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Kurt SA, Taskin F, Kayadibi Y, Ozturk T, Adaletli İ, Icten GE. Role of Combining Grayscale Findings With Superb Microvascular Imaging and Shear Wave Elastography in Standardization and Management of NON-MASS Breast Lesions. Ultrasound Q 2024; 40:e00689. [PMID: 39172910 DOI: 10.1097/ruq.0000000000000689] [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: 08/24/2024]
Abstract
ABSTRACT The non-mass breast lesions on ultrasound (US) are a group of challenging pathology. We aimed to standardize these grayscale findings and investigate the effectiveness of superb microvascular imaging (SMI) and shear wave elastography (SWE). A total of 195 lesions were evaluated by B-mode US, SWE, and SMI in the same session. A "NON-MASS model" was built on grayscale US to group the lesions only as areas and those with associated features: microcalcifications, architectural distortion, ductal changes, and microcysts. The mean stiffness parameters Emean, Eratio, and mean vascular index (VI) were recorded following consecutive measurements. Besides, the microvascularity was graded based on Adler's classification (grades 0 to 3). Lesions were divided into 3 groups: benign, category B3, and malignant. One hundred twelve (57.4%) lesions were benign, 23 (11.8%) were B3, and 60 were (30.8%) in the malignant category. Thirty-eight (19.5%) lesions were observed only as an area, whereas associated features were present in 157 lesions (80.5%). Distortion was the only associated feature predicting malignancy among the grayscale findings (P < 0.001). There was a significant difference between malignant and nonmalignant (benign and B3) groups in terms of Adler's grade, Emean, Eratio, and VI values (P < 0.001). Sensitivity, specificity, and accuracy increased when advanced imaging parameters were added to grayscale findings (P < 0.001). In the presence of microcalcifications, architectural distortion, high elasticity, and hypervascularity in the "NON-MASS" imaging model, the suspicion of malignancy increases. The non-mass findings and advanced imaging techniques have the potential to find greater coverage in the following versions of BI-RADS atlas.
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Affiliation(s)
| | - Fusun Taskin
- Department of Radiology, Acibadem Mehmet Ali Aydinlar University
| | | | - Tulin Ozturk
- Department of Pathology, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | | | - Gul Esen Icten
- Department of Radiology, Acibadem Mehmet Ali Aydinlar University
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2
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Wadsten C, Rask G. Management and risk of upgrade of atypical ductal hyperplasia in the breast: A population-based retrospective cohort study. Scand J Surg 2024; 113:229-236. [PMID: 38414163 DOI: 10.1177/14574969241234115] [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] [Indexed: 02/29/2024]
Abstract
BACKGROUND International guidelines recommend open surgery for atypical ductal hyperplasia (ADH) in the breast due to risk of underestimating malignant disease. Considering the ongoing randomized trials of active surveillance of low-risk ductal carcinoma in situ (DCIS), it seems reasonable to define a low-risk group of women with ADH where a conservative approach is appropriate. The aim here was to evaluate the management and risk for upgrade of lesions diagnosed as ADH in percutaneous breast biopsies in two Swedish hospitals. METHODS All women with a screen-detected or symptomatic breast lesion breast imaging-reporting and data system (BI-RADS) 2-4 and a percutaneous biopsy showing ADH between 2013 and 2022 at Sundsvall Hospital and Umeå University Hospital were included. Information regarding imaging, histopathology, clinical features, and management was retrieved from medical records. Odds ratio (OR) and 95% confidence intervals (CI) for upgrade to malignant diagnosis after surgery were calculated by logistic regression analysis. RESULTS Altogether, 101 women were included with a mean age 56.1 (range 36-93) years. Most women were selected from the national mammography screening program due to microcalcifications. Biopsies were performed with vacuum-assisted biopsy (60.4%) or core-needle biopsy (39.6%). Forty-eight women (47.5%) underwent surgery, of which 11 were upgraded to DCIS, and 7 to invasive breast cancer (upgrade rate 37.5%). Among the 53 women managed conservatively (median follow-up 74 months), one woman (1.9%) developed subsequent ipsilateral DCIS. The combined upgrade rate was 18.8%. No clinical variable statistically significantly correlating to risk of upgrade was identified. CONCLUSIONS The upgrade rate of 37.5% in women undergoing surgery compared to an estimated 5-year risk of ipsilateral malignancy at 1.9% in women managed conservatively indicate that non-surgical management of select women with ADH is feasible. Research should focus on defining reproducible criteria differentiating high-risk from low-risk ADH.
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Affiliation(s)
- Charlotta Wadsten
- Department of Surgery Sundsvall Hospital S-856 43 Sundsvall Sweden
- Department of Diagnostics and Intervention/Surgery Umeå University Umeå Sweden
| | - Gunilla Rask
- Department of Medical Biosciences/Pathology, Umeå University, Umeå, Sweden
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3
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Kader T, Provenzano E, Jayawardana MW, Hendry S, Pang JM, Elder K, Byrne DJ, Tjoeka L, Frazer HM, House E, Jayasinghe SI, Keane H, Murugasu A, Rajan N, Miligy IM, Toss M, Green AR, Rakha EA, Fox SB, Mann GB, Campbell IG, Gorringe KL. Stromal lymphocytes are associated with upgrade of B3 breast lesions. Breast Cancer Res 2024; 26:115. [PMID: 38978071 PMCID: PMC11232297 DOI: 10.1186/s13058-024-01857-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 06/10/2024] [Indexed: 07/10/2024] Open
Abstract
Various histopathological, clinical and imaging parameters have been evaluated to identify a subset of women diagnosed with lesions with uncertain malignant potential (B3 or BIRADS 3/4A lesions) who could safely be observed rather than being treated with surgical excision, with little impact on clinical practice. The primary reason for surgery is to rule out an upgrade to either ductal carcinoma in situ or invasive breast cancer, which occurs in up to 30% of patients. We hypothesised that the stromal immune microenvironment could indicate the presence of carcinoma associated with a ductal B3 lesion and that this could be detected in biopsies by counting lymphocytes as a predictive biomarker for upgrade. A higher number of lymphocytes in the surrounding specialised stroma was observed in upgraded ductal and papillary B3 lesions than non-upgraded (p < 0.01, negative binomial model, n = 307). We developed a model using lymphocytes combined with age and the type of lesion, which was predictive of upgrade with an area under the curve of 0.82 [95% confidence interval 0.77-0.87]. The model can identify some patients at risk of upgrade with high sensitivity, but with limited specificity. Assessing the tumour microenvironment including stromal lymphocytes may contribute to reducing unnecessary surgeries in the clinic, but additional predictive features are needed.
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MESH Headings
- Humans
- Female
- Breast Neoplasms/pathology
- Breast Neoplasms/immunology
- Tumor Microenvironment/immunology
- Middle Aged
- Aged
- Lymphocytes/immunology
- Lymphocytes/pathology
- Stromal Cells/pathology
- Adult
- Neoplasm Grading
- Lymphocytes, Tumor-Infiltrating/immunology
- Lymphocytes, Tumor-Infiltrating/metabolism
- Carcinoma, Intraductal, Noninfiltrating/pathology
- Carcinoma, Intraductal, Noninfiltrating/immunology
- Carcinoma, Ductal, Breast/pathology
- Carcinoma, Ductal, Breast/immunology
- Biomarkers, Tumor
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Affiliation(s)
- Tanjina Kader
- Peter MacCallum Cancer Centre, 305 Grattan St, Melbourne, 3000, Australia
- The Sir Peter MacCallum Department of Oncology, The University of Melbourne, Parkville, 3010, Australia
- Laboratory of Systems Pharmacology, Harvard Medical School, Boston, MA, 02115, USA
| | - Elena Provenzano
- Department of Histopathology, Addenbrookes Hospital, and Cambridge NIH Biomedical Research Centre, Cambridge, UK
| | - Madawa W Jayawardana
- Peter MacCallum Cancer Centre, 305 Grattan St, Melbourne, 3000, Australia
- The Sir Peter MacCallum Department of Oncology, The University of Melbourne, Parkville, 3010, Australia
| | - Shona Hendry
- Department of Anatomical Pathology, St Vincent's Hospital, Fitzroy, Australia
| | - Jia-Min Pang
- Peter MacCallum Cancer Centre, 305 Grattan St, Melbourne, 3000, Australia
| | - Kenneth Elder
- The Breast Service, The Royal Women's Hospital, Melbourne, Australia
- Edinburgh Breast Unit, Edinburgh, UK
| | - David J Byrne
- Peter MacCallum Cancer Centre, 305 Grattan St, Melbourne, 3000, Australia
| | - Lauren Tjoeka
- Peter MacCallum Cancer Centre, 305 Grattan St, Melbourne, 3000, Australia
| | - Helen Ml Frazer
- St Vincent's Breast Screen, St Vincent's Hospital Melbourne, Melbourne, VIC, Australia
- BreastScreen Victoria, Parkville, VIC, Australia
| | - Eloise House
- Department of Anatomical Pathology, St Vincent's Hospital, Fitzroy, Australia
| | - Sureshni I Jayasinghe
- Department of Anatomical Pathology, St Vincent's Hospital, Fitzroy, Australia
- Department of Clinical Pathology, The University of Melbourne, Parkville, 3010, Australia
| | - Holly Keane
- Peter MacCallum Cancer Centre, 305 Grattan St, Melbourne, 3000, Australia
| | - Anand Murugasu
- The Breast Service, The Royal Women's Hospital, Melbourne, Australia
| | - Neeha Rajan
- The Breast Service, The Royal Women's Hospital, Melbourne, Australia
| | - Islam M Miligy
- Nottingham Breast Cancer Research Centre, Academic Unit for Translational Medical Sciences, School of Medicine, Biodiscovery Institute, Department of Histopathology, University of Nottingham, Nottingham University Hospitals NHS Trust, City Hospital, Nottingham, UK
- Histopathology Department, Faculty of Medicine, Menoufia University, Shibin El Kom, Egypt
| | - Michael Toss
- Nottingham Breast Cancer Research Centre, Academic Unit for Translational Medical Sciences, School of Medicine, Biodiscovery Institute, Department of Histopathology, University of Nottingham, Nottingham University Hospitals NHS Trust, City Hospital, Nottingham, UK
- Histopathology Department, Faculty of Medicine, Menoufia University, Shibin El Kom, Egypt
| | - Andrew R Green
- Nottingham Breast Cancer Research Centre, Academic Unit for Translational Medical Sciences, School of Medicine, Biodiscovery Institute, Department of Histopathology, University of Nottingham, Nottingham University Hospitals NHS Trust, City Hospital, Nottingham, UK
| | - Emad A Rakha
- Nottingham Breast Cancer Research Centre, Academic Unit for Translational Medical Sciences, School of Medicine, Biodiscovery Institute, Department of Histopathology, University of Nottingham, Nottingham University Hospitals NHS Trust, City Hospital, Nottingham, UK
- Pathology Department, Hamad Medical Corporation, Doha, Qatar
| | - Stephen B Fox
- Peter MacCallum Cancer Centre, 305 Grattan St, Melbourne, 3000, Australia
| | - G Bruce Mann
- The Royal Melbourne Hospital, Melbourne, Australia
- Department of Surgery, The University of Melbourne, Parkville, 3010, Australia
- The Breast Service, The Royal Women's Hospital, Melbourne, Australia
| | - Ian G Campbell
- Peter MacCallum Cancer Centre, 305 Grattan St, Melbourne, 3000, Australia
- The Sir Peter MacCallum Department of Oncology, The University of Melbourne, Parkville, 3010, Australia
- Department of Clinical Pathology, The University of Melbourne, Parkville, 3010, Australia
| | - Kylie L Gorringe
- Peter MacCallum Cancer Centre, 305 Grattan St, Melbourne, 3000, Australia.
- The Sir Peter MacCallum Department of Oncology, The University of Melbourne, Parkville, 3010, Australia.
- Department of Clinical Pathology, The University of Melbourne, Parkville, 3010, Australia.
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4
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Bernini M, Spolveri F, Tofani L, De Benedetto D, Bicchierai G, Bellini C, Morrone D, Nori Cucchiari J, Bianchi S, Livi L, Orzalesi L, Meattini I. B3 Breast Lesions: Positive Predictive Value and Follow-Up on a Large Single-Institution Series. J Surg Res 2024; 299:366-373. [PMID: 38815523 DOI: 10.1016/j.jss.2024.04.057] [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: 05/09/2023] [Revised: 04/15/2024] [Accepted: 04/22/2024] [Indexed: 06/01/2024]
Abstract
INTRODUCTION Lesions of uncertain malignant potential (B3) represent 10% of core needle biopsies (CNBs) or vacuum-assisted breast biopsies (VABBs). Traditionally, B3 lesions are operated on. This study investigated the association between B3 subtypes and malignancy to determine the best management. METHODS Pre- and postoperative histological reports from 226 patients, who had undergone excisional surgery for B3 lesions, following CNB or VABB, were retrospectively analyzed. The correlation between the CNB/VABB diagnosis and the final pathology was investigated, along with the correlation between malignancy upgrade and the type of mammographic lesion. The positive predictive value (PPV) of malignancy of B3 lesions was calculated by simple logistic regression. Patients without cancer diagnosis underwent a 7-y follow-up. RESULTS Pathology showed 171 (75.6%) benign and 55 (24.3%) malignant lesions. The PPV was 24.3% (P = 0.043), including 31 (13.7%) ductal carcinomas in situ and 24 (10.6%) invasive carcinomas. The most frequently upgraded lesions were atypical ductal hyperplasia, 34.2% (P = 0.004), followed by lobular intraepithelial neoplasia, 27.5% (P = 0.025). The median diameter of mammographic lesions was 1.5 [0.9-2.5] cm, while for surgical specimens, it was 5 [4-7] cm (P < 0.0001). Mammographic findings and histology showed a significant correlation (P = 0.038). After a 7-y follow-up, 15 (8.9%) patients developed carcinoma, and 7 patients (4%) developed a new B3 lesion. CONCLUSIONS We can conclude that atypical ductal hyperplasia and lobular intraepithelial neoplasia still require surgery for a significant PPV. Other types that lacked significance or confidence intervals were too wide to draw any conclusion.
