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Harinath L, Villatoro TM, Clark BZ, Fine JL, Yu J, Carter GJ, Diego E, McAuliffe PF, Mai P, Lu A, Zuley M, Berg WA, Bhargava R. Upgrade Rates of Variant Lobular Carcinoma In Situ Compared to Classic Lobular Carcinoma In Situ Diagnosed in Core Needle Biopsies: A 10-Year Single Institution Retrospective Study. Mod Pathol 2024; 37:100462. [PMID: 38428736 DOI: 10.1016/j.modpat.2024.100462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 02/14/2024] [Accepted: 02/22/2024] [Indexed: 03/03/2024]
Abstract
The primary aim of this study was to determine the upgrade rates of variant lobular carcinoma in situ (V-LCIS, ie, combined florid [F-LCIS] and pleomorphic [P-LCIS]) compared with classic LCIS (C-LCIS) when diagnosed on core needle biopsy (CNB). The secondary goal was to determine the rate of progression/development of invasive carcinoma on long-term follow-up after primary excision. After institutional review board approval, our institutional pathology database was searched for patients with "pure" LCIS diagnosed on CNB who underwent subsequent excision. Radiologic findings were reviewed, radiologic-pathologic (rad-path) correlation was performed, and follow-up patient outcome data were obtained. One hundred twenty cases of LCIS were identified on CNB (C-LCIS = 97, F-LCIS = 18, and P-LCIS = 5). Overall upgrade rates after excision for C-LCIS, F-LCIS, and P-LCIS were 14% (14/97), 44% (8/18), and 40% (2/5), respectively. Of the total cases, 79 (66%) were deemed rad-path concordant. Of these, the upgrade rate after excision for C-LCIS, F-LCIS, and P-LCIS was 7.5% (5 of 66), 40% (4 of 10), and 0% (0 of 3), respectively. The overall upgrade rate for V-LCIS was higher than for C-LCIS (P = .004), even for the cases deemed rad-path concordant (P value: .036). Most upgraded cases (23 of 24) showed pT1a disease or lower. With an average follow-up of 83 months, invasive carcinoma in the ipsilateral breast was identified in 8/120 (7%) cases. Six patients had died: 2 of (contralateral) breast cancer and 4 of other causes. Because of a high upgrade rate, V-LCIS diagnosed on CNB should always be excised. The upgrade rate for C-LCIS (even when rad-path concordant) is higher than reported in many other studies. Rad-path concordance read, surgical consultation, and individualized decision making are recommended for C-LCIS cases. The risk of developing invasive carcinoma after LCIS diagnosis is small (7% with ∼7-year follow-up), but active surveillance is required to diagnose early-stage disease.
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Affiliation(s)
- Lakshmi Harinath
- Department of Pathology, University of Pittsburgh School of Medicine, UPMC Magee-Womens Hospital, Pittsburgh, Pennsylvania
| | - Tatiana M Villatoro
- Department of Pathology, University of Pittsburgh School of Medicine, UPMC Magee-Womens Hospital, Pittsburgh, Pennsylvania
| | - Beth Z Clark
- Department of Pathology, University of Pittsburgh School of Medicine, UPMC Magee-Womens Hospital, Pittsburgh, Pennsylvania
| | - Jeffrey L Fine
- Department of Pathology, University of Pittsburgh School of Medicine, UPMC Magee-Womens Hospital, Pittsburgh, Pennsylvania
| | - Jing Yu
- Department of Pathology, University of Pittsburgh School of Medicine, UPMC Magee-Womens Hospital, Pittsburgh, Pennsylvania
| | - Gloria J Carter
- Department of Pathology, University of Pittsburgh School of Medicine, UPMC Magee-Womens Hospital, Pittsburgh, Pennsylvania
| | - Emilia Diego
- Department of Surgery, University of Pittsburgh School of Medicine, UPMC Magee-Womens Hospital, Pittsburgh, Pennsylvania
| | - Priscilla F McAuliffe
- Department of Surgery, University of Pittsburgh School of Medicine, UPMC Magee-Womens Hospital, Pittsburgh, Pennsylvania
| | - Phuong Mai
- Department of Obstetrics and Gynecology, University of Pittsburgh School of Medicine, UPMC Magee-Womens Hospital, Pittsburgh, Pennsylvania
| | - Amy Lu
- Department of Radiology, University of Pittsburgh School of Medicine, UPMC Magee-Womens Hospital, Pittsburgh, Pennsylvania
| | - Margarita Zuley
- Department of Radiology, University of Pittsburgh School of Medicine, UPMC Magee-Womens Hospital, Pittsburgh, Pennsylvania
| | - Wendie A Berg
- Department of Radiology, University of Pittsburgh School of Medicine, UPMC Magee-Womens Hospital, Pittsburgh, Pennsylvania
| | - Rohit Bhargava
- Department of Pathology, University of Pittsburgh School of Medicine, UPMC Magee-Womens Hospital, Pittsburgh, Pennsylvania.
