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Vicks E, Mason H, Perez Coulter A, Niakan S, Friedrich A, Cho R, Casaubon J. Increased risk of upstage when combinations of breast lesions of uncertain malignant potential are found on core needle biopsy: The need for surgical excision. Am J Surg 2024; 227:6-12. [PMID: 37863800 DOI: 10.1016/j.amjsurg.2023.10.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 09/30/2023] [Accepted: 10/02/2023] [Indexed: 10/22/2023]
Abstract
BACKGROUND Management of breast lesions of uncertain malignant potential diagnosed at core needle biopsy (CNB) is controversial due to variable upstage rate (UR) with surgical excision (SE). METHODS We performed an IRB-approved retrospective analysis of adult women who underwent CNB demonstrating atypical ductal hyperplasia (ADH), flat epithelial atypia, radial scar, or intraductal papilloma then SE between 2010 and 2022. We evaluated CNB pathology for combination diagnoses (CD), defined as multiple primary lesions or primary with lobular neoplasia (LN), and surgical pathology for upstage. RESULTS 719 patients were included. UR was 12.2% (88/719). CD experienced higher UR than pure (17.7% (45/254) vs. 9.2% (43/465), p = 0.001). ADH/LN had the highest UR of all CD (34.6% (9/26), p = 0.001). Increased size (15.6 vs. 10.5 mm, p < 0.001), distance from nipple (79 vs. 66 mm, p < 0.001), and personal history of breast cancer (p = 0.04) were associated with UR. CONCLUSIONS CD was associated with increased UR. ADH/LN had the highest UR.
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Affiliation(s)
- Emily Vicks
- University of Massachusetts Chan Medical School, Worcester, MA, 01655, USA.
| | - Holly Mason
- University of Massachusetts Chan Medical School - Baystate, Division of Surgical Oncology, Springfield, MA, 01199, USA.
| | - Aixa Perez Coulter
- University of Massachusetts Chan Medical School - Baystate, Department of Surgery, Springfield, MA, 01199, USA; Office of Research, Epidemiology/Biostatistics Research Core, Baystate Medical Center, Springfield, MA, 01199, USA.
| | - Shiva Niakan
- University of Massachusetts Chan Medical School - Baystate, Division of Surgical Oncology, Springfield, MA, 01199, USA.
| | - Ann Friedrich
- University of Massachusetts Chan Medical School - Baystate, Division of Surgical Oncology, Springfield, MA, 01199, USA.
| | - Ruth Cho
- University of Massachusetts Chan Medical School - Baystate, Division of Surgical Oncology, Springfield, MA, 01199, USA.
| | - Jesse Casaubon
- University of Massachusetts Chan Medical School - Baystate, Division of Surgical Oncology, Springfield, MA, 01199, USA.
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Strickland S, Turashvili G. Are Columnar Cell Lesions the Earliest Non-Obligate Precursor in the Low-Grade Breast Neoplasia Pathway? Curr Oncol 2022; 29:5664-5681. [PMID: 36005185 PMCID: PMC9406596 DOI: 10.3390/curroncol29080447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 08/09/2022] [Accepted: 08/09/2022] [Indexed: 11/16/2022] Open
Abstract
Columnar cell lesions (CCLs) of the breast comprise a spectrum of morphologic alterations of the terminal duct lobular unit involving variably dilated and enlarged acini lined by columnar epithelial cells. The World Health Organization currently classifies CCLs without atypia as columnar cell change (CCC) and columnar cell hyperplasia (CCH), whereas flat epithelial atypia (FEA) is a unifying term encompassing both CCC and CCH with cytologic atypia. CCLs have been increasingly recognized in stereotactic core needle biopsies (CNBs) performed for the assessment of calcifications. CCLs are believed to represent the earliest non-obligate precursor of low-grade invasive breast carcinomas as they share molecular alterations and often coexist with entities in the low-grade breast neoplasia pathway. Despite this association, however, the risk of progression of CCLs to invasive breast carcinoma appears low and may not exceed that of concurrent proliferative lesions. As the reported upgrade rates of pure CCL/FEA when identified as the most advanced high-risk lesion on CNB vary widely, the management of FEA diagnosed on CNB remains controversial. This review will include a historical overview of CCLs and will examine histologic diagnostic criteria, molecular alterations, prognosis and issues related to upgrade rates and clinical management.
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Affiliation(s)
- Sarah Strickland
- Department of Pathology and Laboratory Medicine, Faculty of Medicine, University of Ottawa, Ottawa, ON K1N 6N5, Canada
| | - Gulisa Turashvili
- Department of Pathology and Laboratory Medicine, Emory University Hospital, Emory University School of Medicine, Atlanta, GA 30322, USA
- Correspondence:
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Benign Breast Disease. Clin Obstet Gynecol 2022; 65:448-460. [PMID: 35708970 DOI: 10.1097/grf.0000000000000719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Benign breast disease presents commonly in routine gynecologic care. Presenting symptoms such as breast mass, nipple discharge, or breast pain may raise concern for malignancy. Once breast cancer is ruled out, gynecologists must identify and appropriately treat benign breast disease. While most benign lesions can be managed conservatively, high-risk breast lesions can increase the future risk of breast cancer and may require additional screening imaging and surgical excision. Pharmacologic therapy may also have a role in certain conditions. Gynecologists should be proficient in the identification and management of benign breast disease.
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Pleasant V. Management of breast complaints and high-risk lesions. Best Pract Res Clin Obstet Gynaecol 2022; 83:46-59. [PMID: 35570155 DOI: 10.1016/j.bpobgyn.2022.03.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Revised: 03/24/2022] [Accepted: 03/28/2022] [Indexed: 11/02/2022]
Abstract
Benign breast disease including palpable breast mass, mastalgia, skin changes, and nipple discharge are common gynecologic symptoms. Practitioners should be well versed in the components of clinical breast care. Workup begins with taking a thorough medical and family history to assess risk and performing a clinical breast examination. Breast imaging is often indicated for further evaluation. A structured approach to the evaluation and management of these breast conditions is critical to distinguish benign disease from malignancy. High-risk breast lesions such as atypical hyperplasia and lobular carcinoma in situ are also frequently encountered, and while benign, they do increase the future risk of breast cancer and patients should be offered intensive surveillance and chemoprevention.
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Affiliation(s)
- Versha Pleasant
- University of Michigan, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA.
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Ferre R, Kuzmiak CM. Upgrade rate of percutaneously diagnosed pure flat epithelial atypia: systematic review and meta-analysis of 1,924 lesions. J Osteopath Med 2022; 122:253-262. [PMID: 35150124 DOI: 10.1515/jom-2021-0206] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Accepted: 12/14/2021] [Indexed: 12/29/2022]
Abstract
CONTEXT Management remains controversial due to the risk of upgrade for malignancy from flat epithelial atypia (FEA). Data about the frequency and malignancy upgrade rates are scant. Namely, observational follow-up is advised by many studies in cases of pure FEA on core biopsy and in the absence of an additional surgical excision. For cases of pure FEA, the American College of Surgeons no longer recommends surgical excision but rather recommends observation with clinical and imaging follow-up. OBJECTIVES The aim of this study is to perform a systematic review and meta-analysis to calculate the pooled upgrade of pure FEA following core needle biopsies. METHODS A search of MEDLINE and Embase databases were conducted in December 2020. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. A fixed- or random-effects model was utilized. Heterogeneity among studies was estimated by utilizing the I2 statistic and considered high if the I2 was greater than 50%. The random-effects model with the DerSimonian and Laird method was utilized to calculate the pooled upgrade rate and its 95% confidence interval. RESULTS A total of 1924 pure FEA were analyzed among 59 included studies. The overall pooled upgrade rate to malignancy was 8.8%. The pooled upgrade rate for mammography only was 8.9%. The pooled upgrade rate for ultrasound was 14%. The pooled upgrade rate for mammography and ultrasound combined was 8.8%. The pooled upgrade rate for MRI-only cases was 27.3%. CONCLUSIONS Although the guidelines for the management of pure FEA are variable, our data support that pure FEA diagnosed at core needle biopsy should undergo surgical excision since the upgrade rate >2%.
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Affiliation(s)
- Romuald Ferre
- Centre hospital de la Sarre, 679 Route 111, La Sarre, QC J9Z 2Y9, Canada
- Department of Radiology, Hopital du Grand Portage, Riviere du Loup, QC, Canada
| | - Cherie M Kuzmiak
- Department of Radiology, UNC School of Medicine, Chapel Hill, NC, USA
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The effect of delay of excisional biopsy on upstage rate for atypical ductal hyperplasia, flat epithelial atypia, intraductal papilloma, and radial scar. Breast Cancer Res Treat 2022; 196:527-534. [PMID: 36181604 PMCID: PMC9526195 DOI: 10.1007/s10549-022-06745-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 09/11/2022] [Indexed: 01/31/2023]
Abstract
PURPOSE When Core Needle Biopsy (CNB) demonstrates Atypical Ductal Hyperplasia (ADH), Flat Epithelial Atypia (FEA), Intraductal Papilloma (IDP), or Radial Scar/Complex Sclerosing Lesion (RS), excisional biopsy (EB) is often performed to rule out underlying malignancy with upstage rates (UR) ranging between 1 and 20%. The COVID-19 pandemic led to delayed EB for many patients. We sought to evaluate whether this delay was associated with higher UR. METHODS We performed a retrospective analysis of women who underwent CNB and then EB for ADH, FEA, IDP, or RS between 2017 and 2021 using an IRB-approved repository. UR was evaluated by days between CNB and EB. RESULTS 473 patients met inclusion. 55 were upstaged to cancer (11.6%). 178 patients had pure ADH on CNB and 37 were upstaged (20.8%). 50 patients had pure FEA and 3 were upstaged (6%). 132 had pure IDP and 7 were upstaged (5.3%). 98 had pure RS and 1 was upstaged (1%). 7/15 (46.7%) had a combination of diagnoses or diagnosis with palpable mass and were upstaged. Days between CNB and EB were < 60 for 275 patients (58.1%), 60-90 for 108 (22.8%), 91-120 for 43 (9.1%), and > 120 for 47 (9.9%). There was no significant difference in UR (10.9% for < 60, 14.8% for 60-90, 7% for 90-120, and 12.8% for > 120, p = 0.54). UR for ADH was clinically increased after 60 days (27.8 vs. 17.5%), but this did not reach statistical significance (p = 0.1). CONCLUSION Surgical delay was not associated with an increased UR.