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MESH Headings
- Humans
- Female
- Breast Neoplasms/pathology
- Breast Neoplasms/surgery
- Breast Neoplasms/diagnosis
- Breast Neoplasms/diagnostic imaging
- Middle Aged
- Retrospective Studies
- Adult
- Aged
- Follow-Up Studies
- Biopsy, Large-Core Needle
- Predictive Value of Tests
- Mammography
- Breast/pathology
- Breast/diagnostic imaging
- Breast/surgery
- Carcinoma, Intraductal, Noninfiltrating/pathology
- Carcinoma, Intraductal, Noninfiltrating/diagnosis
- Carcinoma, Intraductal, Noninfiltrating/surgery
- Carcinoma, Ductal, Breast/pathology
- Carcinoma, Ductal, Breast/surgery
- Carcinoma, Ductal, Breast/diagnosis
- Carcinoma, Ductal, Breast/diagnostic imaging
- Aged, 80 and over
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Affiliation(s)
- Marco Bernini
- Breast Surgery Division, Breast Unit, Oncology Department, Careggi University Hospital, Florence, Italy
| | - Federico Spolveri
- Breast Surgery Division, Breast Unit, San Jacopo Hospital, Pistoia, Italy.
| | - Lorenzo Tofani
- Department of Statistic, Computer Science, Applications, University of Florence, Florence, Italy
| | | | - Giulia Bicchierai
- Diagnostic Senology Unit, Careggi University Hospital, Florence, Italy
| | - Chiara Bellini
- Diagnostic Senology Unit, Careggi University Hospital, Florence, Italy
| | - Doralba Morrone
- Diagnostic Senology Unit, Villa Donatello Clinic, Florence, Italy
| | | | - Simonetta Bianchi
- Pathology Division, Department of Surgery and Translational Medicine, Careggi University Hospital, Florence, Italy
| | - Lorenzo Livi
- Radiation Oncology Division, Breast Unit, Oncology Department, Careggi University Hospital, Florence, Italy
| | - Lorenzo Orzalesi
- Breast Surgery Division, Breast Unit, Oncology Department, Careggi University Hospital, Florence, Italy
| | - Icro Meattini
- Radiation Oncology Division, Breast Unit, Oncology Department, Careggi University Hospital, Florence, Italy
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5
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Warm HL, Kandt LD, Schaumann N, Werlein C, Gronewold M, Christgen H, Hellmann M, Lafos M, Auber B, Hillemanns P, Kreipe H, Christgen M. Immunohistochemical marker profiles for the differentiation of collagenous spherulosis from adenoid cystic carcinoma of the breast. Hum Pathol 2024; 148:7-13. [PMID: 38677556 DOI: 10.1016/j.humpath.2024.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Revised: 04/19/2024] [Accepted: 04/22/2024] [Indexed: 04/29/2024]
Abstract
Collagenous spherulosis (CS) is a rare breast lesion of unknown histogenesis. Adenoid cystic carcinoma (ACC) is a rare basal-like breast carcinoma with low histological grade. CS is a benign lesion but resembles ACC. Both lesions show a similar histomorphology and feature bilineage differentiation. This study compared immunohistochemical markers in CS and ACC. We compiled n = 13 CS cases and n = 18 mammary ACCs. Fourteen marker proteins (ER, PR, HER2, GATA3, CK7, E-cadherin, CD117, CK5/14, p40, p63, SMA, CD10, calponin, P-cadherin) were evaluated by immunohistochemistry (IHC). MYB rearrangement, a common alteration in ACC, was assessed by fluorescence in situ hybridization. Patient age ranged between 40-60 years for CS lesions and 30-90 years for ACCs. 7/13 (54%) CS cases harbored a lobular carcinoma in situ (LCIS) in the luminal component. One CS/LCIS lesion occurred in a carrier of a pathogenic germline variant in CDH1/E-cadherin. MYB rearrangement was detected in 0/11 (0%) CS and 6/16 (37%) ACC cases (P = 0.054). CS was associated with expression of ER in the luminal component (P < 0.001), E-cadherin loss in the luminal component (P = 0.045), and expression of CD10 and calponin in the basal component (P < 0.001). Furthermore, CS was associated with GATA3 expression in the luminal component (12/13 [92%] versus 5/18 [27%], P < 0.001). In summary, IHC for GATA3 and E-cadherin may contribute to the differential diagnosis between CS and ACC, although these markers are not exclusively expressed in either lesion. Histologic evaluation has to take into account that CS is frequently colonized by LCIS, requiring thorough correlation of histomorphology and immunohistochemical features.
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Affiliation(s)
- Henriette L Warm
- Institute of Pathology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.
| | - Leonie D Kandt
- Institute of Pathology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.
| | - Nora Schaumann
- Institute of Pathology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.
| | - Christopher Werlein
- Institute of Pathology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.
| | - Malte Gronewold
- Institute of Pathology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.
| | - Henriette Christgen
- Institute of Pathology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.
| | - Malin Hellmann
- Institute of Pathology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.
| | - Marcel Lafos
- Institute of Pathology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.
| | - Bernd Auber
- Department of Human Genetics, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.
| | - Peter Hillemanns
- Clinic for Obstetrics, Gynecology and Neonatology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.
| | - Hans Kreipe
- Institute of Pathology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.
| | - Matthias Christgen
- Institute of Pathology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.
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6
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Marin C, Weiss A, Gooch JC. Updates in the Surgical Management of Benign and High-Risk Breast Lesions. Clin Breast Cancer 2024; 24:278-285. [PMID: 38171944 DOI: 10.1016/j.clbc.2023.12.008] [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: 11/01/2023] [Revised: 12/18/2023] [Accepted: 12/19/2023] [Indexed: 01/05/2024]
Abstract
Benign breast disease (BBD) is a heterogenous group of lesions often classified as nonproliferative or proliferative, with the latter group further categorized based on the presence of atypia. Although nonproliferative lesions are more common, the risk of breast cancer is elevated in women with proliferative lesions. Historically, the majority of proliferative lesions were excised due to concern for future and/or concomitant breast cancer at the site of the index lesion. However, contemporary data suggest that the risk of cancer associated with various proliferative lesions may be lower than previously thought, and management of BBD has become more nuanced. In this review, we will focus on recent updates in the management of a select group of benign and high-risk lesions.
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Affiliation(s)
- Chelsea Marin
- Department of Surgery, Division of Surgical Oncology, University of Rochester Medical Center, Rochester, NY
| | - Anna Weiss
- Department of Surgery, Division of Surgical Oncology, University of Rochester Medical Center, Rochester, NY; Wilmot Cancer Center, University of Rochester Medical Center, Rochester, NY
| | - Jessica C Gooch
- Department of Surgery, Division of Surgical Oncology, University of Rochester Medical Center, Rochester, NY; Wilmot Cancer Center, University of Rochester Medical Center, Rochester, NY.
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7
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Nicosia L, Mariano L, Pellegrino G, Ferrari F, Pesapane F, Bozzini AC, Frassoni S, Bagnardi V, Pupo D, Mazzarol G, De Camilli E, Sangalli C, Venturini M, Pizzamiglio M, Cassano E. Atypical Ductal Hyperplasia and Lobular In Situ Neoplasm: High-Risk Lesions Challenging Breast Cancer Prevention. Cancers (Basel) 2024; 16:837. [PMID: 38398228 PMCID: PMC10886664 DOI: 10.3390/cancers16040837] [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: 12/29/2023] [Revised: 02/07/2024] [Accepted: 02/15/2024] [Indexed: 02/25/2024] Open
Abstract
This retrospective study investigates the histopathological outcomes, upgrade rates, and disease-free survival (DFS) of high-risk breast lesions, including atypical ductal hyperplasia (ADH or DIN1b) and lobular in situ neoplasms (LIN), following Vacuum-Assisted Breast Biopsy (VABB) and surgical excision. The study addresses the challenge posed by these lesions due to their association with synchronous or adjacent Breast Cancer (BC) and increased future BC risk. The research, comprising 320 patients who underwent stereotactic VABB, focuses on 246 individuals with a diagnosis of ADH (120) or LIN (126) observed at follow-up. Pathological assessments, categorized by the UK B-coding system, were conducted, and biopsy samples were compared with corresponding excision specimens to determine upgrade rates for in situ or invasive carcinoma. Surgical excision was consistently performed for diagnosed ADH or LIN. Finally, patient follow-ups were assessed and compared between LIN and ADH groups to identify recurrence signs, defined as histologically confirmed breast lesions on either the same or opposite side. The results reveal that 176 (71.5%) patients showed no upgrade post-surgery, with ADH exhibiting a higher upgrade rate to in situ pathology than LIN1 (Atypical Lobular Hyperplasia, ALH)/LIN2 (Low-Grade Lobular in situ Carcinoma, LCIS) (38% vs. 20%, respectively, p-value = 0.002). Considering only patients without upgrade, DFS at 10 years was 77%, 64%, and 72% for ADH, LIN1, and LIN2 patients, respectively (p-value = 0.92). The study underscores the importance of a multidisciplinary approach, recognizing the evolving role of VABB. It emphasizes the need for careful follow-up, particularly for lobular lesions, offering valuable insights for clinicians navigating the complex landscape of high-risk breast lesions. The findings advocate for heightened awareness and vigilance in managing these lesions, contributing to the ongoing refinement of clinical strategies in BC care.
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Affiliation(s)
- Luca Nicosia
- Breast Imaging Division, Radiology Department, (IEO) European Institute of Oncology IRCCS, 20141 Milan, Italy; (L.M.); (F.F.); (F.P.); (A.C.B.); (D.P.); (M.P.); (E.C.)
| | - Luciano Mariano
- Breast Imaging Division, Radiology Department, (IEO) European Institute of Oncology IRCCS, 20141 Milan, Italy; (L.M.); (F.F.); (F.P.); (A.C.B.); (D.P.); (M.P.); (E.C.)
| | - Giuseppe Pellegrino
- Postgraduate School of Radiodiagnostics, University of Milan, 20122 Milan, Italy;
| | - Federica Ferrari
- Breast Imaging Division, Radiology Department, (IEO) European Institute of Oncology IRCCS, 20141 Milan, Italy; (L.M.); (F.F.); (F.P.); (A.C.B.); (D.P.); (M.P.); (E.C.)
| | - Filippo Pesapane
- Breast Imaging Division, Radiology Department, (IEO) European Institute of Oncology IRCCS, 20141 Milan, Italy; (L.M.); (F.F.); (F.P.); (A.C.B.); (D.P.); (M.P.); (E.C.)
| | - Anna Carla Bozzini
- Breast Imaging Division, Radiology Department, (IEO) European Institute of Oncology IRCCS, 20141 Milan, Italy; (L.M.); (F.F.); (F.P.); (A.C.B.); (D.P.); (M.P.); (E.C.)
| | - Samuele Frassoni
- Department of Statistics and Quantitative Methods, University of Milan-Bicocca, 20126 Milan, Italy; (S.F.); (V.B.)
| | - Vincenzo Bagnardi
- Department of Statistics and Quantitative Methods, University of Milan-Bicocca, 20126 Milan, Italy; (S.F.); (V.B.)
| | - Davide Pupo
- Breast Imaging Division, Radiology Department, (IEO) European Institute of Oncology IRCCS, 20141 Milan, Italy; (L.M.); (F.F.); (F.P.); (A.C.B.); (D.P.); (M.P.); (E.C.)
| | - Giovanni Mazzarol
- Division of Pathology, (IEO) European Institute of Oncology IRCCS, 20141 Milan, Italy; (G.M.); (E.D.C.)
| | - Elisa De Camilli
- Division of Pathology, (IEO) European Institute of Oncology IRCCS, 20141 Milan, Italy; (G.M.); (E.D.C.)
| | - Claudia Sangalli
- Data Management, (IEO) European Institute of Oncology IRCCS, 20141 Milan, Italy;
| | - Massimo Venturini
- Diagnostic and Interventional Radiology Unit, ASST Settelaghi, Insubria University, 21100 Varese, Italy;
| | - Maria Pizzamiglio
- Breast Imaging Division, Radiology Department, (IEO) European Institute of Oncology IRCCS, 20141 Milan, Italy; (L.M.); (F.F.); (F.P.); (A.C.B.); (D.P.); (M.P.); (E.C.)
| | - Enrico Cassano
- Breast Imaging Division, Radiology Department, (IEO) European Institute of Oncology IRCCS, 20141 Milan, Italy; (L.M.); (F.F.); (F.P.); (A.C.B.); (D.P.); (M.P.); (E.C.)
