Ductal intraepithelial neoplasia (IDH, AIDH and DCIS)

Is Excisional Biopsy Needed for Pure FEA Diagnosed on a Core Biopsy?

BACKGROUND

The management of flat epithelial atypia (FEA) on core needle biopsy remains controversial. The upstaging rates after surgical excision are variable. In this study, we seek to determine the upstaging rate of FEA at our institution.

METHODS

Patients with a diagnosis of FEA were identified from the institution's pathology database from 2009 to 2018. Patients were included in the study if FEA alone, without atypia or cancer, was identified on core needle biopsy. Patient demographics, imaging, management, and pathology characteristics were obtained. Statistical analysis performed using IBM SPSS 26.0 (Armonk, NY, USA).

RESULTS

FEA was diagnosed on core needle biopsy in 235 patients from 2009 to December 2018. Forty-eight patients met the inclusion criteria. The majority of patients presented with calcifications on mammogram (n = 21, 64%) with the remainder as masses (n = 6, 18%) or architectural distortion (n = 6, 18%). Of those, 15 (31%) patients declined surgical excision, of which none developed cancer over a mean follow-up of 4.4 years. Of the 33 (69%) patients undergoing excisional biopsy, 17 (52%) confirmed FEA, 11 (33%) had benign findings, and 3 (9%) demonstrated atypical ductal hyperplasia on final pathology. One (3%) case revealed ductal carcinoma in situ (DCIS) and 1 (3%) was upgraded to invasive cancer for an overall upstaging rate of 4% (2/48). After a mean follow-up of 3.4 years, none of the excisional biopsy patients developed invasive breast cancer. Adjuvant therapy was used in the cases of DCIS and invasive cancer; however, chemoprevention with raloxifene or tamoxifen was not chosen by any of the remaining patients.

CONCLUSION

In our cohort, expectant management of FEA alone appears to be a safe option as our upstaging rate to DCIS or invasive cancer for FEA diagnosed on core biopsy was only 4%. Our study suggests that close follow-up is a safe and feasible option for pure FEA without a radiographic discordance found on core biopsy.

Vacuum-assisted biopsy diagnosis of atypical ductal hyperplasia and patient management

PURPOSE

This study sought to evaluate the accuracy of vacuum-assisted biopsy (VAB) in the diagnosis of atypical ductal hyperplasia (ADH) by determining the rate of VAB underestimation compared with definitive histology. In addition, an attempt was made to identify parameters that could help determine the most appropriate patient management.

MATERIALS AND METHODS

We retrospectively reviewed 1,776 VAB procedures performed between November 1999 and January 2008 for suspicious subclinical breast lesions visible only at mammography. A total of 177 patients with a VAB diagnosis of pure ADH were studied. Patients with a diagnosis of ADH associated with other lesions (lobular intraepithelial neoplasia, papilloma), atypical lobular hyperplasia, lobular carcinoma in situ and any lesions with a microhistological diagnosis other than ADH were excluded. Mammographic appearance of lesions was as follows: 152 mostly clustered microcalcifications (86%); five opacities with microcalcifications (3%); 12 single opacities (3%); and eight parenchymal distortions (4%), of which five were without and three were with microcalcifications. In cases underestimated by VAB, we evaluated the extent of ADH within ducts and lobules. Based on results, patients were subdivided into two groups: ≤2 ADH foci; >2 ADH foci. Patients were subdivided into two groups: one was referred for surgery and the other for follow-up care. The decision to either perform or not perform surgery was based on combined analysis of the following parameters: patient age; risk factors in the patient's history; mammographic extent of microcalcifications; complete excision of microcalcifications at VAB; and final Breast Imaging Reporting and Data System (BI-RADS) assessment.

RESULTS

In the first group (n=98), comparison of microhistology with final histology revealed that 19 cases of ADH had been underestimated by VAB. In the second group (n=79), six cases of ADH showed progression of the mammographic abnormality, which was subsequently confirmed by surgical biopsy.