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Upgrade Rate of Atypical Ductal Hyperplasia: Ten Years Experience and Predictive Factors. J Surg Res 2021; 266:311-318. [PMID: 34044175 DOI: 10.1016/j.jss.2021.03.063] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 01/13/2021] [Accepted: 03/26/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Atypical ductal hyperplasia (ADH) is a benign epithelial proliferative lesion with histologic features resembling those seen in low grade ductal carcinoma in situ (DCIS). Surgical excision of the biopsy site is the standard management approach. The objective of this study was to determine the upgrade rate from ADH on stereotactic breast biopsies to DCIS or invasive carcinoma (IC) in our institution. We also sought to identify clinical, pathologic and radiologic predictive factors associated with risk of upgrade. MATERIALS AND METHODS Clinical charts, mammograms and pathology reports were reviewed for all women with a stereotactic breast biopsy showing ADH and subsequent surgery at our institution between 2008 and 2018. When available, mammograms were re-reviewed by a radiologist for this study. RESULTS 295 biopsies were analyzed in 290 patients. Mean age was 56 y old. Upgrade rate was 10.5% of which 7.5% were DCIS and 3.1% IC. Mammograms were reviewed by a radiologist in 161 patients from 2013 to 2018. In this subset of patients, the rate of upgrade was 8.7% (4.35% DCIS and 4.35% IC). A statistically significant difference he largest size of the microcalcification clusters on mammogram was observed between the upgraded and the non-upgraded subgroups (14.2 mm versus 8.9 mm, P = 0.03) CONCLUSIONS: The evaluation of the largest size of microcalcification clusters on mammogram as a cut-off feature could be considered to choose between an observational versus a surgical approach. This large series provides contemporary data to assist informed decision making regarding the treatment of our patients.
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Wahab RA, Lee SJ, Mulligan ME, Zhang B, Mahoney MC. Upgrade Rate of Pure Flat Epithelial Atypia Diagnosed at Core Needle Biopsy: A Systematic Review and Meta-Analysis. Radiol Imaging Cancer 2021; 3:e200116. [PMID: 33778758 DOI: 10.1148/rycan.2021200116] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 11/11/2020] [Accepted: 11/19/2020] [Indexed: 11/11/2022]
Abstract
Purpose To perform a systematic review and meta-analysis to calculate the pooled upgrade rate of pure flat epithelial atypia (FEA) diagnosed at core needle biopsy (CNB). Materials and Methods A PubMed and Embase database search was performed in December 2019. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. Study quality and publication bias were assessed. The upgrade rate of pure FEA to cancer, invasive carcinoma, and ductal carcinoma in situ (DCIS), as well as the co-occurrence rate of atypical ductal hyperplasia (ADH), with 95% CIs were calculated. A random effect model was used to integrate the proportions and their corresponding 95% CI. Study heterogeneity was calculated using τ2 and I 2 . Results A total of 2482 cases of pure FEA across 42 studies (mean age range, 46-59 years) met inclusion criteria to be analyzed. Significant study heterogeneity was identified (τ2 = 0.001, I 2 = 67%). The pooled upgrade rates reported for pure FEA were 5% (95% CI: 3%, 6%) for breast cancer, 1% (95% CI: 0%, 2%) for invasive carcinoma, and 2% (95% CI: 1%, 3%) for DCIS. When more than 90% of calcifications were removed at CNB, the pooled upgrade rate was 0% (95% CI: 0%, 2%). The pooled co-occurrence rate of ADH at surgical excision was 17% (95% CI: 12%, 21%). Study quality was medium to high with a risk of publication bias (P < .01). Conclusion Pure FEA diagnosed at CNB should be surgically excised due to the pooled upgrade rate of 5% for breast cancer. If more than 90% of the targeted calcifications are removed by CNB for pure FEA, close imaging follow-up is recommended.Keywords: Biopsy/Needle Aspiration, Breast, MammographySupplemental material is available for this article.© RSNA, 2021.
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Affiliation(s)
- Rifat A Wahab
- Department of Radiology, University of Cincinnati Medical Center, 234 Goodman St, ML 0761, Cincinnati, OH 45267-0761 (R.A.W., S.J.L., M.E.M., M.C.M.); and Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio (B.Z.)
| | - Su-Ju Lee
- Department of Radiology, University of Cincinnati Medical Center, 234 Goodman St, ML 0761, Cincinnati, OH 45267-0761 (R.A.W., S.J.L., M.E.M., M.C.M.); and Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio (B.Z.)
| | - Margaret E Mulligan
- Department of Radiology, University of Cincinnati Medical Center, 234 Goodman St, ML 0761, Cincinnati, OH 45267-0761 (R.A.W., S.J.L., M.E.M., M.C.M.); and Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio (B.Z.)
| | - Bin Zhang
- Department of Radiology, University of Cincinnati Medical Center, 234 Goodman St, ML 0761, Cincinnati, OH 45267-0761 (R.A.W., S.J.L., M.E.M., M.C.M.); and Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio (B.Z.)
| | - Mary C Mahoney
- Department of Radiology, University of Cincinnati Medical Center, 234 Goodman St, ML 0761, Cincinnati, OH 45267-0761 (R.A.W., S.J.L., M.E.M., M.C.M.); and Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio (B.Z.)
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9
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Flat epithelial atypia: What the radiologist needs to know in 2021. Clin Imaging 2021; 75:150-156. [PMID: 33592394 DOI: 10.1016/j.clinimag.2021.01.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Revised: 01/10/2021] [Accepted: 01/28/2021] [Indexed: 11/22/2022]
Abstract
The World Health Organization defines flat epithelial atypia (FEA), as a "presumably neoplastic intraductal alteration characterized by the replacement of native epithelial cells by a single layer or three to five layers of mildly atypical cells.". In this article, we will review FEA and compare its characteristics and differences with other atypical high-risk breast lesions. In addition, the imaging appearance of FEA will be described. Finally, we will discuss current outcomes and provide an update on its management based on the last recommendations.
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Mariscotti G, Durando M, Ruggirello I, Belli P, Caumo F, Nori J, Zuiani C, Tagliafico A, Bicchierai G, Romanucci G, Londero V, Campanino PP, Bussone R, Castellano I, Mule' A, Caneva A, Bianchi S, Di Loreto C, Bergamasco L, Calabrese M, Fonio P, Houssami N. Lesions of uncertain malignant potential of the breast (B3) on vacuum-assisted biopsy for microcalcifications: Predictors of malignancy. Eur J Radiol 2020; 130:109194. [PMID: 32795765 DOI: 10.1016/j.ejrad.2020.109194] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Revised: 07/04/2020] [Accepted: 07/21/2020] [Indexed: 12/31/2022]
Abstract
PURPOSE To investigate clinical, radiologic and pathologic features of B3 lesions diagnosed on VABB targeting microcalcifications, for identifying predictors of malignancy. METHOD This retrospective multi-centre study included consecutive VABBs performed over a 10-year period on suspicious microcalcifications not associated with other radiological signs diagnosed as B3 on histology from VABB, with outcomes ascertained by surgical excision. Clinical, demographic, radiological and histological (B3 subcategory) data were collected. For statistical analysis (univariate and binary logistic regression), the primary outcome variable was the upgrade rate to malignancy after surgery. Predictors of upgrade to malignancy were identified from clinical, demographic, radiological and pathological variables (including B3 subcategory). RESULTS Amongst 447 VABBs, there were 57(12.7 %) upgrades to malignancy at surgical histology (36 DCIS and 21 invasive cancer). At univariate analysis, variables significantly associated with increased risk of upgrade to malignancy were age>55 years (p = 0.01), lesion size>10 mm (p < 0.0001), BI-RADS 4b-c and 5 (p = 0.0001), and fine pleomorphic morphology (p = 0.002) of microcalcifications. Binary logistic regression confirmed as significant independent risk factors age, lesion size and BI-RADS category (p = 0.02, 0.02 and 0.0006 respectively). Amongst subcategories of B3 lesions, lobular neoplasia was significantly(p = 0.04) associated with upgrade, confirmed as an independent risk factor [p = 0.03, OR = 2.3(1.1-4.7)]. Flat epithelial atypia was significantly(p = 0.004) associated with reduced odds of upgrade, but binary logistic regression showed only borderline association [p = 0.052, OR = 0.4(0.2-1.01)]. CONCLUSIONS Across B3 lesions diagnosed on histology from VABB of suspicious microcalcifications, older age, size>10 mm, BI-RADS category≥ 4b on imaging, and lobular neoplasia were risk factors for upgrade to malignancy. This information can be used to discuss patients' tailored management options.