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8
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Freeman K, Jenkinson D, Clements K, Wallis MG, Pinder SE, Provenzano E, Stobart H, Stallard N, Kearins O, Sharma N, Shaaban A, Kirwan CC, Hilton B, Thompson AM, Taylor-Phillips S. Atypia detected during breast screening and subsequent development of cancer: observational analysis of the Sloane atypia prospective cohort in England. BMJ 2024; 384:e077039. [PMID: 38302129 PMCID: PMC10831586 DOI: 10.1136/bmj-2023-077039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/22/2023] [Indexed: 02/03/2024]
Abstract
OBJECTIVE To explore how the number and type of breast cancers developed after screen detected atypia compare with the anticipated 11.3 cancers detected per 1000 women screened within one three year screening round in the United Kingdom. DESIGN Observational analysis of the Sloane atypia prospective cohort in England. SETTING Atypia diagnoses through the English NHS breast screening programme reported to the Sloane cohort study. This cohort is linked to the English Cancer Registry and the Mortality and Birth Information System for information on subsequent breast cancer and mortality. PARTICIPANTS 3238 women diagnosed as having epithelial atypia between 1 April 2003 and 30 June 2018. MAIN OUTCOME MEASURES Number and type of invasive breast cancers detected at one, three, and six years after atypia diagnosis by atypia type, age, and year of diagnosis. RESULTS There was a fourfold increase in detection of atypia after the introduction of digital mammography between 2010 (n=119) and 2015 (n=502). During 19 088 person years of follow-up after atypia diagnosis (until December 2018), 141 women developed breast cancer. Cumulative incidence of cancer per 1000 women with atypia was 0.95 (95% confidence interval 0.28 to 2.69), 14.2 (10.3 to 19.1), and 45.0 (36.3 to 55.1) at one, three, and six years after atypia diagnosis, respectively. Women with atypia detected more recently have lower rates of subsequent cancers detected within three years (6.0 invasive cancers per 1000 women (95% confidence interval 3.1 to 10.9) in 2013-18 v 24.3 (13.7 to 40.1) in 2003-07, and 24.6 (14.9 to 38.3) in 2008-12). Grade, size, and nodal involvement of subsequent invasive cancers were similar to those of cancers detected in the general screening population, with equal numbers of ipsilateral and contralateral cancers. CONCLUSIONS Many atypia could represent risk factors rather than precursors of invasive cancer requiring surgery in the short term. Women with atypia detected more recently have lower rates of subsequent cancers detected, which might be associated with changes to mammography and biopsy techniques identifying forms of atypia that are more likely to represent overdiagnosis. Annual mammography in the short term after atypia diagnosis might not be beneficial. More evidence is needed about longer term risks.
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Affiliation(s)
- Karoline Freeman
- Warwick Screening, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - David Jenkinson
- Warwick Screening, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Karen Clements
- Screening Quality Assurance Service, NHS England, Birmingham, UK
| | - Matthew G Wallis
- Cambridge Breast Unit and NIHR Cambridge Biomedical Research Centre, Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - Sarah E Pinder
- School of Cancer & Pharmaceutical Sciences, King's College London, London, UK
- Comprehensive Cancer Centre at Guy's Hospital, King's College London, London, UK
| | - Elena Provenzano
- Histopathology and NIHR Cambridge Biomedical Research Centre, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Hilary Stobart
- Patient representative, Independent Cancer Patients' Voice, UK
| | - Nigel Stallard
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Olive Kearins
- Screening Quality Assurance Service, NHS England, Birmingham, UK
| | - Nisha Sharma
- Breast Screening Unit, Seacroft Hospital, York Road, Leeds, UK
| | - Abeer Shaaban
- University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, Edgbaston, Birmingham, UK
| | - Cliona Clare Kirwan
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Bridget Hilton
- Screening Quality Assurance Service, NHS England, Birmingham, UK
| | - Alastair M Thompson
- Department of Surgical Oncology, Dan L Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, TX, USA
| | - Sian Taylor-Phillips
- Warwick Screening, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
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9
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Elfgen C, Varga Z, Breitling K, Pauli E, Schwegler-Guggemos D, Kampmann G, Kubik-Huch RA, Leo C, Lepori D, Sonnenschein M, Tausch C, Schrading S. Long-Term Follow-Up of High-Risk Breast Lesions at Vacuum-Assisted Biopsy without Subsequent Surgical Resection. Breast Care (Basel) 2024; 19:62-72. [PMID: 38384485 PMCID: PMC10878709 DOI: 10.1159/000533673] [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: 05/03/2023] [Accepted: 08/16/2023] [Indexed: 02/23/2024] Open
Abstract
Introduction B3-lesions of the breast are a heterogeneous group of neoplasms, associated with a higher risk of breast cancer. Recent studies show a low upgrade rate into malignancy after subsequent open surgical excision (OE) of most B3-lesions when proven by vacuum-assisted biopsy (VAB). However, there is a lack of long-term follow-up data after VAB of high-risk lesions. The primary aim of this study was to demonstrate whether follow-up of B3 lesions is a beneficial and reliable alternative to OE in terms of long-term outcome. The secondary aim was to identify patient and lesion characteristics of B3 lesions for which OE is still necessary. Methods This retrospective multicenter study was conducted at 8 Swiss breast centers between 2010 and 2019. A total of 278 women (mean age: 53.5 ± 10.7 years) with 286 B3-lesions who had observation only and who had at least 24 months of follow-up were included. Any event during follow-up (ductal carcinoma in situ [DCIS], invasive cancer, new B3-lesion) was systematically recorded. Data from women who had an event during follow-up were compared with those who did not. The results for the different B3 lesions were analyzed using the t test and Fisher's exact test. A p value of <0.05 was considered statistically significant. Results The median follow-up interval was 59 months (range: 24-143 months) with 52% (148/286) having a follow-up of more than 5 years. During follow-up, in 42 women, 44 suspicious lesions occurred, with 36.4% (16/44) being invasive cancer and 6.8% (3/44) being DCIS. Thus, 6.6% (19/286) of all women developed malignancy during follow-up after a median follow-up interval of 6.5 years (range: 31-119 months). The initial histology of the B3 lesion influenced the subsequent occurrence of a malignant lesion during follow-up (p < 0.038). The highest malignancy-developing rate was observed in atypical ductal hyperplasia (ADH) (24%, 19/79), while all other B3-lesions had malignant findings ipsi- and contralateral between 0% and 6%. The results were not influenced by the VAB method (Mx-, US-, magnetic resonance imaging-guided), the radiological characteristics of the lesion, or the age or menopausal status of the patient (p > 0.12). Conclusion With a low risk of <6% of developing malignancy, VAB followed by long-term follow-up is a safe alternative to OE for most B3-lesions. A higher malignancy rate only occurred in ADH (24%). Based on our results, radiological follow-up should be bilateral, preferable using the technique of initial diagnosis. As we observed a late peak (6-7 years) of breast malignancies after B3-lesions, follow-up should be continued for a longer period (>10 years). Knowledge of these long-term outcome results will be helpful in making treatment decisions and determining the optimal radiological follow-up interval.
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Affiliation(s)
- Constanze Elfgen
- Breast-Center Zurich, Zurich, Switzerland
- Department of Medicine, University of Witten-Herdecke, Witten, Germany
| | - Zsuzsanna Varga
- Department of Pathology and Molecular Pathology, University Hospital Zürich, Zurich, Switzerland
| | - Katrin Breitling
- Breast Center, Kantonsspital Schaffhausen, Schaffhausen, Switzerland
| | - Eliane Pauli
- Breast Center, Kantonsspital Frauenfeld, Frauenfeld, Switzerland
| | | | - Gert Kampmann
- Centro di Radiologia e Senologia Luganese, Lugano, Switzerland
| | | | - Cornelia Leo
- Breast Center, Kantonsspital Baden, Baden, Switzerland
| | | | | | - Christoph Tausch
- Breast-Center Zurich, Zurich, Switzerland
- Department of Medicine, University of Basel, Basel, Switzerland
| | - Simone Schrading
- Department of Radiology and Nuclear Medicine, Kantonsspital Lucerne, Lucerne, Switzerland
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10
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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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11
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Tari DU, De Lucia DR, Santarsiere M, Santonastaso R, Pinto F. Practical Challenges of DBT-Guided VABB: Harms and Benefits, from Literature to Clinical Experience. Cancers (Basel) 2023; 15:5720. [PMID: 38136264 PMCID: PMC10742222 DOI: 10.3390/cancers15245720] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 11/25/2023] [Accepted: 12/04/2023] [Indexed: 12/24/2023] Open
Abstract
Vacuum-assisted breast biopsy (VABB) guided by digital breast tomosynthesis (DBT) represents one of the best instruments to obtain a histological diagnosis of suspicious lesions with no ultrasound correlation or those which are visible only on DBT. After a review of the literature, we retrospectively analyzed the DBT-guided VABBs performed from 2019 to 2022 at our department. Descriptive statistics, Pearson's correlation and χ2 test were used to compare distributions of age, breast density (BD) and early performance measures including histopathology. We used kappa statistics to evaluate the agreement between histological assessment and diagnosis. Finally, we compared our experience to the literature to provide indications for clinical practice. We included 85 women aged 41-84 years old. We identified 37 breast cancers (BC), 26 stage 0 and 11 stage IA. 67.5% of BC was diagnosed in women with high BD. The agreement between VABB and surgery was 0.92 (k value, 95% CI: 0.76-1.08). We found a statistically significant inverse correlation between age and BD. The post-procedural clip was correctly positioned in 88.2%. The post-procedural hematoma rate was 14.1%. No infection or hemorrhage were recorded. When executed correctly, DBT-guided VABB represents a safe and minimally invasive technique with high histopathological concordance, for detecting nonpalpable lesions without ultrasound correlation.
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Affiliation(s)
- Daniele Ugo Tari
- Department of Breast Imaging, Caserta Local Health Authority, District 12 “Palazzo della Salute”, 81100 Caserta, Italy; (D.R.D.L.); (M.S.)
| | - Davide Raffaele De Lucia
- Department of Breast Imaging, Caserta Local Health Authority, District 12 “Palazzo della Salute”, 81100 Caserta, Italy; (D.R.D.L.); (M.S.)
| | - Marika Santarsiere
- Department of Breast Imaging, Caserta Local Health Authority, District 12 “Palazzo della Salute”, 81100 Caserta, Italy; (D.R.D.L.); (M.S.)
| | | | - Fabio Pinto
- Department of Radiology, “A. Guerriero” Hospital, Caserta Local Health Authority, 81025 Marcianise, Italy;
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12
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McLachlan C, Jackson M, Valencia A. Evaluating the use of vacuum-assisted excisions in the management of B3 breast lesions. Br J Radiol 2023; 96:20230528. [PMID: 37750833 PMCID: PMC10607415 DOI: 10.1259/bjr.20230528] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 07/25/2023] [Accepted: 07/26/2023] [Indexed: 09/27/2023] Open
Abstract
OBJECTIVE To evaluate the use of vacuum-assisted excisions (VAEs) in the management of B3 lesions within a single UK breast care centre. Assessment was made by determining the upgrade rates of the different B3 lesions at VAE. METHODS AND MATERIALS The study population comprised all patients who had a B3 result and subsequently underwent a VAE between November 2016 and October 2021. Patients with ipsilateral cancers were excluded. Retrospective biopsy and VAE results were reviewed. Upgrade rates and confidence intervals were calculated, and statistical significance was tested to determine any differences between upgrade rates of the B3 groups. RESULTS 480 VAEs for B3 lesions were performed, with 10 excluded. Overall upgrade rate was 5%. 87.5% of upgrades were to non-invasive disease. Atypical intraductal epithelial proliferation (AIDEP) had a 15% upgrade rate, significantly different to lobular neoplasia (2%), papilloma without atypia (0%), and radial scar without atypia (0%). 10% of B3 lesions with atypia were upgraded, significantly different to 0% of B3 lesions without atypia. B3 lesions diagnosed by vacuum-assisted biopsy (VAB) had a significantly higher upgrade rate of 8% compared with 2% for lesions diagnosed by core biopsy (CBX), although this result was impacted by high numbers of AIDEP diagnosed by VAB. CONCLUSIONS The results suggest using VAE for the management of AIDEP is appropriate. However, they also indicate that by performing VAEs of papillomas and radial scars without atypia, overtreatment may be occurring. ADVANCES IN KNOWLEDGE This study adds to the ongoing discussion on the best treatment of B3 breast lesions.
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Affiliation(s)
- Clare McLachlan
- Bristol Breast Care Centre, North Bristol NHS Trust, Beaufort House, Southmead Hospital, Westbury-on-Trym, Bristol, United Kingdom
| | - Marcus Jackson
- Diagnostic Radiography Section, Centre for Allied Health, St George’s University of London, London, United Kingdom
| | - Alexandra Valencia
- Bristol Breast Care Centre, North Bristol NHS Trust, Bristol, United Kingdom
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13
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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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14
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Harper LK, Carnahan MB, Bhatt AA, Simmons CL, Patel BK, Downs E, Pockaj BA, Yancey K, Eversman SE, Sharpe RE. Imaging Characteristics of and Multidisciplinary Management Considerations for Atypical Ductal Hyperplasia and Flat Epithelial Atypia: Review of Current Literature. Radiographics 2023; 43:e230016. [PMID: 37768862 DOI: 10.1148/rg.230016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/30/2023]
Abstract
High-risk lesions of the breast are frequently encountered in percutaneous biopsy specimens. While benign, these lesions have historically undergone surgical excision due to their potential to be upgraded to malignancy. However, there is emerging evidence that a tailored management approach should be considered to reduce overtreatment of these lesions. Flat epithelial atypia (FEA) and atypical ductal hyperplasia (ADH) are two of the most commonly encountered high-risk lesions. FEA has been shown to have a relatively low rate of progression to malignancy, and some guidelines are now recommending observation over routine excision in select cases. Selective observation may be reasonable in cases where the target lesion is small and completely removed at biopsy and when there are no underlying risk factors, such as a history of breast cancer or genetic mutation or concurrent ADH. ADH has the highest potential upgrade rate to malignancy of all the high-risk lesions. Most society guidelines continue to recommend surgical excision of this lesion. More recently, some literature suggests that ADH lesions that appear completely removed at biopsy, involve limited foci (less than two or three) with no necrosis or significant atypia, manifest as a small group of mammographic calcifications, or demonstrate no enhancement at MRI may be reasonable for observation. Ultimately, management of all high-risk lesions must be based on a multidisciplinary approach that considers all patient, radiologic, clinical, and histopathologic factors. ©RSNA, 2023 Quiz questions for this article are available in the supplemental material.
