Objectives: The purpose of this retrospective study was to assess the sonographic features of benign, high‐risk, and malignant papillary lesions of the breast.Methods: We conducted a search of our institution's breast biopsy database for all papillary lesions with sonographic findings and final surgical pathologic diagnoses from January 1, 2004, to December 31, 2009. We retrospectively reviewed the breast sonographic findings of 23 benign papillomas, 14 papillomas with associated atypical ductal hyperplasia, and 14 papillary carcinomas, all surgically proven. These 51 lesions in 50 patients comprised our data set. The imaging reports, pathologic records, and surgical records of these patients were reviewed, and statistical analysis was performed.Results: The findings for 50 patients (age range, 26–92 years; mean, 55.2 years) with 51 lesions were reviewed. One patient had bilateral breast cancer. Size and margin features showed statistically significant differences (P < .05) between the lesions. Twelve (47.9%) benign papillomas, 10 (71.4%) high‐risk lesions, and 13 (92.9%) malignant lesions were larger than 1 cm. Sixteen (69.6%) benign papillomas, 10 (71.4%) high‐risk lesions, and only 4 (28.6%) malignant lesions had circumscribed margins. With regard to echo pattern, there was a statistically significant difference between the lesions (P< .01). Twenty (87.0%) benign papillomas, 4 (28.6%) high‐risk lesions, and 10 (71.4%) malignant lesions were hypoechoic. Posterior sonographic features were also statistically significant (P < .05), with malignant and high‐risk lesions being associated with posterior enhancement or shadowing. Another statistically significant difference (P < .01) was intralesional vascularity, which was seen more frequently with malignant lesions. Regardless of lesion type, the distance from the nipple, shape, orientation, surrounding tissue change, and associated calcifications were not significant.Conclusions: Our results suggest that sonographic features that may potentially assist in differentiating papillary lesions include size, margin, echo pattern, posterior features, and intralesional vascularity.