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Affiliation(s)
- Giovanna Mariscotti
- Radiology Institute, University of Turin, Department of Diagnostic Imaging and Radiotherapy, A. O. U. Citta della Salute e della Scienza di Torino - Presidio Ospedaliero Molinette, Via Genova 3, 10126, Torino, Italy.
| | - Manuela Durando
- Radiology Institute, University of Turin, Department of Diagnostic Imaging and Radiotherapy, A. O. U. Citta della Salute e della Scienza di Torino - Presidio Ospedaliero Molinette, Via Genova 3, 10126, Torino, Italy.
| | - Irene Ruggirello
- Radiology Institute, University of Turin, Department of Diagnostic Imaging and Radiotherapy, A. O. U. Citta della Salute e della Scienza di Torino - Presidio Ospedaliero Molinette, Via Genova 3, 10126, Torino, Italy.
| | - Paolo Belli
- Department of Radiological, Radiotherapic and Hematological Sciences, Fondazione Policlinico A. Gemelli IRCCS - Universita' Cattolica Sacro Cuore, Largo Agostino Gemelli 8, 00168, Rome, Italy.
| | - Francesca Caumo
- Radiology Department, Veneto Institute of Oncology IOV - IRCCS, Padua, Italy.
| | - Jacopo Nori
- Diagnostic Senology Unit, Azienda Ospedaliero-Universitaria Careggi, Largo G. A. Brambilla 3, 50134, Florence, Italy.
| | - Chiara Zuiani
- Institute of Radiology, Department of Medicine, University of Udine, University Hospital S. Maria della Misericordia, P.le S. Maria della Misericordia, 15, 33100, Udine, Italy.
| | - Alberto Tagliafico
- Department of Health Sciences (DISSAL), University of Genoa, Genova, Italy; Department of Radiology, IRCCS San Martino Hospital, 16132, Genova, Italy.
| | - Giulia Bicchierai
- Diagnostic Senology Unit, Azienda Ospedaliero-Universitaria Careggi, Largo G. A. Brambilla 3, 50134, Florence, Italy.
| | - Giovanna Romanucci
- UOSD Breast Unit ULSS9, Ospedale di Marzana, Piazzale Lambranzi, 1, 37034 Verona, Italy.
| | - Viviana Londero
- Institute of Radiology, Department of Medicine, University of Udine, University Hospital S. Maria della Misericordia, P.le S. Maria della Misericordia, 15, 33100, Udine, Italy.
| | - Pier Paolo Campanino
- Breast Imaging Service, Ospedale Koelliker, C.so Galileo Ferraris 256, 10100, Torino, Italy.
| | - Riccardo Bussone
- Breast Surgery, Presidio Sanitario Ospedale Cottolengo, Via S. Giuseppe Benedetto Cottolengo, 9, 10152, Torino, Italy.
| | | | - Antonino Mule'
- Department of Histopathology and Cytodiagnosis, Fondazione Policlinico A. Gemelli IRCCS -Universita' Cattolica Sacro Cuore, Largo Agostino Gemelli 8, 00168, Rome, Italy.
| | | | - Simonetta Bianchi
- Division of Pathological Anatomy, Department of medical and surgical critical care, University of Florence, Florence, Italy.
| | - Carla Di Loreto
- Anatomic Pathology Institute, Department of Medicine (DAME), University of Udine, Udine, Italy.
| | - Laura Bergamasco
- Department of Surgical Sciences, University of Torino, A. O. U. Citta della Salute e della Scienza di Torino - Presidio Ospedaliero Molinette, C.so Bramante 88, 10126, Torino, Italy.
| | - Massimo Calabrese
- Diagnostic Senology, IRCCS - Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, Italy.
| | - Paolo Fonio
- Radiology Institute, University of Turin, Department of Diagnostic Imaging and Radiotherapy, A. O. U. Citta della Salute e della Scienza di Torino - Presidio Ospedaliero Molinette, Via Genova 3, 10126, Torino, Italy.
| | - Nehmat Houssami
- Screening and Test Evaluation Program, School of Public Health, Sydney Medical School, University of Sydney, Sydney 2006, NSW, Australia.
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Flat Epithelial Atypia in Breast Core Needle Biopsies With Radiologic-Pathologic Concordance: Is Excision Necessary? Am J Surg Pathol 2020; 44:182-190. [PMID: 31609784 DOI: 10.1097/pas.0000000000001385] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Flat epithelial atypia (FEA) is an alteration of terminal duct lobular units by a proliferation of ductal epithelium with low-grade atypia. No consensus exists on whether the diagnosis of FEA in core needle biopsy (CNB) requires excision (EXC). We retrospectively identified all in-house CNBs obtained between January 2012 and July 2018 with FEA. We reviewed all CNB slides and assessed radiologic-pathologic concordance. An upgrade was defined as invasive carcinoma (IC) and/or ductal carcinoma in situ in the EXC. The EXC slides of all upgraded cases were rereviewed. Out of ∼15,700 consecutive CNBs in the study period, 106 CNBs from 106 patients yielded FEA alone or with classic lobular neoplasia (LN). We excluded 52 CNBs (40 patients with prior/concurrent carcinoma and 12 without EXC). After rereview, we reclassified 14 cases (2 marked nuclear atypia, 10 focal atypical ductal hyperplasia, 2 benign). The final FEA study cohort consisted of 40 CNBs from 40 women. The CNB targeted mammographic calcifications in 36 (90%) cases, magnetic resonance imaging nonmass enhancement in 3 (8%), and 1 (2%) sonographic mass. All CNBs were deemed radiologic-pathologic concordant. FEA was present alone in 34 CNBs and with LN in 6. EXC yielded 2 low-grade IC, each spanning <2 mm, identified in tissue sections without biopsy site changes. The remaining 38 cases had no upgrade. Classic LN did not affect the upgrade. The upgrade rate of FEA was 5%; both minute, low-grade "incidental" IC. We conclude that nonsurgical management may be considered in patients without prior/concurrent carcinoma and radiologic-pathologic concordant CNB diagnosis of FEA.
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Liu C, Dingee CK, Warburton R, Pao JS, Kuusk U, Bazzarelli A, Sidhu R, McKevitt EC. Pure flat epithelial atypia identified on core needle biopsy does not require excision. Eur J Surg Oncol 2020; 46:235-239. [DOI: 10.1016/j.ejso.2019.10.029] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Revised: 09/09/2019] [Accepted: 10/23/2019] [Indexed: 11/30/2022] Open
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Falomo E, Adejumo C, Carson KA, Harvey S, Mullen L, Myers K. Variability in the Management Recommendations Given for High-risk Breast Lesions Detected on Image-guided Core Needle Biopsy at U.S. Academic Institutions. Curr Probl Diagn Radiol 2019; 48:462-466. [DOI: 10.1067/j.cpradiol.2018.06.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Revised: 06/01/2018] [Accepted: 06/20/2018] [Indexed: 11/22/2022]
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14
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Winer LK, Hinrichs BH, Lu S, Hanseman D, Huang Y, Reyna C, Lewis J, Shaughnessy EA. Flat epithelial atypia and the risk of sampling error: Determining the value of excision after image-guided core-needle biopsy. Am J Surg 2019; 218:730-736. [PMID: 31399195 DOI: 10.1016/j.amjsurg.2019.07.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Revised: 04/26/2019] [Accepted: 07/16/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND We determined the sampling error rate of flat epithelial atypia (FEA) and evaluated current guidelines recommending excisional biopsy. METHODS A retrospective review of consecutive excisional biopsies after image-guided core-needle biopsy identified patients with isolated FEA diagnosed between 2014 and 2018. Clinical and pathologic parameters were evaluated. RESULTS Twenty-five women with 27 biopsies were included. Based on pathologic review of original core specimens, 44.4% (N = 12) were accurately diagnosed as FEA. Upon excision, lesions were upgraded to ductal carcinoma in situ (N = 2) or invasive ductal carcinoma (N = 1) in 11.1% of cases. Older age, black race, hormone replacement, and calcifications in the image-guided biopsy specimen were associated with the presence of high-risk or malignant lesions in the excisional biopsy (all p ≤ 0.05). CONCLUSIONS In this study, FEA was frequently overcalled. However, lesions suspicious for FEA warrant excision due to their association with malignancy or high-risk lesions, which may necessitate further surgical management and/or risk-reducing strategies.
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Affiliation(s)
- Leah K Winer
- Division of Surgical Oncology, Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way (ML 0558), Cincinnati, OH, 45267, USA
| | - Benjamin H Hinrichs
- Department of Pathology, University of Cincinnati College of Medicine, 234 Goodman Street, Suite 110, Cincinnati, OH, 45219, USA
| | - Sisi Lu
- Division of Surgical Oncology, Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way (ML 0558), Cincinnati, OH, 45267, USA
| | - Dennis Hanseman
- Division of Surgical Oncology, Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way (ML 0558), Cincinnati, OH, 45267, USA
| | - Yuan Huang
- Department of Pathology, University of Cincinnati College of Medicine, 234 Goodman Street, Suite 110, Cincinnati, OH, 45219, USA
| | - Chantal Reyna
- Division of Surgical Oncology, Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way (ML 0558), Cincinnati, OH, 45267, USA
| | - Jaime Lewis
- Division of Surgical Oncology, Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way (ML 0558), Cincinnati, OH, 45267, USA
| | - Elizabeth A Shaughnessy
- Division of Surgical Oncology, Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way (ML 0558), Cincinnati, OH, 45267, USA.
