' contributions
YY, ZY and LS conceived and designed the study and drafted the manuscript. LS, ZK and JW collected the data. XL and WL performed the statistical analysis and helped to draft the manuscript. SY contributed to obtaining the pathological materials and pathology assessment. All authors read and approved the final manuscript.
Ethics approval and consent to participate
This study was conducted in accordance with the amended Declaration of Helsinki. The approval of the Ethical Committee of China-Japan Union Hospital of Jilin University (Jilin, China) was obtained (project approval no. 201620218). We waived the need for ethical approval and informed consent of patients, based on our institutional policy, strict maintenance of anonymity and the observational nature of the study.
Patient consent for publication
Not applicable.
Competing interests
The authors declare that they have no conflict of interests.
References
|
Dundar MM, Badve S, Bilgin G, Raykar V, Jain R, Sertel O and Gurcan MN: Computerized classification of intraductal breast lesions using histopathological images. IEEE Trans Biomed Eng. 58:1977–1984. 2011.PubMed/NCBI View Article : Google Scholar | |
|
Yang L, Wu D and Fan ZM: Retrospective analysis of pathologic nipple discharge. Genet Mol Res. 14:1443–1449. 2015.PubMed/NCBI View Article : Google Scholar | |
|
Han Y, Li J, Han S, Jia S, Zhang Y and Zhang W: Diagnostic value of endoscopic appearance during ductoscopy in patients with pathological nipple discharge. BMC Cancer. 17(300)2017.PubMed/NCBI View Article : Google Scholar | |
|
Lang JE and Kuerer HM: Breast ductal secretions: Clinical features, potential uses, and possible applications. Cancer Control. 14:350–359. 2007.PubMed/NCBI View Article : Google Scholar | |
|
Escobar PF, Crowe JP, Matsunaga T and Mokbel K: The clinical applications of mammary ductoscopy. Am J Surg. 191:211–215. 2006.PubMed/NCBI View Article : Google Scholar | |
|
Montroni I, Santini D, Zucchini G, Fiacchi M, Zanotti S, Ugolini G, Manaresi A and Taffurelli M: Nipple discharge: Is its significance as a risk factor for breast cancer fully understood? Observational study including 915 consecutive patients who underwent selective duct excision. Breast Cancer Res Treat. 123:895–900. 2010.PubMed/NCBI View Article : Google Scholar | |
|
Maxwell AJ, Mataka G and Pearson JM: Benign papilloma diagnosed on image-guided 14 G core biopsy of the breast: Effect of lesion type on likelihood of malignancy at excision. Clin Radiol. 68:383–387. 2013.PubMed/NCBI View Article : Google Scholar | |
|
Sparks CA: Using ductoscopy to detect breast mass at an early stage. AORN J. 76:851–854. 2002.PubMed/NCBI View Article : Google Scholar | |
|
Dubowy A, Raubach M, Topalidis T, Lange T, Eulenstein S and Hünerbein M: Breast duct endoscopy: Ductoscopy from a diagnostic to an interventional procedure and its future perspective. Acta Chir Belg. 111:142–145. 2011.PubMed/NCBI View Article : Google Scholar | |
|
Shiino S, Tsuda H, Yoshida M, Jimbo K, Asaga S, Hojo T and Kinoshita T: Intraductal papillomas on core biopsy can be upgraded to malignancy on subsequent excisional biopsy regardless of the presence of atypical features. Pathol Int. 65:293–300. 2015.PubMed/NCBI View Article : Google Scholar | |
|
Swapp RE, Glazebrook KN, Jones KN, Brandts HM, Reynolds C, Visscher DW and Hieken TJ: Management of benign intraductal solitary papilloma diagnosed on core needle biopsy. Ann Surg Oncol. 20:1900–1905. 2013.PubMed/NCBI View Article : Google Scholar | |
|
