Background Recent studies suggest that US-guided directional vacuum-assisted removal (DVAR) is a satisfactory alternative to surgery for benign papilloma of the breast and recommend discretionary diagnostic US follow-up without intervention. Purpose To compare the outcomes of benign papilloma without atypia diagnosed with core needle biopsy (CNB) in patients who underwent US-guided DVAR, US follow-up without intervention, or surgery. Materials and Methods This retrospective review included consecutive patients with benign papilloma without atypia diagnosed with US-guided CNB between January 2005 and September 2015. Five hundred female patients who underwent surgical excision (n = 206), US-guided DVAR (n = 233), or more than 2 years of US follow-up without intervention (n = 61) were included. The clinical and radiologic findings and cancer upgrade rate were compared among the three groups. Propensity score matching was performed for comparison of the upgrade rate in the surgery and US-guided DVAR groups. Results The mean patient age (±standard deviation) was 46.4 years ± 9.6. The upgrade rate to malignancy was 1.8% (nine of 500 patients; 95% confidence interval [CI]: 0.9%, 3.4%) in the total study population, 1.9% (four of 206 patients; 95% CI: 0.8%, 4.9%) after surgery, 2.1% (five of 233 patients; 95% CI: 0.9%, 4.9%) after US-guided DVAR, and 0% (0 of 61 patients; 95% CI: 0.0%, 5.9%) after US follow-up without intervention (P = .80); after propensity-score matching, the upgrade rate was 1.9% in the surgery group (three of 151 patients; 95% CI: 0.6%, 5.6%) and 3.3% in the US-guided DVAR group (five of 151 patients; 95% CI: 1.4%, 7.5%; P = .48). The recurrence rate after US-guided DVAR was 3.6% (six of 166 patients) during 24-65 months of follow-up; all recurrences were confirmed as benign at subsequent surgery. Fifty-nine of the 61 lesions in the group with US follow-up without intervention (97%) remained stable in size with no growth during a mean follow-up of 43.3 months (range, 25-130 months). Conclusion Low rates of upgrade, recurrence, and growth after US-guided directional vacuum-assisted removal and US follow-up without intervention suggest that benign papilloma without atypia can be managed more conservatively rather than undergoing surgical excision. © RSNA, 2019 Online supplemental material is available for this article.