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Boateng S, Tirada N, Khorjekar G, Richards S, Ioffe O. Excision or Observation: The Dilemma of Managing High-Risk Breast Lesions. Curr Probl Diagn Radiol 2018; 49:124-132. [PMID: 30616911 DOI: 10.1067/j.cpradiol.2018.12.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Accepted: 12/14/2018] [Indexed: 11/22/2022]
Abstract
There is an enduring dilemma on the appropriate management of high-risk breast lesions; is surgical excision always warranted or can conservative management be utilized? We present cases of high-risk breast lesions diagnosed at core needle biopsy at our institution along with relevant factors to consider for appropriate management. We conclude that a nuanced approach is warranted over the broad stroke approach of surgical excision of all high-risk breast lesions.
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Affiliation(s)
- Sheila Boateng
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Nikki Tirada
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD.
| | - Gauri Khorjekar
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Stephanie Richards
- Department of Pathology, University of Maryland School of Medicine, Baltimore, MD
| | - Olga Ioffe
- Department of Pathology, University of Maryland School of Medicine, Baltimore, MD
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16
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All pure flat atypical atypia lesions of the breast diagnosed using percutaneous vacuum-assisted breast biopsy do not need surgical excision. Breast 2018; 40:4-9. [DOI: 10.1016/j.breast.2018.03.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2017] [Revised: 03/18/2018] [Accepted: 03/26/2018] [Indexed: 11/18/2022] Open
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17
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Flat epithelial atypia in directional vacuum-assisted biopsy of breast microcalcifications: surgical excision may not be necessary. Mod Pathol 2018; 31:1097-1106. [PMID: 29467479 DOI: 10.1038/s41379-018-0035-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2017] [Revised: 01/05/2018] [Accepted: 01/07/2018] [Indexed: 11/09/2022]
Abstract
The aim of this study was to analyze the clinicopathological features of patients with flat epithelial atypia, diagnosed in directional vacuum-assisted biopsy targeting microcalcifications, to identify upgrade rate to in situ ductal or invasive breast carcinoma, and determine factors predicting carcinoma in the subsequent excision. We retrospectively evaluated the histological, clinical, and mammographic features of 69 cases from 65 women, with directional vacuum-assisted biopsy-diagnosed flat epithelial atypia with or without atypical ductal hyperplasia or atypical lobular hyperplasia, which underwent subsequent surgical excision. The extent and percentage of microcalcifications sampled by directional vacuum-assisted biopsy were evaluated by mammography. All biopsy and surgical excision slides were reviewed. The age of the women ranged from 40 to 85 years (mean 57 years). All patients presented with mammographically detected microcalcifications only, except in one case that had associated architectural distortion. Extent of calcifications ranged from <1 cm (n = 47), 1-3 cm (n = 15) to > 3 cm (n = 6), and no measurement (n = 1). A mean of 11 cores (range 6-25) was obtained from each lesion. Post-biopsy mammogram revealed >90% removal of calcifications in 81% of cases. Pure flat epithelial atypia represented nearly two-thirds of directional vacuum-assisted biopsy specimens (n = 43, 62%), while flat epithelial atypia coexisted with atypical ductal hyperplasia (18 cases, 26%), or atypical lobular hyperplasia (8 cases, 12%). Upon excision, none of the cases were upgraded to in situ ductal or invasive breast cancer. In one case, however, an incidental, tubular carcinoma (4 mm) was found away from biopsy site. Excluding this case, the upgrade rate was 0%. Our study adds to the growing evidence that diagnosis of flat epithelial atypia on directional vacuum-assisted biopsy for microcalcifications as the only imaging finding is not associated with a significant upgrade to carcinoma on excision, and therefore, excision may not be necessary. Additionally, excision may not be necessary for flat epithelial atypia with atypical ductal hyperplasia limited to ≤2 terminal duct-lobular units, if at least 90% of calcifications have been removed on biopsy.
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Abstract
Benign and atypical lesions associated with breast cancer risk are often encountered in core needle biopsies (CNBs) of the breast. For these lesions, the rate of "upgrade" to carcinoma in excision specimens varies widely in the literature. Many CNB studies are limited by a lack of radiological-pathological correlation, consistent criteria for excision, and clinical follow-up for patients who forego excision. This article highlights contemporary diagnostic criteria and outcome data that would support an evidence-based approach to the management of these nonmalignant lesions of the breast diagnosed on CNB.
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Affiliation(s)
- Benjamin C Calhoun
- Department of Pathology and Laboratory Medicine, University of North Carolina, Women's and Children's Hospitals, 3rd Floor, Room 30212, 101 Manning Drive, Chapel Hill, NC 27514, USA.
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Bahl M, Barzilay R, Yedidia AB, Locascio NJ, Yu L, Lehman CD. High-Risk Breast Lesions: A Machine Learning Model to Predict Pathologic Upgrade and Reduce Unnecessary Surgical Excision. Radiology 2018; 286:810-818. [DOI: 10.1148/radiol.2017170549] [Citation(s) in RCA: 94] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Manisha Bahl
- From the Division of Breast Imaging, Department of Radiology, Massachusetts General Hospital/Harvard Medical School, 55 Fruit St, WAC 240, Boston, MA 02114 (M.B., C.D.L.); and Department of Electrical Engineering and Computer Science, Massachusetts Institute of Technology, Cambridge, Mass (R.B., A.B.Y., N.J.L., L.Y.)
| | - Regina Barzilay
- From the Division of Breast Imaging, Department of Radiology, Massachusetts General Hospital/Harvard Medical School, 55 Fruit St, WAC 240, Boston, MA 02114 (M.B., C.D.L.); and Department of Electrical Engineering and Computer Science, Massachusetts Institute of Technology, Cambridge, Mass (R.B., A.B.Y., N.J.L., L.Y.)
| | - Adam B. Yedidia
- From the Division of Breast Imaging, Department of Radiology, Massachusetts General Hospital/Harvard Medical School, 55 Fruit St, WAC 240, Boston, MA 02114 (M.B., C.D.L.); and Department of Electrical Engineering and Computer Science, Massachusetts Institute of Technology, Cambridge, Mass (R.B., A.B.Y., N.J.L., L.Y.)
| | - Nicholas J. Locascio
- From the Division of Breast Imaging, Department of Radiology, Massachusetts General Hospital/Harvard Medical School, 55 Fruit St, WAC 240, Boston, MA 02114 (M.B., C.D.L.); and Department of Electrical Engineering and Computer Science, Massachusetts Institute of Technology, Cambridge, Mass (R.B., A.B.Y., N.J.L., L.Y.)
| | - Lili Yu
- From the Division of Breast Imaging, Department of Radiology, Massachusetts General Hospital/Harvard Medical School, 55 Fruit St, WAC 240, Boston, MA 02114 (M.B., C.D.L.); and Department of Electrical Engineering and Computer Science, Massachusetts Institute of Technology, Cambridge, Mass (R.B., A.B.Y., N.J.L., L.Y.)
| | - Constance D. Lehman
- From the Division of Breast Imaging, Department of Radiology, Massachusetts General Hospital/Harvard Medical School, 55 Fruit St, WAC 240, Boston, MA 02114 (M.B., C.D.L.); and Department of Electrical Engineering and Computer Science, Massachusetts Institute of Technology, Cambridge, Mass (R.B., A.B.Y., N.J.L., L.Y.)
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20
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Lamb LR, Bahl M, Hughes KS, Lehman CD. Pathologic Upgrade Rates of High-Risk Breast Lesions on Digital Two-Dimensional vs Tomosynthesis Mammography. J Am Coll Surg 2018; 226:858-867. [PMID: 29410346 DOI: 10.1016/j.jamcollsurg.2017.12.049] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Revised: 12/29/2017] [Accepted: 12/29/2017] [Indexed: 11/18/2022]
Abstract
BACKGROUND Our aim was to compare the pathologic upgrade rates of high-risk breast lesions (HRLs) on digital two-dimensional mammography (DM) vs digital breast tomosynthesis (DBT). STUDY DESIGN The study cohort was composed of patients with HRLs diagnosed by image-guided core needle biopsy from December 2007 to February 2011 (DM group, before DBT integration) and from January 2013 to March 2016 (DBT group, after complete DBT integration). Medical records were reviewed for surgical outcomes and follow-up imaging. RESULTS Eight hundred and ninety-three patients with 900 biopsy-proven HRLs underwent surgical excision (97.0% [873 of 900]) or had at least 2 years of imaging follow-up (3.0% [27 of 900]). The most common HRL was atypical ductal hyperplasia in the DM and DBT groups (37.4% [337 of 900]). The overall upgrade rate of HRLs to malignancy was 11.3% (102 of 900). There were no statistically significant differences in overall upgrades rates of HRLs on DM vs DBT (11.4% [54 of 475] vs 11.3% [48 of 425]; p = 0.97) or in upgrade rates of HRL subtypes. However, HRLs that upgraded on DBT were more likely to be invasive rather than in situ carcinoma compared with HRLs that upgraded on DM (39.6% [19 of 48] vs 20.4% [11 of 54]; p = 0.03). Overall, the most common HRL to upgrade was atypical ductal hyperplasia (18.4% [62 of 337]). The least common HRLs to upgrade in the DBT group were biphasic neoplasms (0% [0 of 22]), flat epithelial atypia (1.6% [1 of 62]), and papillomas without atypia (4.5% [2 of 44]). CONCLUSIONS There is no difference in the upgrade rates of HRLs on DM vs DBT, but the proportion of HRL upgrades that are invasive rather than in situ carcinoma is higher with DBT.