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Rubio IT, Wyld L, Marotti L, Athanasiou A, Regitnig P, Catanuto G, Schoones JW, Zambon M, Camps J, Santini D, Dietz J, Sardanelli F, Varga Z, Smidt M, Sharma N, Shaaban AM, Gilbert F. European guidelines for the diagnosis, treatment and follow-up of breast lesions with uncertain malignant potential (B3 lesions) developed jointly by EUSOMA, EUSOBI, ESP (BWG) and ESSO. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:107292. [PMID: 38061151 DOI: 10.1016/j.ejso.2023.107292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 11/17/2023] [Indexed: 01/16/2024]
Abstract
INTRODUCTION Breast lesions of uncertain malignant potential (B3) include atypical ductal and lobular hyperplasias, lobular carcinoma in situ, flat epithelial atypia, papillary lesions, radial scars and fibroepithelial lesions as well as other rare miscellaneous lesions. They are challenging to categorise histologically, requiring specialist training and multidisciplinary input. They may coexist with in situ or invasive breast cancer (BC) and increase the risk of subsequent BC development. Management should focus on adequate classification and management whilst avoiding overtreatment. The aim of these guidelines is to provide updated information regarding the diagnosis and management of B3 lesions, according to updated literature review evidence. METHODS These guidelines provide practical recommendations which can be applied in clinical practice which include recommendation grade and level of evidence. All sections were written according to an updated literature review and discussed at a consensus meeting. Critical appraisal by the expert writing committee adhered to the 23 items in the international Appraisal of Guidelines, Research and Evaluation (AGREE) tool. RESULTS Recommendations for further management after core-needle biopsy (CNB) or vacuum-assisted biopsy (VAB) diagnosis of a B3 lesion reported in this guideline, vary depending on the presence of atypia, size of lesion, sampling size, and patient preferences. After CNB or VAB, the option of vacuum-assisted excision or surgical excision should be evaluated by a multidisciplinary team and shared decision-making with the patient is crucial for personalizing further treatment. De-escalation of surgical intervention for B3 breast lesions is ongoing, and the inclusion of vacuum-assisted excision (VAE) will decrease the need for surgical intervention in further approaches. Communication with patients may be different according to histological diagnosis, presence or absence of atypia, or risk of upgrade due to discordant imaging. Written information resources to help patients understand these issues alongside with verbal communication is recommended. Lifestyle interventions have a significant impact on BC incidence so lifestyle interventions need to be suggested to women at increased BC risk as a result of a diagnosis of a B3 lesion. CONCLUSIONS These guidelines provide a state-of-the-art overview of the diagnosis, management and prognosis of B3 lesions in modern multidisciplinary breast practice.
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Affiliation(s)
- Isabel T Rubio
- Breast Surgical Oncology, Clinica Universidad de Navarra, Madrid, Spain; European Society of Breast Cancer Specialists (EUSOMA), Florence, Italy; European Society of Surgical Oncology (ESSO), Brussels, Belgium.