Li X, Weaver O, Desouki MM, Dabbs D, Shyum S, Carter G and Zhao C: Microcalcification is an important factor in the management of breast intraductal papillomas diagnosed on core biopsy. Am J Clin Pathol. 138:789–795. 2012.PubMed/NCBI View Article : Google Scholar | |
|
Chang JM, Moon WK, Cho N, Han W, Noh DY, Park IA and Jung EJ: Risk of carcinoma after subsequent excision of benign papilloma initially diagnosed with an ultrasound (US)-guided 14-gauge core needle biopsy: A prospective observational study. Eur Radiol. 20:1093–1100. 2010.PubMed/NCBI View Article : Google Scholar | |
|
Sakr R, Rouzier R, Salem C, Antoine M, Chopier J, Darai E and Uzan S: Risk of breast cancer associated with papilloma. Eur J Surg Oncol. 34:1304–1308. 2008.PubMed/NCBI View Article : Google Scholar | |
|
Fatemi Y, Hurley R, Grant C, Henrichsen T, Chen B and Ghosh K: Challenges in the management of giant intraductal breast papilloma. Clin Case Rep. 3:7–10. 2015.PubMed/NCBI View Article : Google Scholar | |
|
Sydnor MK, Wilson JD, Hijaz TA, Massey HD and Shaw de Paredes ES: Underestimation of the presence of breast carcinoma in papillary lesions initially diagnosed at core-needle biopsy. Radiology. 242:58–62. 2007.PubMed/NCBI View Article : Google Scholar | |
|
Yi W, Xu F, Zou Q and Tang Z: Completely removing solitary intraductal papillomas using the mammotome system guided by ultrasonography is feasible and safe. World J Surg. 37:2613–2617. 2013.PubMed/NCBI View Article : Google Scholar | |
|
Mosier AD, Keylock J and Smith DV: Benign papillomas diagnosed on large-gauge vacuum-assisted core needle biopsy which span <1.5 cm do not need surgical excision. Breast J. 19:611–617. 2013.PubMed/NCBI View Article : Google Scholar | |
|
Ward EM, DeSantis CE, Lin CC, Kramer JL, Jemal A, Kohler B, Brawley OW and Gansler T: Cancer statistics: Breast cancer in situ. CA Cancer J Clin. 65:481–495. 2015.PubMed/NCBI View Article : Google Scholar | |
|
Foote FW and Stewart FW: Lobular carcinoma in situ: A rare form of mammary cancer. Am J Pathol. 17:491–496.3. 1941.PubMed/NCBI View Article : Google Scholar | |
|
Wen HY and Brogi E: Lobular carcinoma in situ. Surg Pathol Clin. 11:123–145. 2018.PubMed/NCBI View Article : Google Scholar | |
|
Yang WT and Zhu XZ: The introduction of 2012 WHO classification of tumours of the breast. Zhonghua Bing Li Xue Za Zhi. 42:78–80. 2013.(In Chinese). PubMed/NCBI View Article : Google Scholar | |
|
Zhu Y, Zhang S, Liu P, Lu H, Xu Y and Yang WT: Solitary intraductal papillomas of the breast: MRI features and differentiation from small invasive ductal carcinomas. AJR Am J Roentgenol. 199:936–942. 2012.PubMed/NCBI View Article : Google Scholar | |
|
Wang LC, DeMartini WB, Partridge SC, Peacock S and Lehman CD: MRI-detected suspicious breast lesions: Predictive values of kinetic features measured by computer-aided evaluation. AJR Am J Roentgenol. 193:826–831. 2009.PubMed/NCBI View Article : Google Scholar | |
|
Jung SY, Kang HS, Kwon Y, Min SY, Kim EA, Ko KL, Lee S and Kim SW: Risk factors for malignancy in benign papillomas of the breast on core needle biopsy. World J Surg. 34:261–265. 2010.PubMed/NCBI View Article : Google Scholar | |
|
Lewis JT, Hartmann LC, Vierkant RA, Maloney SD, Shane Pankratz V, Allers TM, Frost MH and Visscher DW: An analysis of breast cancer risk in women with single, multiple, and atypical papilloma. Am J Surg Pathol. 30:665–672. 2006.PubMed/NCBI View Article : Google Scholar | |
|
Page DL, Salhany KE, Jensen RA and Dupont WD: Subsequent breast carcinoma risk after biopsy with atypia in a breast papilloma. Cancer. 78:258–266. 1996.PubMed/NCBI View Article : Google Scholar | |
|