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Affiliation(s)
- Leslie R Lamb
- Department of Radiology, Massachusetts General Hospital, Boston, MA
| | - Manisha Bahl
- Department of Radiology, Massachusetts General Hospital, Boston, MA.
| | - Kevin S Hughes
- Department of Surgery, Massachusetts General Hospital, Boston, MA
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21
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Chan PMY, Chotai N, Lai ES, Sin PY, Chen J, Lu SQ, Goh MH, Chong BK, Ho BCS, Tan EY. Majority of flat epithelial atypia diagnosed on biopsy do not require surgical excision. Breast 2018; 37:13-17. [DOI: 10.1016/j.breast.2017.10.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Revised: 08/14/2017] [Accepted: 10/10/2017] [Indexed: 11/16/2022] Open
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22
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Schiaffino S, Gristina L, Villa A, Tosto S, Monetti F, Carli F, Calabrese M. Flat epithelial atypia: conservative management of patients without residual microcalcifications post-vacuum-assisted breast biopsy. Br J Radiol 2018; 91:20170484. [PMID: 29072858 PMCID: PMC5966211 DOI: 10.1259/bjr.20170484] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Revised: 10/02/2017] [Accepted: 10/14/2017] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVE To determine the malignancy rate (defined in this study as stability or absence of malignancy developed on close imaging follow-up post-biopsy) of conservative management in patients with a vacuum-assisted breast biopsy (VAB) diagnosis of flat epithelial atypia (FEA), performed on single group of microcalcifications, completely removed during procedure. METHODS This is a retrospective, monocentric, observational study, approved by IRB. Inclusion criteria were: VAB performed on a single group of microcalcifications; the absence of residual calcifications post-VAB; diagnosis of isolated FEA as the most advanced proliferative lesion; radiological follow-up at least of 12 months. The personal history of breast cancer or other high-risk lesions was an exclusion criteria. The patients enrolled were conservatively managed, without surgical excision, through close follow-up: the first two mammographies performed with an interval of 6 months after biopsy, followed by annual mammographic and clinical checks. RESULTS 48 consecutive patients were enrolled in the study, all females, with age range of 39-76 years (mean 53,3 years) and radiological follow-up range of 13-75 months (mean 41.5 months). All the lesions were classified as BI-RADS 4b. The diameter range of the group of calcifications was 3-10 mm (mean 5, 6 mm). In each patient, 7 to 15 samples (mean 11) were obtained. Among all the patients, there was only one case (2%) of new microcalcifications, developed in the same breast, 26 months after and 8 mm from the site of previous VAB, and interpreted as ADH at surgical excision. All the checks of the other patients were negative. CONCLUSION Even with a limited follow-up, we found a malignancy rate lower than 2%, through a defined population. Further studies with bigger number of patients and extended follow-up are needed to reinforce this hypothesis. Advances in knowledge: Surgical excision may not be necessary in patients with VAB diagnosis of isolated FEA, without residual microcalcifications post-procedure and considered concordant with the mammographic presentation, considering the low rate of malignancy at subsequent follow-ups.
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Affiliation(s)
| | - Licia Gristina
- Department of Radiology, University of Genoa, Genoa, Italy
| | - Alessandro Villa
- Department of Radiology, Ospedale San Bartolomeo, Sarzana, Italy
| | - Simona Tosto
- Department of Radiology, Policlinico San Martino, Genoa, Italy
| | | | - Franca Carli
- Department of Pathologic Anatomy, Policlinico San Martino, Genoa, Italy
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23
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Lamb LR, Bahl M, Gadd MA, Lehman CD. Flat Epithelial Atypia: Upgrade Rates and Risk-Stratification Approach to Support Informed Decision Making. J Am Coll Surg 2017; 225:696-701. [DOI: 10.1016/j.jamcollsurg.2017.08.022] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2017] [Accepted: 08/24/2017] [Indexed: 10/18/2022]
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24
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Rudin AV, Hoskin TL, Fahy A, Farrell AM, Nassar A, Ghosh K, Degnim AC. Flat Epithelial Atypia on Core Biopsy and Upgrade to Cancer: a Systematic Review and Meta-Analysis. Ann Surg Oncol 2017; 24:3549-3558. [PMID: 28831724 DOI: 10.1245/s10434-017-6059-0] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Indexed: 11/18/2022]
Abstract
BACKGROUND No consensus exists on whether flat epithelial atypia (FEA) diagnosed percutaneously should be surgically excised. A systematic review and meta-analysis of the frequency of upgrade to cancer or an atypical ductal hyperplasia (ADH) at surgical excision of FEA was performed. METHODS Embase, MEDLINE, Scopus, and Web of Science databases from January 2003 to November 2015 were searched. The inclusion criteria required a manuscript in English with original data on FEA diagnosed percutaneously, data including the presence or absence of other concurrent high-risk lesions, and data including outcome of cancer at surgical excision. Studies were assessed for quality, and two reviewers extracted data. Random-effects meta-analysis was used to pool estimates. The impact of study-level characteristics was assessed by stratified meta-analysis and meta-regression. RESULTS The inclusion criteria was met by 32 studies. A total of 1966 core needle biopsies showed pure FEA, and 1517 (77%) showed surgical excision. The proportions of patients with upgrade to cancer varied from 0 to 42%, with an overall pooled estimate of 11.1%. Heterogeneity was observed, with the greatest impact based on whether a study included cases of FEA diagnosed before 2003. With restriction of the investigation to 16 higher-quality studies, the cancer upgrade pooled estimate was 7.5% (95% confidence interval [CI], 5.4-10.4%), and the rate of invasive cancer was 3% (95% CI 1.9-4.5%). For upgrade to ADH, data from 22 studies including 937 patients were analyzed. The proportion of patients upgraded to ADH ranged from 0 to 60%, with a pooled estimate of 17.9% overall and 18.6% among high-quality studies. CONCLUSIONS With patient management change potential for approximately 25% of patients, this analysis supports a general recommendation for surgical excision of FEA diagnosed by core biopsy.
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Affiliation(s)
| | - Tanya L Hoskin
- Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Aodhnait Fahy
- Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Ann M Farrell
- Mayo Clinic Libraries, Mayo Clinic, Rochester, MN, USA
| | - Aziza Nassar
- Laboratory Medicine and Pathology, Mayo Clinic, Jacksonville, FL, USA
| | - Karthik Ghosh
- Breast Clinic, General Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Amy C Degnim
- Department of Surgery, Mayo Clinic, Rochester, MN, USA.
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25
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Racz JM, Carter JM, Degnim AC. Challenging Atypical Breast Lesions Including Flat Epithelial Atypia, Radial Scar, and Intraductal Papilloma. Ann Surg Oncol 2017; 24:2842-2847. [DOI: 10.1245/s10434-017-5980-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Indexed: 11/18/2022]
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26
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Samples LS, Rendi MH, Frederick PD, Allison KH, Nelson HD, Morgan TR, Weaver DL, Elmore JG. Surgical implications and variability in the use of the flat epithelial atypia diagnosis on breast biopsy specimens. Breast 2017; 34:34-43. [PMID: 28475933 DOI: 10.1016/j.breast.2017.04.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Revised: 03/31/2017] [Accepted: 04/06/2017] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVES Flat epithelial atypia (FEA) is a relatively new diagnostic term with uncertain clinical significance for surgical management. Any implied risk of invasive breast cancer associated with FEA is contingent upon diagnostic reproducibility, yet little is known regarding its use. MATERIALS AND METHODS Pathologists in the Breast Pathology Study interpreted one of four 60-case test sets, one slide per case, constructed from 240 breast biopsy specimens. An electronic data form with standardized diagnostic categories was used; participants were instructed to indicate all diagnoses present. We assessed participants' use of FEA as a diagnostic term within: 1) each test set; 2) 72 cases classified by reference as benign without FEA; and 3) six cases classified by reference as FEA. 115 pathologists participated, providing 6900 total independent assessments. RESULTS Notation of FEA ranged from 0% to 35% of the cases interpreted, with most pathologists noting FEA on 4 or more test cases. At least one participant noted FEA in 34 of the 72 benign non-FEA cases. For the 6 reference FEA cases, participant agreement with the case reference FEA diagnosis ranged from 17% to 52%; diagnoses noted by participating pathologists for these FEA cases included columnar cell hyperplasia, usual ductal hyperplasia, atypical lobular hyperplasia, and atypical ductal hyperplasia. CONCLUSIONS We observed wide variation in the diagnosis of FEA among U.S. pathologists. This suggests that perceptions of diagnostic criteria and any implied risk associated with FEA may also vary. Surgical excision following a core biopsy diagnosis of FEA should be reconsidered and studied further.
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Affiliation(s)
- Laura S Samples
- Department of Medicine, University of Washington School of Medicine, 325 Ninth Ave, Box 359780, Seattle, WA 98104, USA
| | - Mara H Rendi
- Department of Pathology, University of Washington School of Medicine, 1959 NE Pacific St., Box 356100, Seattle, WA, USA
| | - Paul D Frederick
- Department of Medicine, University of Washington School of Medicine, 325 Ninth Ave, Box 359780, Seattle, WA 98104, USA
| | - Kimberly H Allison
- Department of Pathology, Stanford University School of Medicine, 300 Pasteur Drive, Lane 235, Stanford, CA 94305, USA
| | - Heidi D Nelson
- Providence Cancer Center, Providence Health and Services Oregon, and Departments of Medical Informatics and Clinical Epidemiology and Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Mail Code FM, Portland, OR 97239, USA
| | - Thomas R Morgan
- Department of Medicine, University of Washington School of Medicine, 325 Ninth Ave, Box 359780, Seattle, WA 98104, USA
| | - Donald L Weaver
- Department of Pathology and University of Vermont Cancer Center, University of Vermont, Given Courtyard, 89 Beaumont Ave, Burlington, VT 05405, USA
| | - Joann G Elmore
- Department of Medicine, University of Washington School of Medicine, 325 Ninth Ave, Box 359780, Seattle, WA 98104, USA.