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Affiliation(s)
- Laura K Harper
- From the Departments of Radiology (L.K.H., M.B.C., B.K.P., K.Y., S.E.E., R.E.S.), Pathology (E.D.), and Surgery (B.A.P.), Mayo Clinic, 5777 E Mayo Blvd, Phoenix, AZ 85054; Department of Radiology, Mayo Clinic, Rochester, Minn (A.A.B.); and Department of Radiology, Phoenix Children's Hospital, Phoenix, Ariz (C.L.S.)
| | - Molly B Carnahan
- From the Departments of Radiology (L.K.H., M.B.C., B.K.P., K.Y., S.E.E., R.E.S.), Pathology (E.D.), and Surgery (B.A.P.), Mayo Clinic, 5777 E Mayo Blvd, Phoenix, AZ 85054; Department of Radiology, Mayo Clinic, Rochester, Minn (A.A.B.); and Department of Radiology, Phoenix Children's Hospital, Phoenix, Ariz (C.L.S.)
| | - Asha A Bhatt
- From the Departments of Radiology (L.K.H., M.B.C., B.K.P., K.Y., S.E.E., R.E.S.), Pathology (E.D.), and Surgery (B.A.P.), Mayo Clinic, 5777 E Mayo Blvd, Phoenix, AZ 85054; Department of Radiology, Mayo Clinic, Rochester, Minn (A.A.B.); and Department of Radiology, Phoenix Children's Hospital, Phoenix, Ariz (C.L.S.)
| | - Curtis L Simmons
- From the Departments of Radiology (L.K.H., M.B.C., B.K.P., K.Y., S.E.E., R.E.S.), Pathology (E.D.), and Surgery (B.A.P.), Mayo Clinic, 5777 E Mayo Blvd, Phoenix, AZ 85054; Department of Radiology, Mayo Clinic, Rochester, Minn (A.A.B.); and Department of Radiology, Phoenix Children's Hospital, Phoenix, Ariz (C.L.S.)
| | - Bhavika K Patel
- From the Departments of Radiology (L.K.H., M.B.C., B.K.P., K.Y., S.E.E., R.E.S.), Pathology (E.D.), and Surgery (B.A.P.), Mayo Clinic, 5777 E Mayo Blvd, Phoenix, AZ 85054; Department of Radiology, Mayo Clinic, Rochester, Minn (A.A.B.); and Department of Radiology, Phoenix Children's Hospital, Phoenix, Ariz (C.L.S.)
| | - Erinn Downs
- From the Departments of Radiology (L.K.H., M.B.C., B.K.P., K.Y., S.E.E., R.E.S.), Pathology (E.D.), and Surgery (B.A.P.), Mayo Clinic, 5777 E Mayo Blvd, Phoenix, AZ 85054; Department of Radiology, Mayo Clinic, Rochester, Minn (A.A.B.); and Department of Radiology, Phoenix Children's Hospital, Phoenix, Ariz (C.L.S.)
| | - Barbara A Pockaj
- From the Departments of Radiology (L.K.H., M.B.C., B.K.P., K.Y., S.E.E., R.E.S.), Pathology (E.D.), and Surgery (B.A.P.), Mayo Clinic, 5777 E Mayo Blvd, Phoenix, AZ 85054; Department of Radiology, Mayo Clinic, Rochester, Minn (A.A.B.); and Department of Radiology, Phoenix Children's Hospital, Phoenix, Ariz (C.L.S.)
| | - Kristina Yancey
- From the Departments of Radiology (L.K.H., M.B.C., B.K.P., K.Y., S.E.E., R.E.S.), Pathology (E.D.), and Surgery (B.A.P.), Mayo Clinic, 5777 E Mayo Blvd, Phoenix, AZ 85054; Department of Radiology, Mayo Clinic, Rochester, Minn (A.A.B.); and Department of Radiology, Phoenix Children's Hospital, Phoenix, Ariz (C.L.S.)
| | - Sarah E Eversman
- From the Departments of Radiology (L.K.H., M.B.C., B.K.P., K.Y., S.E.E., R.E.S.), Pathology (E.D.), and Surgery (B.A.P.), Mayo Clinic, 5777 E Mayo Blvd, Phoenix, AZ 85054; Department of Radiology, Mayo Clinic, Rochester, Minn (A.A.B.); and Department of Radiology, Phoenix Children's Hospital, Phoenix, Ariz (C.L.S.)
| | - Richard E Sharpe
- From the Departments of Radiology (L.K.H., M.B.C., B.K.P., K.Y., S.E.E., R.E.S.), Pathology (E.D.), and Surgery (B.A.P.), Mayo Clinic, 5777 E Mayo Blvd, Phoenix, AZ 85054; Department of Radiology, Mayo Clinic, Rochester, Minn (A.A.B.); and Department of Radiology, Phoenix Children's Hospital, Phoenix, Ariz (C.L.S.)
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15
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van de Voort EMF, Struik GM, Birnie E, Sinke RHJA, Verver D, van Streun SP, Macco M, Verhoef C, Klem TMAL. Implementation of vacuum-assisted excision as a management option for benign and high-risk breast lesions. Br J Radiol 2023; 96:20220776. [PMID: 37171394 PMCID: PMC10321268 DOI: 10.1259/bjr.20220776] [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: 08/15/2022] [Revised: 02/02/2023] [Accepted: 03/14/2023] [Indexed: 05/13/2023] Open
Abstract
OBJECTIVE Previous studies have shown that vacuum-assisted excision (VAE) is a safe and effective alternative for surgical excision (SE) of benign breast lesions. However, the use of VAE in high-risk lesions is controversial and guidelines are ambiguous. This study describes the impact of the implementation of VAE in terms of management and outcomes compared to a cohort before implementation. METHODS A single centre retrospective study with two cohorts: 'before' and 'after' implementation of VAE was performed. All patients with a benign or high-risk lesion treated by VAE or SE between 2016 and 2019 were included. Excision, complication, and upgrade rates were compared between both cohorts. Cox regression was used for the evaluation of recurrences and re-excisions. RESULTS The overall excision rate of all benign and high-risk lesions was comparable in both cohorts (17% vs 16%, p = 0.700). After implementation, benign lesions were significantly more often managed by VAE (101/151, 67%, p < 0.001). Re-excision, recurrence, and complication rates were low and comparable between cohorts (4.3% vs 3.9%, p > 0.999; 3.0 vs 2.0%, p = 0.683; 3.4 vs 6.6%, p = 0.289, respectively). CONCLUSION SE could safely be replaced by VAE in 58% of patients treated for a benign or high-risk lesion. With this shift in management, the use of operating rooms and general anaesthesia can safely be omitted in this patient group. Further research on high-risk lesions is warranted since our data are exploratory. ADVANCES IN KNOWLEDGE This study provides supportive data for the use of VAE as a management option for both benign (up to 5 cm) and high-risk lesions. Outcomes on re-excision, recurrence should be confirmed in prospective studies especially in high-risk lesions.
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Affiliation(s)
| | | | | | - Renata HJA Sinke
- Department of Pathology, Franciscus Gasthuis & Vlietland, Kleiweg, Rotterdam, Netherlands
| | | | | | - Maura Macco
- Department of Radiology, Franciscus Gasthuis & Vlietland, Kleiweg, Rotterdam, Netherlands
| | - C. Verhoef
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Doctor Molewaterplein, Rotterdam, Netherlands
| | - Taco MAL Klem
- Department of Surgery, Franciscus Gasthuis, Rotterdam, Netherlands
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16
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Miranda BMM, Bitencourt AGV. Vacuum-assisted excision of breast lesions in surgical de-escalation: where are we? Radiol Bras 2023; 56:150-156. [PMID: 37564079 PMCID: PMC10411769 DOI: 10.1590/0100-3984.2022.0078-en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 09/27/2022] [Indexed: 08/12/2023] Open
Abstract
Vacuum-assisted excision of breast lesions has come to be widely used in clinical practice. Increased acceptance and availability of the procedure, together with the use of larger needles, has allowed the removal of a greater amount of sample, substantially reducing the surgical upgrade rate and thus increasing the reliability of the results of the procedure. These characteristics result in the potential for surgical de-escalation in selected cases and gain strength in a scenario in which the aim is to reduce costs, as well as the rates of underestimation and overtreatment, without compromising the quality of patient care. The objective of this article is to review the technical parameters and current clinical indications for performing vacuum-assisted excision of breast lesions.
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Affiliation(s)
- Beatriz Medicis Maranhão Miranda
- Breast Center, Instituto de Medicina Integral Prof. Fernando
Figueira - IMIP, Recife, PE. Brazil
- Lucilo Maranhão Diagnósticos, Recife, PE, Brazil
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Bicchierai G, Pugliese F, Amato F, De Benedetto D, Boeri C, Vanzi E, Di Naro F, Bianchi S, Cossu E, Miele V, Nori J. Percutaneous vacuum-assisted excision (VAE) of breast lesions of uncertain malignant potential (B3 lesions): a preliminary single-centre Italian experience. LA RADIOLOGIA MEDICA 2023; 128:528-536. [PMID: 37029852 DOI: 10.1007/s11547-023-01626-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 03/27/2023] [Indexed: 04/09/2023]
Abstract
PURPOSE In recent years vacuum-assisted excision (VAE) has been described as an alternative treatment for some B3 lesions. This study aims to assess the effectiveness of using VAE to manage selected B3 lesions by quantifying the number of B3 lesions undergoing VAE, the malignant upgrade rate, and the complications encountered. MATERIALS AND METHODS Our department evaluated all B3 lesions diagnosed between January 2019 and October 2021 and treated them with VAE. The data were collected during the initial biopsy and final histology based on VAE image guidance, also considering initial lesions and complications. The exclusion criteria were: B3 lesion of size > 20 mm, presence of a concomitant malignant lesion, lesion < 5.0 mm distant from the skin, nipple or pectoral muscle, phyllodes tumours or indeterminate B3 lesions. Lesions that upgraded to malignancy underwent surgical excision, while benign lesions performed radiological follow-ups. RESULTS From 416 B3 lesions diagnosed, 67 (16.1%) underwent VAE. VAE was performed under X-ray (50/67) or ultrasound guidance (17/67). Five cases (7.5%) upgraded to a malignant lesion, 2 ADH, 2 LIN and one papillary lesion that underwent surgery. No malignancy or new lesions has occurred at the site of the VAE, with an average radiological follow-up of 14.9 months. CONCLUSIONS VAE could be a safe and effective pathway for managing selected B3 lesions. Lesions initially subjected to CNB with ADH and LN outcome, before undergoing VAE, should perform a VAB for better tissue characterization and management.
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Affiliation(s)
- Giulia Bicchierai
- Diagnostic Senology Unit, Azienda Ospedaliero-Universitaria Careggi, Largo G. A. Brambilla 3, 50134, FlorenceFlorence, Italy.
| | - Francesca Pugliese
- Diagnostic Senology Unit, Azienda Ospedaliero-Universitaria Careggi, Largo G. A. Brambilla 3, 50134, FlorenceFlorence, Italy
| | - Francesco Amato
- Radiology Department, Ospedale San Giovanni di Dio, Agrigento, Italy
| | - Diego De Benedetto
- Diagnostic Senology Unit, Azienda Ospedaliero-Universitaria Careggi, Largo G. A. Brambilla 3, 50134, FlorenceFlorence, Italy
| | - Cecilia Boeri
- Diagnostic Senology Unit, Azienda Ospedaliero-Universitaria Careggi, Largo G. A. Brambilla 3, 50134, FlorenceFlorence, Italy
| | - Ermanno Vanzi
- Diagnostic Senology Unit, Azienda Ospedaliero-Universitaria Careggi, Largo G. A. Brambilla 3, 50134, FlorenceFlorence, Italy
| | - Federica Di Naro
- Diagnostic Senology Unit, Azienda Ospedaliero-Universitaria Careggi, Largo G. A. Brambilla 3, 50134, FlorenceFlorence, Italy
| | - Simonetta Bianchi
- Division of Pathological Anatomy, University of Florence, Florence, Italy
| | - Elsa Cossu
- Diagnostic and Interventional Imaging, University Hospital Policlinico Tor Vergata, Rome, Italy
| | - Vittorio Miele
- Emergency Radiology Department, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Jacopo Nori
- Diagnostic Senology Unit, Azienda Ospedaliero-Universitaria Careggi, Largo G. A. Brambilla 3, 50134, FlorenceFlorence, Italy
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Tu S, Yin Y, Yuan C, Chen H. Management of Intraductal Papilloma of the Breast Diagnosed on Core Needle Biopsy: Latest Controversies. PHENOMICS (CHAM, SWITZERLAND) 2023; 3:190-203. [PMID: 37197642 PMCID: PMC10110831 DOI: 10.1007/s43657-022-00085-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 11/12/2022] [Accepted: 11/15/2022] [Indexed: 05/19/2023]
Abstract
Intraductal papillomas (IDPs), including central papilloma and peripheral papilloma, are common in the female population. Due to the lack of specific clinical manifestations of IDPs, it is easy to misdiagnose or miss diagnose. The difficulty of differential diagnosis using imaging techniques also contributes to these conditions. Histopathology is the gold standard for the diagnosis of IDPs while the possibility of under sample exists in the percutaneous biopsy. There have been some debates about how to treat asymptomatic IDPs without atypia diagnosed on core needle biopsy (CNB), especially when the upgrade rate to carcinoma is considered. This article concludes that further surgery is recommended for IDPs without atypia diagnosed on CNB who have high-risk factors, while appropriate imaging follow-up may be suitable for those without risk factors.