Glenn ME, Throckmorton AD, Thomison JB III and Bienkowski RS: Papillomas of the breast 15 mm or smaller: 4-Year experience in a community-based dedicated breast imaging clinic. Ann Surg Oncol. 22:1133–1139. 2015.PubMed/NCBI View Article : Google Scholar | |
|
Pareja F, Corben AD, Brennan SB, Murray MP, Bowser ZL, Jakate K, Sebastiano C, Morrow M, Morris EA and Brogi E: Breast intraductal papillomas without atypia in radiologic-pathologic concordant core-needle biopsies: Rate of upgrade to carcinoma at excision. Cancer. 122:2819–2827. 2016.PubMed/NCBI View Article : Google Scholar | |
|
Chang JM, Moon WK, Cho N, Han W, Noh DY, Park IA and Jung EJ: Management of ultrasonographically detected benign papillomas of the breast at core needle biopsy. AJR Am J Roentgenol. 196:723–729. 2011.PubMed/NCBI View Article : Google Scholar | |
|
Rizzo M, Linebarger J, Lowe MC, Pan L, Gabram SG, Vasquez L, Cohen MA and Mosunjac M: Management of papillary breast lesions diagnosed on core-needle biopsy: Clinical pathologic and radiologic analysis of 276 cases with surgical follow-up. J Am Coll Surg. 214:280–287. 2012.PubMed/NCBI View Article : Google Scholar | |
|
Suh JS, Yoo KY, Kwon OJ, Yun IJ, Han SH, Noh DY and Choe KJ: Menstrual and reproductive factors related to the risk of breast cancer in Korea. Ovarian hormone effect on breast cancer. J Korean Med Sci. 11:501–508. 1996.PubMed/NCBI View Article : Google Scholar | |
|
Huang Y, Zhang X, Li W, Song F, Dai H, Wang J, Gao Y, Liu X, Chen C, Yan Y, et al: A meta-analysis of the association between induced abortion and breast cancer risk among Chinese females. Cancer Causes Control. 25:227–236. 2014.PubMed/NCBI View Article : Google Scholar | |
|
Arthur R, Wang Y, Ye K, Glass AG, Ginsberg M, Loudig O and Rohan T: Association between lifestyle, menstrual/reproductive history, and histological factors and risk of breast cancer in women biopsied for benign breast disease. Breast Cancer Res Treat. 165:623–631. 2017.PubMed/NCBI View Article : Google Scholar | |
|
Jung S, Egleston BL, Chandler DW, Van Horn L, Hylton NM, Klifa CC, Lasser NL, LeBlanc ES, Paris K, Shepherd JA, et al: Adolescent endogenous sex hormones and breast density in early adulthood. Breast Cancer Res. 17(77)2015.PubMed/NCBI View Article : Google Scholar | |
|
Noroozian M, Stein LF, Gaetke-Udager K and Helvie MA: Long-term clinical outcomes in women with breast pain in the absence of additional clinical findings: Mammography remains indicated. Breast Cancer Res Treat. 149:417–424. 2015.PubMed/NCBI View Article : Google Scholar | |
|
Preece PE, Baum M, Mansel RE, Webster DJ, Fortt RW, Gravelle IH and Hughes LE: Importance of mastalgia in operable breast cancer. Br Med J (Clin Res Ed). 284:1299–1300. 1982.PubMed/NCBI View Article : Google Scholar | |
|
Hsu HH, Yu JC, Hsu GC, Chang WC, Yu CP, Tung HJ, Tzao C and Huang GS: Ultrasonographic alterations associated with the dilatation of mammary ducts: Feature analysis and BI-RADS assessment. Eur Radiol. 20:293–302. 2010.PubMed/NCBI View Article : Google Scholar | |
|
Francis A, England D, Rowlands D and Bradley S: Breast papilloma: Mammogram, ultrasound and MRI appearances. Breast. 11:394–397. 2002.PubMed/NCBI View Article : Google Scholar | |
|
Zhu QL, Zhang J, Lai XJ, Wang HY, Xiao MS and Jiang YX: Characterisation of breast papillary neoplasm on automated breast ultrasound. Br J Radiol. 86(20130215)2013.PubMed/NCBI View Article : Google Scholar | |
|
Chang JM, Han W, Moon WK, Cho N, Noh DY, Park IA and Jung EJ: Papillary lesions initially diagnosed at ultrasound-guided vacuum-assisted breast biopsy: Rate of malignancy based on subsequent surgical excision. Ann Surg Oncol. 18:2506–2514. 2011.PubMed/NCBI View Article : Google Scholar |