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Paradigm Shifts in Breast Care Delivery: Impact of Imaging in a Multidisciplinary Environment. AJR Am J Roentgenol 2016; 208:248-255. [PMID: 27929664 DOI: 10.2214/ajr.16.17130] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE The practice of breast imaging in a collaborative multidisciplinary environment adds significant value to outcomes in women's health care. In this article, we describe multidisciplinary considerations in breast cancer screening and early detection, the impact of imaging and histopathologic findings in the diagnostic evaluation and management of breast abnormalities, and the contribution of imaging to surgical and radiation therapy planning for the breast cancer patient. CONCLUSION The multidisciplinary delivery of breast care for women that incorporates screening, diagnosis of borderline and high-risk lesions, and management of the breast cancer patient adds considerable value to outcomes in health care.
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Flat epithelial atypia on core needle biopsy, must we surgically excise? Am J Surg 2016; 212:1211-1213. [DOI: 10.1016/j.amjsurg.2016.09.019] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2016] [Revised: 09/06/2016] [Accepted: 09/06/2016] [Indexed: 11/23/2022]
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Upgrade rates of high-risk breast lesions diagnosed on core needle biopsy: a single-institution experience and literature review. Mod Pathol 2016; 29:1471-1484. [PMID: 27538687 DOI: 10.1038/modpathol.2016.127] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2016] [Revised: 05/31/2016] [Accepted: 06/02/2016] [Indexed: 11/08/2022]
Abstract
Optimal management of high-risk breast lesions detected by mammogram yielding atypical ductal hyperplasia, flat epithelial atypia, atypical lobular hyperplasia, lobular carcinoma in situ, and radial scar without atypia on core needle biopsy is controversial. This is a single-institution retrospective review of 5750 core needle biopsy cases seen over 14.5 years, including 249 (4.3%), 72 (1.3%), 50 (0.9%), 37 (0.6%), and 54 (0.9%) cases of atypical ductal hyperplasia, flat epithelial atypia, atypical lobular hyperplasia, lobular carcinoma in situ, and radial scar without atypia, respectively. Patient age, radiologic characteristics, needle gauge, and excision diagnoses were recorded. Of 462 high-risk cases analyzed, 333 (72%) underwent excision. Upgrade rate to ductal carcinoma in situ, pleomorphic carcinoma in situ, or invasive mammary carcinoma was 18% for atypical ductal hyperplasia, 11% for flat epithelial atypia, 9% for atypical lobular hyperplasia, 28% for lobular carcinoma in situ, and 16% for radial scar. Carcinoma diagnosed on excision was more likely to be in situ than invasive, and if invasive, more likely to be low grade than high grade. Overall, cases that were benign (vs high risk or carcinoma) on excision were less likely to have residual calcifications after biopsy (17% vs 27%, P=0.013), and more likely to have a smaller mass size (<1 cm) (82% vs 50%, P=0.001). On subgroup analysis, atypical ductal hyperplasia cases that were benign (vs high risk or carcinoma) on excision were more likely to have smaller mass size (<1 cm) (P=0.025). Lobular neoplasia diagnosed incidentally (vs targeted) on core needle biopsy was less likely to upgrade on excision (5% vs 39%, P=0.002). A comprehensive literature review was performed, identifying 116 studies reporting high-risk lesion upgrade rates, and our upgrade rates were similar to those of more recent larger studies. Careful radiological-pathological correlation is needed to identify high-risk lesion subgroups that may not need excision.
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Dion L, Racin A, Brousse S, Beltjens F, Cauchois A, Levêque J, Coutant C, Lavoué V. Atypical epithelial hyperplasia of the breast: state of the art. Expert Rev Anticancer Ther 2016; 16:943-53. [PMID: 27367571 DOI: 10.1080/14737140.2016.1204916] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Atypical epithelial hyperplasia (AEH) of the breast is considered benign histological lesions with breast cancer risk. This review focuses on clinical signification and management of AEH that remains controversial. AREAS COVERED A review of published studies was performed using medline database. In this review, we fully describe the current evidence available. In particular, we describe 1) data from immunohistochemistry and molecular studies that suggest AEH is a precursor of breast cancer; 2) epidemiological studies demonstrate low rate of breast cancer in women with AEH; 3) surgical excision is necessary after diagnosis of AEH, such as lobular carcinoma in situ or atypical ductal hyperplasia, on core needle biopsy; 4) although current recommendations are evolving to fewer (if not no) excisions for flat epithelial with atypia and classic lobular neoplasia found on percutaneous biopsy (without radiologic indications for excision). Expert commentary: HEA management steel need prospective evidences, but recent retrospective data give some clue for less invasive management for some of HEA.
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Affiliation(s)
- Ludivine Dion
- a Department of Gynaecology , Rennes University Hospital , Rennes , Cedex 2 , France
| | - Adelaïde Racin
- a Department of Gynaecology , Rennes University Hospital , Rennes , Cedex 2 , France
| | - Susie Brousse
- a Department of Gynaecology , Rennes University Hospital , Rennes , Cedex 2 , France
| | - Françoise Beltjens
- b Department of Tumour Pathology , Georges-François Leclerc Cancer Centre - Unicancer , Dijon , France.,c University of Burgundy-Franche Comté , Dijon , France.,d Department of Surgical Oncology , Georges-François Leclerc Cancer Centre - Unicancer , Dijon , France
| | - Aurélie Cauchois
- e Department of Tumour Pathology , Rennes University Hospital, University of Rennes 1 , Rennes , France
| | - Jean Levêque
- a Department of Gynaecology , Rennes University Hospital , Rennes , Cedex 2 , France.,f Regional University Centre of Mastology, CRLCC Eugène Marquis , Rennes , Cedex , France.,g ER440, Oncogenesis, Stress and Signaling , INSERM , Rennes , France
| | - Charles Coutant
- b Department of Tumour Pathology , Georges-François Leclerc Cancer Centre - Unicancer , Dijon , France.,c University of Burgundy-Franche Comté , Dijon , France.,d Department of Surgical Oncology , Georges-François Leclerc Cancer Centre - Unicancer , Dijon , France
| | - Vincent Lavoué
- a Department of Gynaecology , Rennes University Hospital , Rennes , Cedex 2 , France.,f Regional University Centre of Mastology, CRLCC Eugène Marquis , Rennes , Cedex , France.,g ER440, Oncogenesis, Stress and Signaling , INSERM , Rennes , France
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Calhoun BC, Collins LC. Recommendations for excision following core needle biopsy of the breast: a contemporary evaluation of the literature. Histopathology 2015; 68:138-51. [DOI: 10.1111/his.12852] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Affiliation(s)
| | - Laura C Collins
- Department of Pathology; Beth Israel Deaconess Medical Center and Harvard Medical School; Boston MA USA
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32
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[Benign proliferative breast disease with and without atypia]. ACTA ACUST UNITED AC 2015; 44:980-95. [PMID: 26545856 DOI: 10.1016/j.jgyn.2015.09.037] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Accepted: 09/18/2015] [Indexed: 11/22/2022]
Abstract
In the last few years, diagnostics of high-risk breast lesions (atypical ductal hyperplasia [ADH], flat epithelial atypia [FEA], lobular neoplasia: atypical lobular hyperplasia [ALH], lobular carcinoma in situ [LCIS], radial scar [RS], usual ductal hyperplasia [UDH], adenosis, sclerosing adenosis [SA], papillary breast lesions, mucocele-like lesion [MLL]) have increased with the growing number of breast percutaneous biopsies. The management of these lesions is highly conditioned by the enlarged risk of breast cancer combined with either an increased probability of finding cancer after surgery, either a possible malignant transformation (in situ or invasive cancer), or an increased probability of developing cancer on the long range. An overview of the literature reports grade C recommendations concerning the management and follow-up of these lesions: in case of ADH, FEA, ALH, LCIS, RS, MLL with atypia, diagnosed on percutaneous biopsies: surgical excision is recommended; in case of a diagnostic based on vacuum-assisted core biopsy with complete disappearance of radiological signal for FEA or RS without atypia: surgical abstention is a valid alternative approved by multidisciplinary meeting. In case of ALH (incidental finding) associated with benign lesion responsible of radiological signal: abstention may be proposed; in case of UDH, adenosis, MLL without atypia, diagnosed on percutaneous biopsies: the concordance of radiology and histopathology findings must be ensured. No data is available to recommend surgery; in case of non-in sano resection for ADH, FEA, ALH, LCIS (except pleomorphic type), RS, MLL: surgery does not seem to be necessary; in case of previous ADH, ALH, LCIS: a specific follow-up is recommended in accordance with HAS's recommendations. In case of FEA and RS or MLL combined with atypia, little data are yet available to differ the management from others lesions with atypia; in case of UDH, usual sclerosing adenosis, RS without atypia, fibro cystic disease: no specific follow-up is recommended in agreement with HAS's recommendations.