| | - Lynda Wyld
- Department of Oncology and Metabolism, University of Sheffield Medical School, Beech Hill Road, Sheffield, S10 2RX, UK; Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust, Doncaster, UK
| | - Lorenza Marotti
- European Society of Breast Cancer Specialists (EUSOMA), Florence, Italy
| | | | - Peter Regitnig
- Diagnostic and Research Institute of Pathology, Medical University of Graz, Graz, Austria
| | - Giuseppe Catanuto
- Humanitas-Istituto Clinico Catanese Misterbianco, Italy; Fondazione G.Re.T.A., ETS, Napoli, Italy
| | - Jan W Schoones
- Research Policy & Graduate School Advisor, Leiden University Medical Center Leiden, the Netherlands
| | - Marzia Zambon
- Europa Donna - The European Breast Cancer Coalition, Milan, Italy
| | - Julia Camps
- Breast Health Units in Ribera Salud Hospitals.Valencia, Spain
| | - Donatella Santini
- Department of Pathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy
| | - Jill Dietz
- The American Society of Breast Surgeons, Columbia, MD, USA
| | - Francesco Sardanelli
- Department of Biomedical Sciences for Health, Università Degli Studi di Milano, Milan, Italy; Unit of Radiology, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Zsuzsanna Varga
- Department of Pathology and Molecular Pathology, University Hospital Zurich, Zurich, Switzerland
| | - Marjolein Smidt
- GROW-School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, the Netherlands; Department of Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Nisha Sharma
- Breast Unit, Level 1 Chancellor Wing, St James Hospital, Beckett Street Leeds, West Yorkshire, LS9 7TF, UK
| | - Abeer M Shaaban
- Cellular Pathology, Queen Elizabeth Hospital Birmingham, Birmingham, UK; Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Fiona Gilbert
- Department of Radiology, University of Cambridge, Cambridge Biomedical Campus, UK.
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Heller SL, Gao Y. Update on Lobular Neoplasia. Radiographics 2023; 43:e220188. [PMID: 37676825 DOI: 10.1148/rg.220188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Abstract
Lobular neoplasia (LN) is a histopathologic entity that encompasses both lobular carcinoma in situ (LCIS) and atypical lobular hyperplasia (ALH). Management of LN is known to be variable and institutionally dependent. The variability in approach after a diagnosis of LN at percutaneous breast biopsy derives in part from heterogeneity in the literature, resulting in a range of reported upgrade rates to malignancy after initial identification at percutaneous biopsy, and also from historical shifts in understanding of the natural history of LN. It has become increasingly recognized that not all LN is the same and that distinct variants of LN such as pleomorphic LCIS and florid LCIS have distinct natural histories and distinct likelihoods of upgrade to malignancy. In addition, it is also increasingly understood that appropriate management of LN relies on scrupulous radiologic-pathologic correlation. This review details the imaging features and histopathologic nature of ALH, classic-type LCIS, and the LCIS variants; addresses changes in the historical understanding of this entity contributing to confusion regarding its management; and discusses the importance of performing radiologic-pathologic correlation after percutaneous biopsy to help guide appropriate management steps when LN is encountered. In addition to the short-term implications of an LN diagnosis in terms of upgrade and surgical outcomes, the long-term implications of an LN diagnosis regarding risk of developing a later breast cancer are examined. ©RSNA, 2023 Quiz questions for this article are available through the Online Learning Center.
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Affiliation(s)
- Samantha L Heller
- From the NYU Grossman School of Medicine, 160 E 34th St, New York, NY 10016
| | - Yiming Gao
- From the NYU Grossman School of Medicine, 160 E 34th St, New York, NY 10016
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Quintana LM, Collins LC. Diagnostic Pitfalls in Breast Cancer Pathology With an Emphasis on Core Needle Biopsy Specimens. Arch Pathol Lab Med 2023; 147:1025-1038. [PMID: 37651393 DOI: 10.5858/arpa.2023-0007-ra] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/23/2023] [Indexed: 09/02/2023]
Abstract
CONTEXT.— Breast pathology has many mimics and diagnostic pitfalls. Evaluation of malignant breast lesions, particularly in the biopsy setting, can be especially challenging, with diagnostic errors having significant management implications. OBJECTIVE.— To discuss the pitfalls encountered when evaluating ductal carcinoma in situ and invasive breast carcinomas, providing histologic clues and guidance for appropriate use and interpretation of immunohistochemistry to aid in the correct diagnosis. DATA SOURCES.— Data were obtained from review of pertinent literature of ductal carcinoma in situ and invasive breast carcinomas and from the experience of the authors as practicing breast pathologists. CONCLUSIONS.— Awareness of the pitfalls in diagnosing breast cancers is important when creating a differential diagnosis for each breast lesion evaluated. This review will cover some of these scenarios to aid in the diagnostic process.
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Affiliation(s)
- Liza M Quintana
- From the Department of Pathology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - Laura C Collins
- From the Department of Pathology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
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