Malignant upgrade risk and risk-stratified management of breast intraductal papilloma after percutaneous biopsy: an umbrella review

Background Management of biopsy-diagnosed intraductal papilloma, particularly lesions without atypia, remains controversial. This umbrella review synthesized evidence on malignant upgrade, malignancy underestimation, predictors, and management strategies. Methods PubMed, Embase, Web of Science, and the Cochrane Library were searched from inception to May 30, 2026. Eligible systematic reviews and meta-analyses reported papillary lesion-specific outcomes after percutaneous biopsy. Two reviewers independently performed study selection, data extraction, and AMSTAR 2 appraisal. Estimates were synthesized narratively without additional meta-analysis; primary-study overlap was assessed using the corrected covered area. The protocol was registered in PROSPERO (CRD420261417131). Results Six reviews were included from 304 records. The citation matrix comprised 181 occurrences representing 123 primary studies, with moderate overlap (corrected covered area, 9.43%; sensitivity analysis, 9.67%). All reviews received critically low AMSTAR 2 ratings. Malignant upgrade estimates were 1.4% for radiologic–pathologic concordant intraductal papilloma without atypia and 2.82%–5.0% for broader benign populations. Malignant upgrade or malignancy underestimation estimates were 32%–36% for lesions with atypia. Overall malignancy underestimation estimates were 12%–15.7% in broader nonmalignant papillary lesion populations. Outcome definitions, denominators, and verification methods varied across reviews, and composite upgrade outcomes were distinguished from carcinoma-specific outcomes. Atypia was the strongest indication for surgery; discordance, suspicious imaging, inadequate sampling, suspicious residual abnormalities, and concurrent breast cancer supported further individualized assessment. Conclusions Evidence supports risk-stratified rather than routine surgical management. Papillomas with atypia generally warrant surgical excision, although selected cases may benefit from additional preoperative vacuum-assisted diagnostic sampling when clarification could alter treatment planning. For papillomas without atypia, diagnostic vacuum-assisted sampling may improve tissue assessment without requiring complete lesion removal. Imaging surveillance should be restricted to carefully selected radiologic–pathologic concordant lesions with adequate representative benign sampling, no major adverse features, and reliable follow-up; complete removal may provide additional reassurance. The proposed management framework is not clinically validated, and confidence remains limited by critically low review quality and primary-study overlap. Systematic Review Registration PROSPERO CRD420261417131.