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Cheung YC, Juan YH, Ueng SH, Lo YF, Huang PC, Lin YC, Chen SC. Assessment of Breast Specimens With or Without Calcifications in Diagnosing Malignant and Atypia for Mammographic Breast Microcalcifications Without Mass: A STARD-Compliant Diagnostic Accuracy Article. Medicine (Baltimore) 2015; 94:e1832. [PMID: 26496323 PMCID: PMC4620838 DOI: 10.1097/md.0000000000001832] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Presence of microcalcifications within the specimens frequently signifies a successful attempt of stereotactic vacuum-assisted breast biopsy (VABB) in obtaining a pathologic diagnosis of the breast microcalcifications. In this study, the authors aimed to assess and compare the accuracy and consistency of calcified or noncalcified specimens obtained from same sites of sampling on isolated microcalcifications without mass in diagnosing high-risk and malignant lesions. To the best of our knowledge, an individual case-based prospective comparison has not been reported.With the approval from institutional review board of our hospital (Chang Gung Memorial Hospital), the authors retrospectively reviewed all clinical cases of stereotactic VABBs on isolated breast microcalcifications without mass from our database. The authors included those having either surgery performed or had clinical follow-up of at least 3 years for analysis. All the obtained specimens with or without calcification were identified using specimen radiographs and separately submitted for pathologic evaluation. The concordance of diagnosis was assessed for both atypia and malignant lesions.A total of 390 stereotactic VABB procedures (1206 calcified and 1456 noncalcified specimens) were collected and reviewed. The consistent rates between calcified and noncalcified specimens were low for atypia and malignant microcalcifications (44.44% in flat epithelial atypia, 46.51% in atypical ductal hyperplasia, 55.73% in ductal carcinoma in situ, and 71.42% in invasive ductal carcinoma). The discordance in VABB diagnoses indicated that 41.33% of malignant lesions would be misdiagnosed by noncalcified specimens. Furthermore, calcified specimens showed higher diagnostic accuracy of breast cancer as compared with the noncalcified specimens (91.54 % versus 69.49%, respectively). The evaluation of both noncalcified specimens and calcified specimens did not show improvement of diagnostic accuracy as compared with evaluating calcified specimens alone (91.54% versus 91.54%, respectively).The high prevalence of diagnostic discordance between the calcified and noncalcified specimens indicated the higher value of calcified specimens in diagnosing atypia and malignant microcalcifications. Noncalcified specimens did not provide additional diagnostic benefit from this study. The separation of calcified and noncalcified specimens may facilitate more focused interpretation from pathologists among the large number of specimens.
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Affiliation(s)
- Yun-Chung Cheung
- From the Department of Medical Imaging and Intervention (Y-CC, Y-HJ, P-CH, Y-CL), Department of Pathology (S-HU), Department of Surgery (Y-FL, S-CC); and Medical College of Chang Gung University, Taoyuan, Taiwan (Y-CC, Y-HJ, S-HU, Y-FL, P-CH, Y-CL, S-CC)
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34
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Said SM, Visscher DW, Nassar A, Frank RD, Vierkant RA, Frost MH, Ghosh K, Radisky DC, Hartmann LC, Degnim AC. Flat epithelial atypia and risk of breast cancer: A Mayo cohort study. Cancer 2015; 121:1548-55. [PMID: 25639678 PMCID: PMC4424157 DOI: 10.1002/cncr.29243] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2014] [Revised: 11/20/2014] [Accepted: 12/02/2014] [Indexed: 11/11/2022]
Abstract
BACKGROUND Based on its cytologic features, and its co-occurrence with atypical hyperplasia and breast cancer, flat epithelial atypia (FEA) has been proposed as a precursor lesion on the pathway to the development of breast cancer. It is often referred to as an "atypical" or high-risk lesion. However, to the authors' knowledge, the long-term risk of breast cancer in women with FEA is undefined. METHODS Specimens with FEA were identified among excisional breast biopsies in the Mayo Clinic Benign Breast Disease Cohort, which includes 11,591 women who had benign biopsy findings at the Mayo Clinic in Rochester, Minnesota between 1967 and 2001. Breast cancer risk among subsets of patients with FEA and nonproliferative, proliferative, and atypical hyperplasia (AH) was assessed using standardized incidence ratios (SIRs) compared with the Iowa Surveillance, Epidemiology, and End Results registry. RESULTS FEA was identified in 282 women (2.4%); 130 had associated AH (46%) and 152 (54%) were classified as having proliferative disease without atypia (PDWA). With median follow-up of 16.8 years, the SIR for breast cancer in patients with AH plus FEA was 4.74 (95% confidence interval [95% CI], 3.17-6.81) versus 4.23 (95% CI, 3.44-5.13) for those with AH without FEA (P = .59). The SIR for patients with PDWA plus FEA was 2.04 (95% CI, 1.23-3.19) versus 1.90 (95% CI, 1.72-2.09) for patients with PDWA without FEA (P = .76). CONCLUSIONS FEA is an uncommon finding in women with benign breast disease. FEA does not appear to convey an independent risk of breast cancer beyond that of the associated PDWA or AH.
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Affiliation(s)
- Samar M. Said
- Division of Anatomic Pathology, Mayo Clinic, Rochester, MN, United States
| | - Daniel W. Visscher
- Division of Anatomic Pathology, Mayo Clinic, Rochester, MN, United States
| | - Aziza Nassar
- Division of Anatomic Pathology, Mayo Clinic, Jacksonville, Florida, United States
| | - Ryan D. Frank
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, United States
| | - Robert A. Vierkant
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, United States
| | - Marlene H. Frost
- Department of Medical Oncology, Mayo Clinic, Rochester, MN, United States
| | - Karthik Ghosh
- Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | | | - Lynn C. Hartmann
- Department of Medical Oncology, Mayo Clinic, Rochester, MN, United States
| | - Amy C. Degnim
- Department of Surgery, Mayo Clinic, Rochester, MN, United States
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35
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Management of flat epithelial atypia on breast core biopsy may be individualized based on correlation with imaging studies. Mod Pathol 2015; 28:670-6. [PMID: 25412845 DOI: 10.1038/modpathol.2014.159] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2014] [Revised: 10/15/2014] [Accepted: 10/16/2014] [Indexed: 11/08/2022]
Abstract
Flat epithelial atypia of the breast commonly co-exists with atypical ductal hyperplasia, lobular neoplasia, and indolent forms of invasive carcinomas such as tubular carcinoma. Most patients with pure flat epithelial atypia on core biopsy undergo surgical excision to evaluate for carcinoma in the adjacent breast tissue. Studies to date have reported varying upgrade rates with most recommending follow-up excision. These studies have often lacked detailed radiographic correlation, central review by breast pathologists and information regarding the biology of the carcinomas identified upon excision. In this study, we report the frequency of upgrade to invasive carcinoma or ductal carcinoma in situ in excision specimens following a diagnosis of pure flat epithelial atypia on core biopsy. Radiographic correlation is performed for each case and grade/receptor status of detected carcinomas is reported. Seventy-three (73) core biopsies containing pure flat epithelial atypia were identified from our files, meeting inclusion criteria for the study. In the subsequent excision biopsies, five (7%) cases contained invasive carcinoma or ductal carcinoma in situ and seventeen (23%) contained atypical ductal hyperplasia or lobular neoplasia. All of the ductal carcinoma in situ cases with estrogen receptor results were estrogen receptor positive and intermediate grade. The invasive tumors were small (pT1a) hormone receptor-positive, HER2-negative, low-grade invasive ductal or tubular carcinomas with negative sentinel lymph-node biopsies. No upgrades were identified in the 14 patients who had all of their calcifications removed by the stereotactic core biopsy. Our rate of upgrade to carcinoma, once cases with discordant imaging are excluded, is at the lower end of the range reported in the literature. Given the low upgrade rate and indolent nature of the carcinomas associated with flat epithelial atypia, case management may be individualized based on clinical and radiographic findings. Excision may not be necessary for patients without remaining calcifications following core biopsy.
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36
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Yu CC, Ueng SH, Cheung YC, Shen SC, Kuo WL, Tsai HP, Lo YF, Chen SC. Predictors of Underestimation of Malignancy after Image-Guided Core Needle Biopsy Diagnosis of Flat Epithelial Atypia or Atypical Ductal Hyperplasia. Breast J 2015; 21:224-32. [DOI: 10.1111/tbj.12389] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Affiliation(s)
- Chi-Chang Yu
- Department of Surgery; Chang Gung Memorial Hospital; Chang Gung University Medical College; Taoyuan Taiwan
| | - Shir-Hwa Ueng
- Department of Pathology; Chang Gung Memorial Hospital; Chang Gung University Medical College; Taoyuan Taiwan
| | - Yun-Chung Cheung
- Department of Diagnostic Radiology; Chang Gung Memorial Hospital; Chang Gung University Medical College; Taoyuan Taiwan
| | - Shih-Che Shen
- Department of Surgery; Chang Gung Memorial Hospital; Chang Gung University Medical College; Taoyuan Taiwan
| | - Wen-Lin Kuo
- Department of Surgery; Chang Gung Memorial Hospital; Chang Gung University Medical College; Taoyuan Taiwan
| | - Hsiu-Pei Tsai
- Department of Surgery; Chang Gung Memorial Hospital; Chang Gung University Medical College; Taoyuan Taiwan
| | - Yung-Feng Lo
- Department of Surgery; Chang Gung Memorial Hospital; Chang Gung University Medical College; Taoyuan Taiwan
| | - Shin-Cheh Chen
- Department of Surgery; Chang Gung Memorial Hospital; Chang Gung University Medical College; Taoyuan Taiwan
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37
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Colin C, Devouassoux-Shisheboran M, Sardanelli F. Is breast cancer overdiagnosis also nested in pathologic misclassification? Radiology 2015; 273:652-5. [PMID: 25420166 DOI: 10.1148/radiol.14141116] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Catherine Colin
- From the Radiology Unit, Hospices Civils de Lyon, Centre Hospitalo-Universitaire Lyon Sud, 69495 Pierre Bénite Cedex, France (C.C.); Pathology Unit, Hospices Civils de Lyon, Hôpital de la Croix Rousse 103, Lyon, France (M.D.S.); Department of Biomedical Sciences for Health, Università degli Studi di Milano, Milan, Italy (F.S.); and Radiology Unit, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy (F.S.)