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Affiliation(s)
- Siyuan Tu
- Department of Breast Surgery, Longhua Hospital, Shanghai University of Traditional Chinese Medicine, 725 South Wanping Road, Shanghai, 200030 China
| | - Yulian Yin
- Department of Breast Surgery, Longhua Hospital, Shanghai University of Traditional Chinese Medicine, 725 South Wanping Road, Shanghai, 200030 China
| | - Chunchun Yuan
- Spine Institute, Longhua Hospital, Shanghai University of Traditional Chinese Medicine, 725 South Wanping Road, Shanghai, 200030 China
| | - Hongfeng Chen
- Department of Breast Surgery, Longhua Hospital, Shanghai University of Traditional Chinese Medicine, 725 South Wanping Road, Shanghai, 200030 China
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Willers N, Neven P, Floris G, Colpaert C, Oldenburger E, Han S, Van Ongeval C, Smeets A, Duhoux FP, Wildiers H, Denolf P, Laudus N, Dequeker E, De Brabander I, Van Damme N, De Schutter H. The Upgrade Risk of B3 Lesions to (Pre)Invasive Breast Cancer After Diagnosis on Core Needle or Vacuum Assisted Biopsy. A Belgian National Cohort Study. Clin Breast Cancer 2023; 23:e273-e280. [PMID: 37085379 DOI: 10.1016/j.clbc.2023.03.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 03/15/2023] [Accepted: 03/16/2023] [Indexed: 04/23/2023]
Abstract
INTRODUCTION Flat epithelial atypia (FEA), lobular neoplasia (LN), papillary lesions (PL), radial scar (RS) and atypical ductal hyperplasia (ADH) are lesions of uncertain malignant potential and classified as B3 lesions by the European guidelines for quality assurance in breast cancer screening and diagnosis. Current management is usually wide local excision (WE), surveillance may be sufficient for some. We investigated the upgrade rate of B3 lesions to breast malignancy in a subsequent resection specimen after diagnosis on core needle-or vacuum assisted biopsy (CNB-VAB) in a national population-based series. METHODS Using data from the Belgian Cancer Registry (BCR) between January 1, 2013 and December 31, 2016, inclusion criteria were new diagnosis of a B3 lesion on CNB or VAB with subsequent histological assessment on a wider excision specimen. Histological agreement between first- and follow-up investigation was analyzed to determine the upgrade risk to ductal adenocarcinoma in situ (DCIS) or invasive breast cancer (IC) according to the type of B3 lesion. RESULTS Of 1855 diagnosed B3 lesions, 812 were included in this study: 551 after CNB-261 after VAB. After diagnosis on CNB and VAB, we found 19.0% and 14.9% upgrade to malignancy respectively. Upgrade risks after CNB and VAB were: FEA 39.5% and 17.6%; LN 40.5% and 4.3%; PL 10.4% and 12.5%; RS 25.7%and 0.0%; ADH 29.5% and 20.0%. CONCLUSION Based on the observed upgrade rate we propose three recommendations: first, resection of ADH, and FEA with WE; second, resection of RS and classical LN with therapeutic VAB and further surveillance when radio-pathological correlation is concordant; third, surveillance of PL.
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Affiliation(s)
- Nynke Willers
- Department of Oncology, KU Leuven - University of Leuven, Leuven, Belgium; Department of Senology, AZ Sint Blasius, Dendermonde, Belgium.
| | - Patrick Neven
- Department of Oncology, KU Leuven - University of Leuven, Leuven, Belgium; Department of Gynecological Oncology, University Hospitals Leuven, Leuven, Belgium
| | - Giuseppe Floris
- Department of Imaging and Pathology, Laboratory of Translational Cell & Tissue Research, KU Leuven - University of Leuven, Leuven, Belgium; Department of Pathology, University Hospitals Leuven, Leuven, Belgium
| | - Cecile Colpaert
- Department of Pathology, University Hospitals Leuven, Leuven, Belgium; Research Department, Belgian Cancer Registry, Brussels, Belgium
| | - Eva Oldenburger
- Department of Oncology, KU Leuven - University of Leuven, Leuven, Belgium; Department of Radiation Oncology, University Hospitals Leuven, Leuven, Belgium
| | - Sileny Han
- Department of Oncology, KU Leuven - University of Leuven, Leuven, Belgium; Department of Gynecological Oncology, University Hospitals Leuven, Leuven, Belgium
| | - Chantal Van Ongeval
- Department of Oncology, KU Leuven - University of Leuven, Leuven, Belgium; Department of Radiology, University Hospitals Leuven, Leuven, Belgium
| | - Ann Smeets
- Department of Oncology, KU Leuven - University of Leuven, Leuven, Belgium; Department of Surgical Oncology, University Hospitals Leuven, Leuven, Belgium
| | - Francois P Duhoux
- Institut de Recherche Expérimentale et Clinique, Université catholique de Louvain, and Breast Clinic, King Albert II Cancer Institute, Cliniques universitaires Saint-Luc, Brussels, Belgium
| | - Hans Wildiers
- Department of Oncology, KU Leuven - University of Leuven, Leuven, Belgium; Department of Oncology, University Hospitals Leuven, Leuven, Belgium
| | - Petra Denolf
- Research Department, Belgian Cancer Registry, Brussels, Belgium
| | - Nele Laudus
- Department of Biomedical Quality Assurance, KU Leuven-University of Leuven, Belgium
| | - Els Dequeker
- Department of Biomedical Quality Assurance, KU Leuven-University of Leuven, Belgium
| | | | - Nancy Van Damme
- Research Department, Belgian Cancer Registry, Brussels, Belgium
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van de Voort EMF, Struik GM, van Streun SP, Verhoef C, Uyl-de Groot CA, Klem TMAL. Hospital costs and cosmetic outcome of benign and high-risk breast lesions managed by vacuum-assisted excision versus surgical excision. Br J Radiol 2022; 95:20220117. [PMID: 35604725 PMCID: PMC10162056 DOI: 10.1259/bjr.20220117] [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: 01/26/2022] [Revised: 03/14/2022] [Accepted: 03/24/2022] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVES Although vacuum-assisted excision (VAE) is a safe and effective alternative to surgical excision (SE), the latter is most commonly used for the management of benign and high-risk breast lesions. To evaluate the healthcare benefit of VAE, hospital costs and cosmetic outcome after VAE were compared to SE. Additionally, the impact of VAE implementation on hospital costs was investigated. METHODS This was a single-centre retrospective cohort study with two cohorts: "VAE" and "SE". All patients with a benign or high-risk lesion excised by VAE or SE from January 2016 up to December 2019 were included. Cosmetic outcome was measured with the BCTOS-cosmetic subscale, and hospital costs were presented as mean (SD) and median (IQR). RESULTS During the study period, 258 patients with 295 excised lesions were included. The initial procedure was VAE in 102 patients and SE in 156 patients. Hospital costs after (median € 2324) were significantly lower than before (median € 3,144) implementation of VAE (mean difference € 1,004, p < 0.001), most likely attributable to the lower costs for patients treated with VAE (mean difference € 1,979, p < 0.001). Mean cosmetic outcome was comparable between VAE (median 1.35) and SE (median 1.44, p = 0.802). CONCLUSIONS Implementing VAE as an alternative treatment option for benign and high-risk breast lesions resulted in a large decrease in hospital costs but a cosmetic benefit of VAE could not be demonstrated in this retrospective study. ADVANCES IN KNOWLEDGE Costs associated with the complete patient pathway were included and not only VAE was compared to SE but also the before cohort was compared to the after cohort to demonstrate the benefit of VAE implementation in clinical practice. Additionally, cosmetic outcome was compared between VAE and SE using patient reported outcome measures.
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Affiliation(s)
| | | | - Sophia P van Streun
- Department of Surgery, Franciscus Gasthuis & Vlietland, Rotterdam, the Netherlands
| | - Cornelis Verhoef
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | | | - Taco MAL Klem
- Department of Surgery, Franciscus Gasthuis & Vlietland, Rotterdam, the Netherlands
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Liu C, Liu S, Zhao L, Zheng W, Wang K, Tian Y, Gui Z, Zhang L. Intraductal papillary carcinoma of breast with invasion: A nomogram and survival from the analysis of the SEER database. Cancer Med 2022; 12:1305-1318. [PMID: 35837839 PMCID: PMC9883418 DOI: 10.1002/cam4.5007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 05/10/2022] [Accepted: 06/24/2022] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Intraductal papillary carcinoma (IPC) with invasion is a rare type of breast cancer. There have been few studies on its prognosis, and a nomogram that predicts the prognosis of the disease has not been described to date. METHODS Patients who were diagnosed with invasive IPC were screened from the Surveillance, Epidemiology, and End Results (SEER) database. The screened patients were randomly divided into a training cohort and a verification cohort at 7:3. A Cox proportional hazard regression model was performed to analyze the effects of different variables on the risk of death in invasive IPC. A nomogram was constructed to quantify the possibility of death. The concordance index (C-index), calibration plots, receiver operating characteristic (ROC) curves, and decision curves analysis (DCA) were used to verify the proposed model. RESULTS We included a total of 803 patients diagnosed with invasive IPC, including 563 patients in the training cohort and 240 patients in the validation cohort. The median follow-up times in the training cohort and validation cohort were 63 months (range, 2-155 months) and 61 months (range, 1-154 months), respectively. For all patients, the probability of death with invasive IPC was 1.4% within 5 years and 5.4% within 10 years. In multivariate analysis, sex, race, tumor size, lymph node status, type of treatment, and chemotherapy were related to the prognosis of invasive IPC. We constructed a nomogram to predict the possibility of death in patients with invasive IPC. CONCLUSION Patients with invasive IPC had a high survival rate. The proven nomogram was helpful to both patients and clinical decision makers.
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Affiliation(s)
- Chenguang Liu
- Department of Thyroid and Breast SurgeryTongji Hospital of Tongji Medical College of Huazhong University of Science and TechnologyWuhanChina
| | - Shiyang Liu
- Department of Thyroid and Breast SurgeryTongji Hospital of Tongji Medical College of Huazhong University of Science and TechnologyWuhanChina
| | - Lu Zhao
- Department of Thyroid and Breast SurgeryTongji Hospital of Tongji Medical College of Huazhong University of Science and TechnologyWuhanChina
| | - Weihong Zheng
- Department of Thyroid and Breast SurgeryTongji Hospital of Tongji Medical College of Huazhong University of Science and TechnologyWuhanChina
| | - Kun Wang
- Department of Thyroid and Breast SurgeryTongji Hospital of Tongji Medical College of Huazhong University of Science and TechnologyWuhanChina
| | - Yao Tian
- Department of Thyroid and Breast SurgeryTongji Hospital of Tongji Medical College of Huazhong University of Science and TechnologyWuhanChina
| | - Zhengwei Gui
- Department of Thyroid and Breast SurgeryTongji Hospital of Tongji Medical College of Huazhong University of Science and TechnologyWuhanChina
| | - Lin Zhang
- Department of Thyroid and Breast SurgeryTongji Hospital of Tongji Medical College of Huazhong University of Science and TechnologyWuhanChina
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Forrai G, Kovács E, Ambrózay É, Barta M, Borbély K, Lengyel Z, Ormándi K, Péntek Z, Tünde T, Sebő É. Use of Diagnostic Imaging Modalities in Modern Screening, Diagnostics and Management of Breast Tumours 1st Central-Eastern European Professional Consensus Statement on Breast Cancer. Pathol Oncol Res 2022; 28:1610382. [PMID: 35755417 PMCID: PMC9214693 DOI: 10.3389/pore.2022.1610382] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Accepted: 04/29/2022] [Indexed: 12/11/2022]
Abstract
Breast radiologists and nuclear medicine specialists updated their previous recommendation/guidance at the 4th Hungarian Breast Cancer Consensus Conference in Kecskemét. A recommendation is hereby made that breast tumours should be screened, diagnosed and treated according to these guidelines. These professional guidelines include the latest technical developments and research findings, including the role of imaging methods in therapy and follow-up. It includes details on domestic development proposals and also addresses related areas (forensic medicine, media, regulations, reimbursement). The entire material has been agreed with the related medical disciplines.