CONCLUSIONS

The most relevant parameters affecting the decision to proceed to surgical excision were lesion diameter >7 mm on mammography, >2 ADH foci, incomplete removal of the calcifications and a family and/or personal history of breast cancer. Although there are no definite mammographic predictors of malignancy, a radiological assessment of suspicious lesion in the presence of an additional equivocal parameter always warrants surgical management.

Frequency of Clinically Occult Intraepithelial and Invasive Neoplasia in Reduction Mammoplasty Specimens: A Study of 516 Cases

Reduction mammoplasty is a frequently performed procedure for the treatment of macromastia and for the achievement of symmetry in breast cancer patients following lumpectomy. Slides from 516 consecutive bilateral reduction mammoplasties performed for macromastia over 15 years were reviewed. Among these, 92 (18%) low-risk ductal intraepithelial neoplasia/intraductal hyperplasia, 28 (5%) ductal intraepithelial neoplasia 1 (1 low-grade ductal carcinoma in situ, 11 atypical intraductal hyperplasia, and 16 flat type), 17 (3%) lobular intraepithelial neoplasia, and 1 (0.2%) tubular carcinoma were identified. The patients were categorized into 3 age groups: <40 (n = 352), 40 to 50 (n = 107), and over 50 years (n = 57); the frequency of the lesions increased with age. These data confirm the low frequency of clinically occult malignancies identified in reduction mammoplasty specimens and provide substantial information about the frequency of a variety of intraepithelial proliferations. Preoperative mammography, specimen orientation, and inking of margins with 1 color are advised when reduction mammoplasty is scheduled for women ≥ 40 years of age.

Ductal Carcinoma in situ and related lesions of the breast: recent advances in pathology practice

The incidence of ductal carcinoma in situ (DCIS) of the breast has increased significantly in Japanese women. It comprises 14.1% (172/1216) of all primary breast cancers at our institute, and nowadays this histological type is familiar to the surgeons and pathologists of any institute. Several subclassifications have been published recently. Most based on nuclear atypia and the presence of comedonecrosis, and sometimes on the structures of the involved glands. These classifications are correlated with the biological behavior, tumor extent and the risk for local recurrences. The diagnostic accuracy of minimally invasive procedures (aspiration biopsy cytology/core needle biopsy) may differ between subclasses. Atypical ductal hyperplasia (ADH) and microinvasive ductal carcinomas are lesions which resemble but deviate from the DCIS spectrum. The incidence of ADH seems to be lower than in Western countries. Patients with ADH may have a risk for subsequent breast cancer, because ADH is frequently associated with contralateral breast carcinomas. Microinvasion should be treated with caution, but we could not find any metastatic foci in microinvasive ductal carcinomas (T1mic). Tentatively, ADH may be treated similarly to non-comedo (low-grade) DCIS cases, according to our limited clinical experience.

p63 expression in normal, hyperplastic and malignant breast tissues

BACKGROUND

p63 is a homologue of the p53 tumor suppressor gene and its protein is selectively expressed in the basal cells of a variety of epithelial tissues. It has recently been confirmed that p63 is expressed in the basal cells of normal prostate glands but not in prostatic carcinomas. Whether expression of p63 in breast correlates with tumor progression is the focus of this study.

METHODS

Forty cases, which all contained normal breast tissue, ductal hyperplasia, ductal carcinoma in situ and invasive ductal carcinoma in the same patient were included in this investigation using an indirect immunohistochemical method and double staining.

RESULTS

p63 was exclusively expressed in the myoepithelial cells of normal breast, partially expressed in ductal hyperplasia, rarely expressed in carcinoma in situ and not expressed in invasive carcinomas.

CONCLUSION

The results suggest an association between loss of p63 expression and progression of breast ductal carcinoma. p63 immunostaining might be of assistance for distinguishing invasive ductal carcinoma from ductal carcinoma in situ or rare questionable ductal hyperplastic lesions, leading to correct therapy clinically.