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38
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Morrow M, Schnitt SJ, Norton L. Current management of lesions associated with an increased risk of breast cancer. Nat Rev Clin Oncol 2015; 12:227-38. [PMID: 25622978 DOI: 10.1038/nrclinonc.2015.8] [Citation(s) in RCA: 79] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
High-risk breast lesions, which comprise benign lesions and in situ carcinomas (lobular carcinoma in situ and ductal carcinoma in situ), are clinically, morphologically, and biologically heterogeneous and are associated with an increased risk of invasive breast cancer development, albeit to varying degrees. Recognition and proactive management of such lesions can help to prevent progression to invasive disease, and might, therefore, reduce breast cancer incidence, morbidity, and mortality. However, this opportunity comes with the possibility of overdiagnosis and overtreatment, necessitating risk-based intervention. Notably, despite the progress in defining the molecular changes associated with carcinogenesis, alterations identifying the individuals with high-risk lesions that will progress to invasive carcinoma remain to be identified. Thus, until reproducible clinicopathological or molecular features predicting an individual's risk of breast cancer are found, management strategies must be defined by population-level risks as determined by models such as the Gail or IBIS models, as well as patient attitudes toward the risks and benefits of interventions. Herein, we review the contemporary approaches to diagnosis and management of high-risk breast lesions. Progress in this area will ultimately be dependent on the ability to individualize risk prediction through better definition of the key drivers in the carcinogenic process.
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Affiliation(s)
- Monica Morrow
- Breast Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Stuart J Schnitt
- Department of Pathology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA 02215, USA
| | - Larry Norton
- Breast Cancer Medicine Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
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39
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Abstract
Diagnostics of high-risk breast lesions have increased these last years with the augmentation of breast percutaneous biopsies. They are lesions that confer an enlarged risk of breast cancer, either because of an increased probability of finding cancer after open surgery, a possible evolution toward in situ or invasive cancer, or because of an increased probability of developing breast cancer over the long term. Much progress has been made these last years in their histological diagnostic, classification and pathogenesis. Nevertheless, no consensus exists to date on the management of these "high-risk" lesions. In particular, surgical indications and follow-up modalities remain controversial for each histological type. In this review, the principal factors that could impact surgical decision and long-term follow-up are discussed with areas of controversy highlighted.
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40
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Prowler VL, Joh JE, Acs G, Kiluk JV, Laronga C, Khakpour N, Lee MC. Surgical excision of pure flat epithelial atypia identified on core needle breast biopsy. Breast 2014; 23:352-6. [DOI: 10.1016/j.breast.2014.01.013] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2013] [Revised: 01/02/2014] [Accepted: 01/19/2014] [Indexed: 11/30/2022] Open
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41
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Maeda I, Kanemaki Y, Tozaki M, Koizumi H, Oana Y, Okanami Y, Tsuchiya K, Shimo A, Kojima Y, Hayami R, Nishikawa T, Kawamoto H, Yabuki Y, Tsugawa K, Takagi M. Positive predictive value for malignancy of pure flat epithelial atypia diagnosis by percutaneous needle biopsy of the breast: management of FEA in ultrasonography. Breast Cancer 2014; 22:634-40. [PMID: 24760612 DOI: 10.1007/s12282-014-0530-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2013] [Accepted: 04/07/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND Some reports suggest that the rate of definitive diagnosis of malignant tumors, namely, the final diagnosis being revised to a higher stage, in patients diagnosed as having flat epithelial atypia (FEA) by percutaneous needle biopsy of the breast (PNB) is as low as 0-3 %. However, other reports suggest that the rate is as high as 10 % or more, bringing confusion on this issue. We examined the positive predictive value for malignancy in the patients diagnosed as having pure FEA and the patients' radiolopathological characteristics observed in our hospital. METHODS Of the patients who underwent PNB in our facility, those who were diagnosed as having pure FEA were recruited as the subjects of this study. RESULTS Of the 4,197 consecutive patients who underwent PNB, 44 (1.0 %) were diagnosed as having pure FEA following a re-examination. Among 44 cases, 39 cases were selected as the subjects of this study. Among the 39 patients, six patients were diagnosed as having malignant lesions, two of whom had invasive carcinoma of no special type (papillotubular type), one had tubular carcinoma, one had ductal carcinoma in situ (DCIS) of high nuclear grade, one had DCIS of intermediate nuclear grade, and one had DCIS of low nuclear grade. The diameters of 6 malignant lesions were 10-30 mm at ultrasonography (US) examination. Five of the 39 patients had contralateral breast cancer. CONCLUSION The positive predictive value for malignancy of pure FEA was 15.7 %. The patients with pure FEA may make a follow up without an excisional biopsy when the lesion sizes less than 10 mm on US examination.
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Affiliation(s)
- Ichiro Maeda
- Department of Pathology, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, 216-8511, Japan. .,Department of Breast and Endocrine Surgery, St. Marianna University School of Medicine, Kawasaki, Japan.
| | - Yoshihide Kanemaki
- Department of Radiology, St. Marianna University School of Medicine, Kawasaki, Japan.,Department of Breast and Endocrine Surgery, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Mitsuhiro Tozaki
- Breast Center, Kameda Medical Center, Kamogawa, Japan.,Department of Breast and Endocrine Surgery, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Hirotaka Koizumi
- Department of Pathology, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, 216-8511, Japan.,Department of Breast and Endocrine Surgery, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Yoshiyasu Oana
- Department of Pathology, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, 216-8511, Japan.,Department of Breast and Endocrine Surgery, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Yuko Okanami
- Department of Pathology, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, 216-8511, Japan.,Department of Breast and Endocrine Surgery, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Kyoko Tsuchiya
- Breast Center, Kameda Medical Center, Kamogawa, Japan.,Department of Breast and Endocrine Surgery, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Arata Shimo
- Breast Center, Kameda Medical Center, Kamogawa, Japan.,Department of Breast and Endocrine Surgery, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Yasuyuki Kojima
- Breast Center, Kameda Medical Center, Kamogawa, Japan.,Department of Breast and Endocrine Surgery, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Ryousuke Hayami
- Breast Center, Kameda Medical Center, Kamogawa, Japan.,Department of Breast and Endocrine Surgery, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Toru Nishikawa
- Breast Center, Kameda Medical Center, Kamogawa, Japan.,Department of Breast and Endocrine Surgery, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Hisanori Kawamoto
- Breast Center, Kameda Medical Center, Kamogawa, Japan.,Department of Breast and Endocrine Surgery, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Yukari Yabuki
- Breast Center, Kameda Medical Center, Kamogawa, Japan.,Department of Breast and Endocrine Surgery, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Koichiro Tsugawa
- Breast Center, Kameda Medical Center, Kamogawa, Japan.,Department of Breast and Endocrine Surgery, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Masayuki Takagi
- Department of Pathology, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, 216-8511, Japan.,Department of Breast and Endocrine Surgery, St. Marianna University School of Medicine, Kawasaki, Japan
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42
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Verschuur-Maes AHJ, Kornegoor R, de Bruin PC, Oudejans JJ, van Diest PJ. Do columnar cell lesions exist in the male breast? Histopathology 2014; 64:818-25. [PMID: 24267518 DOI: 10.1111/his.12333] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2013] [Revised: 11/11/2013] [Accepted: 11/19/2013] [Indexed: 11/27/2022]
Abstract
AIMS In females, columnar cell lesions (CCLs) have been recognized as putative precursor lesions of low-grade breast cancer, but their role in male breast carcinogenesis is as yet unclear. METHODS AND RESULTS We reviewed surgical resections from males with breast cancer (n = 89), gynaecomastia (n = 20) and normal breast specimens from autopsies (n = 5) for the presence of CCL. In addition, we performed immunohistochemistry for cytokeratin 5/6 (CK5/6), CK14 and oestrogen receptor alpha (ER). In 19 of 89 resections (two DCIS cases and 17 invasive carcinoma), some individual ducts were found to contain cells with snouts on the luminal border but lacking further typical columnar cell lesion features. We mainly found three-layered ductal epithelium, characteristic for gynaecomastia and confirmed by immunohistochemistry. Moreover, we found a few ducts in male breast cancer sections that were clonally negative for basal cytokeratins. CONCLUSION We found no lesions with convincing CCL morphology at the periphery of invasive male breast cancers, in gynaecomastia or in normal male breast specimens. Although we cannot completely exclude the existence of CCLs in the male breast, these lesions seem to be very uncommon and are therefore unlikely to play a major role in male breast carcinogenesis.
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43
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[Diagnostics of benign ductal epithelial cell proliferation of the breast in biopsy material]. DER PATHOLOGE 2014; 35:18-25. [PMID: 24448666 DOI: 10.1007/s00292-013-1886-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The pathological evaluation of radiological or sonographical abnormalities by needle core biopsy of the breast frequently involves the differential diagnosis of benign epithelial cell proliferations. The lesions to be considered include usual type and atypical ductal epithelial cell hyperplasia, columnar cell changes including flat epithelial cell atypia, the spectrum of hyperplastic and atypical apocrine epithelial cell proliferations and papillary lesions. This review provides an overview of the diagnostic criteria, the current terminology and the differential diagnosis of these lesions. The clinical management and the prognosis of the lesions are discussed.
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44
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Uzan C, Mazouni C, Ferchiou M, Ciolovan L, Balleyguier C, Mathieu MC, Vielh P, Delaloge S. A Model to Predict the Risk of Upgrade to Malignancy at Surgery in Atypical Breast Lesions Discovered on Percutaneous Biopsy Specimens. Ann Surg Oncol 2013; 20:2850-7. [DOI: 10.1245/s10434-013-2989-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2013] [Indexed: 11/18/2022]
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