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Affiliation(s)
- Gábor Forrai
- GÉ-RAD Kft., Budapest, Hungary
- Duna Medical Center, Budapest, Hungary
| | - Eszter Kovács
- GÉ-RAD Kft., Budapest, Hungary
- Duna Medical Center, Budapest, Hungary
| | | | | | - Katalin Borbély
- National Institute of Oncology, Budapest, Hungary
- Ministry of Human Capacities, Budapest, Hungary
| | | | | | | | - Tasnádi Tünde
- Dr Réthy Pál Member Hospital of Békés County Central Hospital, Békéscsaba, Hungary
| | - Éva Sebő
- Kenézy Gyula University Hospital, University of Debrecen, Debrecen, Hungary
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Hennessy G, Boland M, Bambrick M, Crone L, Lloyd A, Abdelwahab S, Downey E, Staunton M, Hambly N, Mhuircheartaigh NN, Kerr J, Power C, Duke D, Hill ADK. Value of long-term follow-up in surgically excised lesions of uncertain malignant potential in the breast – Is 5 years necessary? Clin Breast Cancer 2022; 22:699-704. [DOI: 10.1016/j.clbc.2022.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 04/30/2022] [Accepted: 05/29/2022] [Indexed: 11/29/2022]
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Mohrmann S, Maier-Bode A, Dietzel F, Reinecke P, Krawczyk N, Kaleta T, Kreimer U, Antoch G, Fehm TN, Roth KS. Malignancy Rate and Malignancy Risk Assessment in Different Lesions of Uncertain Malignant Potential in the Breast (B3 Lesions): An Analysis of 192 Cases from a Single Institution. Breast Care (Basel) 2022; 17:159-165. [PMID: 35702494 PMCID: PMC9149469 DOI: 10.1159/000517109] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Accepted: 05/02/2021] [Indexed: 02/26/2024] Open
Abstract
BACKGROUND The question of how to deal with B3 lesions is of emerging interest. METHODS In the breast diagnostics of 192 patients between 2009 and 2016, a minimally invasive biopsy revealed a B3 lesion with subsequent resection. This study investigates the malignancy rate of different B3 subgroups and the risk factors that play a role in obtaining a malignant finding. RESULTS The distribution of B3 lesions after minimally invasive biopsy was as follows: atypical ductal hyperplasia (ADH), 7.3%; flat epithelial atypia (FEA), 7.8%; lobular neoplasia (LN), 7.8%; papilloma (Pa), 49.5%; phylloidal tumour (PT), 8.9%; radial sclerosing scar (RS), 3.1%; mixed findings, 10.4%; and other B3 lesions, 5.2%. Most B3 lesions were detected by stereotactic vacuum-assisted biopsy (44.3%), 36.5% by ultrasound-assisted biopsy, and 19.3% by magnetic resonance imaging-assisted biopsy. Most B3 lesions (55.2%) were verified by surgical resection, whereas 30.7% were downgraded to a benign lesion. About 14.1% of the cases were upgraded to malignant lesions, 9.4% to ductal carcinoma in situ and 4.7% to invasive carcinoma. In relation to individual B3 lesions, the following malignancy rates were found: 28.6% (ADH), 13.3% (FEA), 33.3% (LN), 12.6% (Pa), 5.9% (PT), and 0% (RS). The most important risk factor was increasing age. Postmenopausal status was considered an increased risk for an upgrade (p = 0.015). A known malignancy in the ipsilateral breast was a significant risk factor for a malignant upgrade (p = 0.003). CONCLUSION Increasing knowledge about B3 lesions allows us to develop a "lesion-specific" therapy approach in the heterogeneous group of B3 lesions, with follow-up imaging for some lesions with less malignant potential and concordance with imaging or further surgical resection in cases of disconcordance with imaging or higher malignant potential.
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Affiliation(s)
- Svjetlana Mohrmann
- Department of Gynecology and Obstetrics, Medical Faculty, Interdisciplinary Breast Centre, University of Düsseldorf, Düsseldorf, Germany
| | - Anna Maier-Bode
- Department of Gynecology and Obstetrics, Medical Faculty, Interdisciplinary Breast Centre, University of Düsseldorf, Düsseldorf, Germany
| | - Frederic Dietzel
- Department of Diagnostic and Interventional Radiology, Medical Faculty, University of Düsseldorf, Düsseldorf, Germany
| | - Petra Reinecke
- Institute of Pathology, Medical Faculty, University of Düsseldorf, Düsseldorf, Germany
| | - Natalia Krawczyk
- Department of Gynecology and Obstetrics, Medical Faculty, Interdisciplinary Breast Centre, University of Düsseldorf, Düsseldorf, Germany
| | - Thomas Kaleta
- Department of Gynecology and Obstetrics, Medical Faculty, Interdisciplinary Breast Centre, University of Düsseldorf, Düsseldorf, Germany
| | - Ulrike Kreimer
- Department of Gynecology and Obstetrics, Medical Faculty, Interdisciplinary Breast Centre, University of Düsseldorf, Düsseldorf, Germany
| | - Gerald Antoch
- Department of Diagnostic and Interventional Radiology, Medical Faculty, University of Düsseldorf, Düsseldorf, Germany
| | - Tanja N. Fehm
- Department of Gynecology and Obstetrics, Medical Faculty, Interdisciplinary Breast Centre, University of Düsseldorf, Düsseldorf, Germany
| | - Katrin Sabine Roth
- Department of Diagnostic and Interventional Radiology, Medical Faculty, University of Düsseldorf, Düsseldorf, Germany
- ZRN Rheinland, Center for Radiology and Nuclear Medicine, Korschenbroich, Germany
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Cullinane C, Byrne J, Kelly L, O Sullivan M, Antony Corrigan M, Paul Redmond H. The positive predictive value of vacuum assisted biopsy (VAB) in predicting final histological diagnosis for breast lesions of uncertain malignancy (B3 lesions): A systematic review & meta-analysis. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2022; 48:1464-1474. [PMID: 35491362 DOI: 10.1016/j.ejso.2022.04.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 03/22/2022] [Accepted: 04/08/2022] [Indexed: 10/18/2022]
Abstract
INTRODUCTION High-risk or B3 breast lesions are considered lesions of uncertain malignant potential and comprise between 5 and 12% of initial biopsy results. We sought to perform a systematic review and meta-analysis of studies published within the last twenty years to determine the pooled Positive Predictive Value (PPV) of VAB in selected B3 lesions. METHODS The study report is based on the guidelines of PRISMA and Meta-Analysis of Observational Studies in Epidemiology. OUTCOMES The primary outcome of this study was to determine the PPV of VAB in determining final histological diagnosis in B3 breast lesions using pooled estimates. The secondary outcomes were to determine if needle gauge or the re-classification of Lobular Carcinoma in Situ(LCIS) introduced in 2012 influenced pooled estimates. RESULTS 78 studies incorporating 6,377 B3 lesions were included in this review, 1214 of which were upgraded to DCIS or invasive malignancy following surgical excision(19%). The pooled PPV of VAB in Atypical Ductal Hyperplasia(ADH) and Lobular Neoplasia(LN) were 0.79(CI 0.76-0.83) and 0.84(CI 0.8-0.88). VAB of Flat Epithelial Atypia(FEA), radial scar and papillary lesions with/without atypia all had a pooled PPV >90% (underestimation rates 7%, 1%, 5% and 3% respectively). Needle gauge size and the change in LCIS classification did not appear to influence underestimation rates on subgroup analysis. CONCLUSION Results from this meta-analysis suggests it is reasonable to perform VAB as definitive treatment for certain B3 lesions, specifically LN, FEA, radial scar, and papillary lesions when specific criteria are fulfilled. Surgical excision should continue as the mainstay of treatment for ADH.
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Jones VM, Pearce JB, Khalil M, Cain O, Coldren D, Martin H, Howard-McNatt M, Levine E, Chiba A. Upstage Rate of Complex Sclerosing Lesions/Radial Scars. Am Surg 2022; 88:964-967. [PMID: 35262438 DOI: 10.1177/00031348211056282] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Radial scars (RS) and complex sclerosing lesions (CSL) are breast radiologic findings described as small, stellate lesions causing architectural distortion. This can mimic malignancy. Core needle biopsy (CNB) is often performed. Advances in breast imaging have led to increased detection of RS/CSL. The upstage rate of RS/CSL to in situ or invasive disease is 0-40%. We sought to determine the upstaging rate of RS/CSL to in situ, invasive disease, or high-risk lesion at our institution to create excision guidelines. METHODS The pathology database of a single center was searched for RS/CSL, from January 2013 to September 2020. We included CNB without malignancy or high-risk lesion (eg, atypical ductal hyperplasia). Patient demographics, indications for biopsy, imaging findings, biopsy procedure, and final pathology were collected. RESULTS Forty-four patients were included. 52.3% had CNB for architectural distortion on mammography, 18.2% for mass, 11.4% for calcifications, 2.3% for abnormal MRI, and 15.9% for multiple reasons (eg, calcifications and mass). Most had an ultrasound: 43.2% had no abnormality and 34.1% had a mass. All CNB were vacuum assisted, 65.9% with 9-gauge needle, and averaged 10.0 cores. 77.3% were stereotactic biopsies, 13.6% ultrasound, and 6.8% MRI. 59.1% had excision after CNB. 82.1% of patients did not upstage. One patient upstaged to invasive ductal carcinoma (3.6%) and two patients to high-risk lesion (7.1%). DISCUSSION There was low upstage rate of RS/CSL on excisional biopsy. Centers could consider close surveillance for RS/CSL on CNB. Longer follow-up in cases of deferred excision is needed to ensure oncologic safety.
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Affiliation(s)
- Veronica M Jones
- Department of Surgery, 12279Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Jane B Pearce
- 12279Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Maryam Khalil
- 12279Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | | | - Daniel Coldren
- Department of Pathology, 12279Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Harrison Martin
- Department of Pathology, 12279Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Marissa Howard-McNatt
- Department of Surgery, 12279Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Edward Levine
- Department of Surgery, 12279Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Akiko Chiba
- Department of Surgery, 12279Wake Forest University School of Medicine, Winston-Salem, NC, USA
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El-Sheikh S, Rathbone M, Chaudhary K, Joshi A, Lee J, Muthukumar S, Mylona E, Roxanis I, Rees J. Rates and Outcomes of Breast Lesions of Uncertain Malignant Potential (B3) benchmarked against the National Breast Screening Pathology Audit; Improving Performance in a High Volume Screening Unit. Clin Breast Cancer 2022; 22:381-390. [DOI: 10.1016/j.clbc.2022.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 02/01/2022] [Accepted: 02/02/2022] [Indexed: 11/29/2022]
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Indeterminate (B3) Breast Lesions and the Ongoing Role of Diagnostic Open Biopsy. Int J Breast Cancer 2022; 2021:5555458. [PMID: 34987869 PMCID: PMC8723853 DOI: 10.1155/2021/5555458] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 12/01/2021] [Indexed: 12/02/2022] Open
Abstract
Introduction Due to their uncertain malignant potential, indeterminate breast lesions on core needle biopsy (CNB) require diagnostic open biopsy (DOB). This study evaluated DOB results given largely benign pathology. Lesions included are atypical papilloma, atypical ductal hyperplasia (ADH), atypical lobular hyperplasia (ALH), and radial scar/complex sclerosing lesions (RS/CSL). Methodology. A retrospective audit from 2010 to 2017 analysed patients with a screen-detected suspicious lesion and indeterminate (B3) CNB diagnosis. Primary outcome was the malignancy upgrade rate, with secondary evaluation of patient factors predictive of malignancy including age, symptoms, mammogram characteristics, lesion size, biopsy method, and past and family history. Results 152 patients (median age 57 years) were included, with atypical papillomas being the largest subgroup (44.7%). On DOB histology, 99.34% were benign, resulting in a 0.66% malignancy upgrade rate. Patient characteristic analysis identified 86.84% of B3 lesions were in patients greater than 50 years old. 90.13% were asymptomatic, whilst 98.68% and 72.37% had a negative past and family history. Majority 46.71% of lesions had the mammogram characteristic of being a mass. However, with 57.89% of the lesion imaging size less than 4 mm, a corresponding 60.5% of core needle biopsies were performed stereotactically. The small malignant subgroup limited predictive factor evaluation. Conclusion Albeit a low 0.66% malignancy upgrade rate in B3 lesions, no statistically significant patient predictive factors were identified. Until predictive factors and further assessment of vacuum-assisted excision (VAE) techniques evolve, DOB remains the standard of care.
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Brzuszkiewicz K, Hodorowicz-Zaniewska D, Miękisz J, Matyja A. Comparison of two minimally invasive biopsy techniques - Breast Lesion Excision System and vacuum-assisted biopsy - for diagnosing and treating breast lesions. Arch Med Sci 2022; 18:1453-1459. [PMID: 36457991 PMCID: PMC9710256 DOI: 10.5114/aoms.2019.85656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 05/07/2019] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION The vacuum-assisted biopsy (VAB) and the Breast Lesion Excision System (BLES) are minimally invasive biopsy techniques, both used as diagnostic and therapeutic tools. The aim of the study is to compare these two methods and assess them in the context of discomfort, early and late complications and their diagnostic and therapeutic potential. MATERIAL AND METHODS The study involved 173 patients who underwent a VAB or a BLES breast biopsy in the period between 2009 and 2016. Approximately 3 months after the biopsy, the patients completed a questionnaire in which they assessed the procedure for discomfort associated with the procedure and the final cosmetic outcome. The cosmetic effect of the biopsy was also assessed by a surgeon. RESULTS The BLES and the VAB breast biopsies did not differ in terms of pain, duration, and discomfort of the procedure, breast bruising, breast tenderness about 24 h after the procedure or pain lasting over 3 months after the biopsy. Subsequently, the biopsies were evaluated in terms of the cosmetic effect assessed by the patient and by a surgeon and no differences were observed. There were no significant differences between the VAB and the BLES breast biopsies in the course of the procedure, early and late complications and cosmetic effect. CONCLUSIONS Since the BLES breast biopsy makes it possible to evaluate the margins, it is a good alternative to the open breast biopsy.
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Affiliation(s)
- Karolina Brzuszkiewicz
- First Chair of General Surgery, Department of General, Oncological and Gastroenterological Surgery, Jagiellonian University Medical College, Krakow, Poland
| | - Diana Hodorowicz-Zaniewska
- First Chair of General Surgery, Department of General, Oncological and Gastroenterological Surgery, Jagiellonian University Medical College, Krakow, Poland
| | | | - Andrzej Matyja
- Second Chair of Endoscopic, Metabolic and Soft Tissue Cancer Surgery, Jagiellonian University Medical College, Krakow, Poland
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Park KW, Han BK, Rhee SJ, Cho SY, Ko EY, Ko ES, Choi JS. Atypical Ductal Hyperplasia: Risk Factors for Predicting Pathologic Upgrade on Excisional Biopsy. JOURNAL OF THE KOREAN SOCIETY OF RADIOLOGY 2022; 83:632-644. [PMID: 36238508 PMCID: PMC9514512 DOI: 10.3348/jksr.2021.0109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Revised: 07/28/2021] [Accepted: 08/16/2021] [Indexed: 11/20/2022]
Abstract
Purpose To determine the incidence of atypical ductal hyperplasia (ADH) in needle biopsy and the upgrade rate to carcinoma, and to evaluate difference in findings between the upgrade and non-upgrade groups. Materials and Methods Among 9660 needle biopsies performed over 48 months, we reviewed the radiologic and histopathologic findings of ADH and compared the differences in imaging findings (mammography and breast US) and biopsy methods between the upgrade and non-upgrade groups. Results The incidence of ADH was 1.7% (169/9660). Of 112 resected cases and 30 cases followed-up for over 2 years, 35 were upgraded to carcinoma (24.6%, 35/142). The upgrade rates were significantly different according to biopsy methods: US-guided core needle biopsy (US-CNB) (40.7%, 22/54) vs. stereotactic-vacuum-assisted biopsy (S-VAB) (16.0%, 12/75) vs. US-guided VAB (US-VAB) (7.7%, 1/13) (p = 0.002). Multivariable analysis showed that only US-CNB (odds ratio = 5.19, 95% confidence interval: 2.16–13.95, p < 0.001) was an independent predictor for pathologic upgrade. There was no upgrade when a sonographic mass was biopsied by US-VAB (n = 7) Conclusion The incidence of ADH was relatively low (1.7%) and the upgrade rate was 24.6%. Surgical excision should be considered because of the considerable upgrade rate, except in the case of US-VAB.
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Affiliation(s)
- Ko Woon Park
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Boo-Kyung Han
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sun Jung Rhee
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Soo Youn Cho
- Department of Pathology and Translational Genomics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Eun Young Ko
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Eun Sook Ko
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ji Soo Choi
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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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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Anderson S, Parker E, Rahbar H, Scheel JR. IV Ductal Carcinoma In Situ, Including its Histologic Subtypes and Grades. CURRENT BREAST CANCER REPORTS 2021. [DOI: 10.1007/s12609-021-00439-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Panzironi G, Moffa G, Galati F, Pediconi F. Ultrasound-guided 8-Gauge vacuum-assisted excision for selected B3 breast lesions: a preliminary experience. Radiol Med 2021; 127:57-64. [PMID: 34800217 DOI: 10.1007/s11547-021-01429-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 11/08/2021] [Indexed: 11/24/2022]
Abstract
PURPOSE Nowadays, surgical excision is no longer justified for all B3 lesions and a minimally-invasive therapeutic treatment has been encouraged. The aim of this study was to evaluate the feasibility and the therapeutic efficacy of ultrasound-guided vacuum-assisted excision (US-VAE) for the treatment of selected breast lesions of uncertain malignant potential (B3). MATERIAL AND METHODS From July 2018 to December 2019, 11/48 breast lesions classified as B3 after ultrasound-guided core needle biopsy were treated with US-VAE in our Institution. Inclusion criteria were: B3 nodules ultrasonographically detectable for which VAE is recommended by international guidelines2, size ranging between 5 and 25 mm, circumscribed margins, and lesion position at least 5 mm from the skin and the nipple. A radiological follow-up to evaluate the completeness of excision, the presence of post-procedural hematoma or of residual disease/recurrence was performed after 10 and 30 days and 6 and 12 months. 12-month ultrasound was considered the gold standard. All patients were asked to complete a satisfaction survey and a full assessment of the costs of US-VAE was performed. RESULTS Complete excision was achieved in 81.8% of US-VAE. No lesions were upgraded to carcinoma and no patients had to undergo surgery. No complications occurred during or after US-VAE. All patients were satisfied with the procedure and the cosmetic result (100%). US-VAE cost approximately 422 Euros per procedure. CONCLUSION US-VAE has proven to be an optimal tool for the therapeutic excision of selected B3 lesions, with high success rate, good patient compliance and considerable money savings compared to surgery. This technique has the potential to reduce unnecessary surgery and healthcare costs.
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Affiliation(s)
- Giovanna Panzironi
- Department of Radiological, Oncological and Pathological Sciences, Sapienza - University of Rome, Rome, Italy
| | - Giuliana Moffa
- Department of Radiological, Oncological and Pathological Sciences, Sapienza - University of Rome, Rome, Italy.
| | - Francesca Galati
- Department of Radiological, Oncological and Pathological Sciences, Sapienza - University of Rome, Rome, Italy
| | - Federica Pediconi
- Department of Radiological, Oncological and Pathological Sciences, Sapienza - University of Rome, Rome, Italy
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Girardi V, Guaragni M, Ruzzenenti N, Palmieri F, Fogazzi G, Cozzi A, Lucchini D, Buffoli A, Schiaffino S, Sardanelli F. B3 Lesions at Vacuum-Assisted Breast Biopsy under Ultrasound or Mammography Guidance: A Single-Center Experience on 3634 Consecutive Biopsies. Cancers (Basel) 2021; 13:5443. [PMID: 34771606 PMCID: PMC8582448 DOI: 10.3390/cancers13215443] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 10/22/2021] [Accepted: 10/26/2021] [Indexed: 11/30/2022] Open
Abstract
The rate of upgrade to cancer for breast lesions with uncertain malignant potential (B3 lesions) diagnosed at needle biopsy is highly influenced by several factors, but large series are seldom available. We retrospectively assessed the upgrade rates of a consecutive series of B3 lesions diagnosed at ultrasound- or mammography-guided vacuum-assisted biopsy (VAB) at an EUSOMA-certified Breast Unit over a 7-year timeframe. The upgrade rate was defined as the number of ductal carcinoma in situ (DCIS) or invasive cancer at pathology after excision or during follow-up divided by the total number of B3 lesions. All lesions were reviewed by one of four pathologists with a second opinion for discordant assessments of borderline cases. Excision or surveillance were defined by the multidisciplinary tumor board, with 6- and 12-month follow-up. Out of 3634 VABs (63% ultrasound-guided), 604 (17%) yielded a B3 lesion. After excision, 17/604 B3 lesions were finally upgraded to malignancy (2.8%, 95% confidence interval [CI] 1.8-4.5%), 10/17 (59%) being upgraded to DCIS and 7/17 (41%) to invasive carcinoma. No cases were upgraded during follow-up. B3a lesions showed a significantly lower upgrade rate (0.4%, 95% CI 0.1-2.1%) than B3b lesions (4.7%, 95% CI 2.9-7.5%, p = 0.001), that had a 22.0 adjusted odds ratio for upgrade (95% CI 2.1-232.3). No significant difference was found in upgrade rates according to imaging guidance or needle caliper. Surveillance-oriented management can be considered for B3a lesions, while surgical excision should be pursued for B3b lesions.
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Affiliation(s)
- Veronica Girardi
- Breast Radiology, EUSOMA-Certified Breast Unit, Istituto Clinico Sant’Anna, Via del Franzone 31, 25127 Brescia, Italy;
| | - Monica Guaragni
- Breast Pathology, EUSOMA-Certified Breast Unit, Istituto Clinico Sant’Anna, Via del Franzone 31, 25127 Brescia, Italy; (M.G.); (N.R.)
| | - Nella Ruzzenenti
- Breast Pathology, EUSOMA-Certified Breast Unit, Istituto Clinico Sant’Anna, Via del Franzone 31, 25127 Brescia, Italy; (M.G.); (N.R.)
| | - Fabrizio Palmieri
- Breast Surgery, EUSOMA-Certified Breast Unit, Istituto Clinico Sant’Anna, Via del Franzone 31, 25127 Brescia, Italy;
| | - Gianluca Fogazzi
- Breast Medical Oncology, EUSOMA-Certified Breast Unit, Istituto Clinico Sant’Anna, Via del Franzone 31, 25127 Brescia, Italy;
| | - Andrea Cozzi
- Department of Biomedical Sciences for Health, Università degli Studi di Milano, Via Mangiagalli 31, 20133 Milano, Italy;
| | - Diana Lucchini
- Breast Psycho-Oncology, EUSOMA-Certified Breast Unit, Istituto Clinico Sant’Anna, Via del Franzone 31, 25127 Brescia, Italy;
| | - Alberto Buffoli
- Radiation Oncology, EUSOMA-Certified Breast Unit, Istituto Clinico Sant’Anna, Via del Franzone 31, 25127 Brescia, Italy;
| | - Simone Schiaffino
- Unit of Radiology, IRCCS Policlinico San Donato, Via Morandi 30, 20097 San Donato Milanese, Italy;
| | - Francesco Sardanelli
- Department of Biomedical Sciences for Health, Università degli Studi di Milano, Via Mangiagalli 31, 20133 Milano, Italy;
- Unit of Radiology, IRCCS Policlinico San Donato, Via Morandi 30, 20097 San Donato Milanese, Italy;
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El Sanharawi I, Bataillon G, Journo G, Farkhondeh F, Sebbag-Sfez D, Malhaire C, Tardivon A, Mosseri V, Thibault FE. Clinical management of atypical ductal hyperplasia on vacuum-assisted biopsy of microcalcifications: External validation study of a decision tree selecting patients eligible for surveillance. Eur J Radiol 2021; 141:109826. [PMID: 34174485 DOI: 10.1016/j.ejrad.2021.109826] [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: 03/02/2021] [Revised: 05/31/2021] [Accepted: 06/14/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Atypical lesions found on percutaneous breast biopsy raise specific management issues. The aim of this study was to validate the previous performance of a decision tree defined by Forgeard et al to select a subset of patients at low-risk of surgical diagnostic upgrade that would be eligible for surveillance. METHODS A consecutive series of 211 patients diagnosed with ADH on vacuum-assisted biopsy (VAB) of clustered microcalcifications alone, then operated in our institution, was reviewed. Histological findings on percutaneous cores were compared with definitive diagnoses on surgical specimens. The rate of cancer underestimation on VAB was analyzed in the four arms and two management attitudes defined in the scheme, using size and quality of microcalcification removal and the number of ADH foci. RESULTS Ninety-eight women with ADH met the inclusion criteria. Overall, 20 cancers were diagnosed at surgery, showing a malignancy rate of 44% (17/39 patients) in the surgery group and of 5% (3/59 patients) in the surveillance group, which was not significantly different from the 2% rate in the monitored reference group (p > 0.64). The malignancy rate increased significantly with the size of clustered microcalcifications (0% when < 6mm, 17% when between 6mm and 21 mm, 48% when > 21 mm, p < 0001) and the number of ADH foci on VAB (14% when ≤ 2, 45% when > 2, p < 0.005). CONCLUSION Our results corroborate - within the limits of large confidence intervals - those obtained with the reference decision tree. Due to statistical uncertainty, however, they need to be prospectively validated in a broader series.
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Affiliation(s)
- Imane El Sanharawi
- Département d'Imagerie Médicale, Institut Curie, 26 rue d'Ulm, F-75005, Paris, France
| | - Guillaume Bataillon
- Pôle de Médecine Diagnostique et Théranostique, Institut Curie, 26 rue d'Ulm, F-75005, Paris, France
| | - Gabrielle Journo
- Département d'Imagerie Médicale, Institut Curie, 35 rue Dailly, F-92210, Saint-Cloud, France
| | - Fereshteh Farkhondeh
- Pôle de Médecine Diagnostique et Théranostique, Institut Curie, 26 rue d'Ulm, F-75005, Paris, France
| | - Delphine Sebbag-Sfez
- Département d'Imagerie Médicale, Institut Curie, 26 rue d'Ulm, F-75005, Paris, France
| | - Caroline Malhaire
- Département d'Imagerie Médicale, Institut Curie, 26 rue d'Ulm, F-75005, Paris, France; Laboratoire d'Imagerie Translationnelle en Oncologie, INSERM, Institut Curie, 91401, Orsay, France
| | - Anne Tardivon
- Département d'Imagerie Médicale, Institut Curie, 26 rue d'Ulm, F-75005, Paris, France
| | - Véronique Mosseri
- PSL Research University, DRCI, Biométrie, 35 Rue Dailly, F-92210, Saint-Cloud, France
| | - Fabienne E Thibault
- Département d'Imagerie Médicale, Institut Curie, 26 rue d'Ulm, F-75005, Paris, France.
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Apparent diffusion coefficient values in borderline breast lesions upgraded and not upgraded at definitive histopathological examination after surgical excision. Pol J Radiol 2021; 86:e255-e261. [PMID: 34093923 PMCID: PMC8147718 DOI: 10.5114/pjr.2021.105857] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Accepted: 05/13/2020] [Indexed: 01/04/2023] Open
Abstract
Purpose The study aims were to evaluate if the apparent diffusion coefficient (ADC) value could distinguish between breast lesions classified as B3 at core needle biopsy (CNB) that show or do not show atypia or malignancy at definitive histopathological examination (DHE) after surgical excision. Material and methods From January 2013 to December 2017, 141 patients with a B3 breast lesion underwent magnetic resonance imaging and were included in the study. The ADC value was assessed drawing a ROI outlining the entire lesion, evaluating the mean (ADCmean) and minimum ADC values (ADCmin). Results Both ADCmean and ADCmin values showed a statistically significant difference between B3 lesions without and with malignancy or, for B3a lesions, atypia at DHE. They both showed a statistically significant difference also between B3a lesions without or with atypia or malignancy at DHE, but only ADCmin (not ADCmean) showed statistically significant difference between B3b lesions without or with malignancy at DHE. Conclusions The ADC value could help distinguish between B3a lesions without or with atypia/malignancy at DHE after surgical excision and between B3b lesions without or with malignancy at DHE. Therefore, it could be used to help guide the diagnostic-therapeutic pathway of these lesions, particularly of B3a lesions.
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Effectiveness of percutaneous vacuum-assisted excision (VAE) of breast lesions of uncertain malignant potential (B3 lesions) as an alternative to open surgical biopsy. Eur Radiol 2021; 31:9540-9547. [PMID: 34100998 DOI: 10.1007/s00330-021-08060-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 04/08/2021] [Accepted: 05/07/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVES Traditionally B3 breast lesions are treated surgically, but overtreatment is a concern, as the majority have a final benign diagnosis. A national screening program introduced vacuum-assisted excision (VAE) for managing B3 lesions in late 2016. This retrospective study aimed to assess the outcomes associated with this approach. METHODS All B3 lesions diagnosed between 01/2017 and 12/2019 were identified at two centres. Information was obtained on the initial biopsy and final histology, and method of VAE image guidance, needle size and number of cores. Lesions were excluded if there was cancer elsewhere in the breast at the time of diagnosis; the lesion was not suitable for VAE due to position in the breast or had B3 pathology for which open biopsy was still required. The final decision to offer VAE was always made at a multidisciplinary meeting (MDM). Risk difference was used to test the significance at p ≤ .05. RESULTS In total, 258 B3 lesions were diagnosed, 105 (40.7%) met the inclusion criteria and underwent VAE. VAE was performed under X-ray (89/105) or ultrasound guidance (16/105), taking an average of 18.5 cores with the 10-G needle or 10.8 cores with the 7-G needle. Nine cases (8.6%) were upgraded to a malignant diagnosis following VAE. Malignancy was found in 15.5% (9/58) of B3 lesions with epithelial atypia, but in none without atypia (0/47) (p = .004). No new lesions or malignancy has occurred at the site of the VAE with an average mammographic follow-up of 2.2 years. CONCLUSION Upgrade to malignancy following VAE was uncommon (8.6%) and associated with atypia in the initial biopsy. VAE is an alternative approach to the management of B3 lesions, reducing open surgical procedures. KEY POINTS • Upgrade to malignancy after a vacuum-assisted excision of a B3 breast lesion is uncommon with an 8.6% upgrade rate. • The risk of a malignant diagnosis after a vacuum-assisted excision was significantly higher for B3 lesions with atypia compared to those without (+15.5% difference, p = .004).
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Papillary neoplasms of the breast-reviewing the spectrum. Mod Pathol 2021; 34:1044-1061. [PMID: 33462367 DOI: 10.1038/s41379-020-00732-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 11/15/2020] [Accepted: 11/24/2020] [Indexed: 12/14/2022]
Abstract
Papillary neoplasms of the breast encompass a wide range of tumor types ranging from the benign intraductal papilloma to in situ and invasive papillary carcinomas. In this review, we considered each tumor entity listed under the Papillary Neoplasms category in the latest WHO Classification of Breast Tumors (5th edition), namely intraductal papilloma, papillary ductal carcinoma in situ, encapsulated papillary carcinoma, solid-papillary carcinoma, and invasive papillary carcinoma. We examined their pathological features, current issues pertaining to diagnosis and prognostication, as well as the latest molecular findings. We also briefly addressed adenomyoepithelioma and the newly included tall cell carcinoma with reversed polarity, highlighting areas where they overlap with papillary neoplasms.
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Catanzariti F, Avendano D, Cicero G, Garza-Montemayor M, Sofia C, Venanzi Rullo E, Ascenti G, Pinker-Domenig K, Marino MA. High-risk lesions of the breast: concurrent diagnostic tools and management recommendations. Insights Imaging 2021; 12:63. [PMID: 34037876 PMCID: PMC8155169 DOI: 10.1186/s13244-021-01005-6] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 05/04/2021] [Indexed: 12/14/2022] Open
Abstract
Breast lesions with uncertain malignant behavior, also known as high-risk or B3 lesions, are composed of a variety of pathologies with differing risks of associated malignancy. While open excision was previously preferred to manage all high-risk lesions, tailored management has been increasingly favored to reduce overtreatment and spare patients from unnecessary anxiety or high healthcare costs associated with surgical excision. The purpose of this work is to provide the reader with an accurate overview focused on the main high-risk lesions of the breast: atypical intraductal epithelial proliferation (atypical ductal hyperplasia), lobular neoplasia (including the subcategories lobular carcinoma in situ and atypical lobular hyperplasia), flat epithelial atypia, radial scar and papillary lesions, and phyllodes tumor. Beyond merely presenting the radiological aspects of these lesions and the recent literature, information about their potential upgrade rates is discussed in order to provide a useful guide for appropriate clinical management while avoiding the risks of unnecessary surgical intervention (overtreatment).
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Affiliation(s)
- Francesca Catanzariti
- Department of Biomedical Sciences and Morphologic and Functional Imaging, University of Messina, Messina, Italy
| | - Daly Avendano
- Department of Breast Imaging, Breast Cancer Center TecSalud, ITESM Monterrey, Nuevo Leon, Mexico
| | - Giuseppe Cicero
- Department of Biomedical Sciences and Morphologic and Functional Imaging, University of Messina, Messina, Italy
| | | | - Carmelo Sofia
- Department of Biomedical Sciences and Morphologic and Functional Imaging, University of Messina, Messina, Italy
| | - Emmanuele Venanzi Rullo
- Unit of Infectious Diseases, Department of Clinical and Experimental Medicine, University of Messina, 98124, Messina, Italy
| | - Giorgio Ascenti
- Department of Biomedical Sciences and Morphologic and Functional Imaging, University of Messina, Messina, Italy
| | - Katja Pinker-Domenig
- Department of Radiology, Breast Imaging Service, Memorial Sloan Kettering Cancer Center, Suite 705, 300 E 66th Street, New York, NY, 10065, USA. .,Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria.
| | - Maria Adele Marino
- Department of Biomedical Sciences and Morphologic and Functional Imaging, University of Messina, Messina, Italy
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Clinical practice guidelines for intraductal papilloma: Chinese Society of breast surgery (CSBrS) practice guidelines 2021. Chin Med J (Engl) 2021; 134:1658-1660. [PMID: 34039866 PMCID: PMC8318653 DOI: 10.1097/cm9.0000000000001533] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Atypical Ductal Hyperplasia on Ultrasonography-Guided Vacuum-Assisted Biopsy of the Breast: Considerations for Further Surgical Excision. Ultrasound Q 2021; 36:192-198. [PMID: 32511211 DOI: 10.1097/ruq.0000000000000478] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The purposes of this study are to evaluate the upgrade rate of atypical ductal hyperplasia (ADH) diagnosed with ultrasonography (US)-guided vacuum-assisted biopsy (VAB) to malignancy and to identify the factors behind the underestimation. We retrospectively reviewed the pathologic results of US-guided VAB of the breast. A total of 50 ADH lesions that were surgically excised or with more than 12 months of follow-up were included. The upgrade rate of ADH was determined by dividing the number of lesions that were proven malignant on surgical excision by the total number of ADH diagnosed on VAB. Clinical, radiologic, procedural, and pathologic variables were analyzed to identify the factors behind the underestimation. The upgrade rate of ADH was found to be 16.0% (8/50 lesions). In univariable and multivariable analyses, the upgrade rates of ADH did not significantly differ among variables. In a subgroup analysis, according to history of breast cancer, the upgrade rates of ADH were significantly lower for lesions of mass than for lesions of nonmass (0% [0/23 lesions] vs 28.6% [4/14 lesions], P = 0.015), and for lesions without calcifications than for lesions with calcifications (0% [0/22 lesions] vs 26.7% [4/15 lesions], P = 0.021) in the negative history subgroup. ADH lesions in masses or without calcifications in patients without a family or personal history of breast cancer were associated with low upgrade rates. Thus, we suggest that ADH with these features can be followed rather than surgically excised after US-guided VAB.
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Abstract
Abstract
Purpose of Review
Lobular carcinoma in situ (LCIS) encompasses classical LCIS and other rarer and more recently recognised variants, namely pleomorphic LCIS (PLCIS) and florid LCIS. Each of those entities has characteristic histological diagnostic criteria, different rates of underestimation of malignancy and recommended management. In addition, those lesions can mimic a number of benign and malignant breast lesions and can particularly be mistaken for ductal carcinoma in situ (DCIS). Accurate diagnosis of those lesions is critical to ensuring the appropriate patient management.
Recent Findings
Several international guidelines refining the pathological classification, staging and management of those lesions have recently been updated. This review will provide an up-to-date pathological overview of the current knowledge of LCIS with emphasis on the multidisciplinary management implications.
Summary
Close correlation between imaging and pathology in a multidisciplinary pathway is essential in LCIS management. Classical LCIS on core biopsy/vacuum-assisted biopsy (VAB) is coded as B3 and, if without discordant imaging, should further be sampled by vacuum-assisted excision (VAE). PLCIS should be coded and managed as per high-grade DCIS. Florid LCIS is a rare entity that is thought to be more aggressive than classical LCIS. Excision with clear margin is advised.
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The impact of vacuum-assisted excision in the management of indeterminate B3 lesions in the NHS Breast Screening Programme in England. Clin Radiol 2021; 76:470.e23-470.e29. [PMID: 33814122 DOI: 10.1016/j.crad.2021.01.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 01/26/2021] [Indexed: 11/21/2022]
Abstract
AIM To assess the impact of vacuum-assisted excision (VAE) on the management of B3 lesions in the England NHS Breast Screening Programme following an update of national guidance. A secondary aim was to investigate the histological features of malignancies resulting from upgrade of B3 lesions by either VAE or surgery. MATERIALS AND METHODS The study population was all women recalled for assessment after breast screening who had a wide-bore needle biopsy with a B3 result over the period 01/04/2018 to 31/03/2019. Data were extracted from the National Breast Screening Service (NBSS) computer system at unit level. Women with a B3 result were split into those with and without atypia. The upgrade rates and histological features of malignancies in the different groups were analysed. RESULTS In total, 2,234,514 women attended for screening between 1/4/218 and 31/3/2019, 84,559 women were referred to assessment, and of those 40,037 women had a core biopsy resulting in 3,355 were B3 lesions (8.38%). Within these, 556 cancers were diagnosed, giving an upgrade rate of 16.57% (556/3,355). The upgrade for B3 lesions with atypia was significantly higher than for B3 lesions without atypia (29.1% versus 13.3%, p<0.001). CONCLUSION The introduction of the new B3 guidelines has resulted in 73.8% of B3 lesions with atypia and 65.1% of B3 lesions with no atypia having VAE rather than surgery. The data highlights the importance of managing these indeterminate lesions appropriately with an overall upgrade rate of 16.57%.
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Schizas N, Lazopoulos A, Rallis T, Paliouras D, Barbetakis N. Relapsing phyllodes cystosarcoma and chest wall invasion with long-term survival: is aggressive surgery worthwhile? Indian J Thorac Cardiovasc Surg 2021; 37:447-450. [PMID: 34220029 DOI: 10.1007/s12055-020-01118-5] [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: 09/26/2020] [Revised: 11/28/2020] [Accepted: 12/07/2020] [Indexed: 10/22/2022] Open
Abstract
A case of a 46-year-old woman with disease relapse and surgical intervention with a transverse rectus abdominalis muscle flap (TRAM) of the chest wall is reported. Long-term survival (64 months) following aggressive surgery was succeeded.
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Affiliation(s)
- Nikolaos Schizas
- Thoracic Surgery Department, Theagenio Cancer Hospital, Thessaloniki, Greece.,Department of Cardio-Thoracic and Vascular Surgery, Evangelismos General Hospital of Athens, Athens, Greece
| | - Achileas Lazopoulos
- Thoracic Surgery Department, Theagenio Cancer Hospital, Thessaloniki, Greece
| | - Thomas Rallis
- Thoracic Surgery Department, Theagenio Cancer Hospital, Thessaloniki, Greece
| | - Dimitris Paliouras
- Thoracic Surgery Department, Theagenio Cancer Hospital, Thessaloniki, Greece
| | - Nikos Barbetakis
- Thoracic Surgery Department, Theagenio Cancer Hospital, Thessaloniki, Greece
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Bennett I, de Viana D, Law M, Saboo A. Surgeon-Performed Vacuum-Assisted Biopsy of the Breast: Results from a Multicentre Australian Study. World J Surg 2020; 44:819-824. [PMID: 31712841 DOI: 10.1007/s00268-019-05266-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Image-guided interventional techniques such as vacuum-assisted biopsy are being increasingly utilised in the diagnosis and management of breast conditions. The purpose of this study was to report the outcome of a series of vacuum-assisted biopsies and vacuum-assisted excisions performed by specialist breast surgeons in a largely outpatient setting. METHODS An Australian multicentre trial of ultrasound-guided surgeon-performed vacuum-assisted biopsy (VAB) and vacuum-assisted excision (VAE) of breast lesions was conducted involving three surgeons in three participating centres. VAEs were performed for presumed or proven benign breast lesions only. RESULTS A total of 225 surgeon-performed ultrasound-guided vacuum-assisted procedures were undertaken in 197 patients. Of the 225 VAB procedures, 51 (22.7%) were performed as diagnostic cores and 174 (77.3%) were undertaken as core excisions. Of the 174 VAE procedures undertaken with intent of completely excising the lesion, successful excision of the lesion was achieved in 165 of these cases (94.8%), with complete excision being judged by the absence of any lesion seen on ultrasound following the procedure or the absence of the lesion on a subsequent interval ultrasound examination. A total of 199 procedures were performed in the outpatients setting under local anaesthesia, and 26 procedures were performed in an operating theatre setting under neurolept anaesthesia. The average size of lesions was 19.3 mm in the diagnostic core group and 10.6 mm in the core excision group. The average time for either procedure was approximately 14 min. CONCLUSION Specialist breast surgeons familiar with ultrasound can be readily upskilled to perform vacuum-assisted procedures safely and expeditiously. VAE represents a minimally invasive method of breast lesion management and is a technique with which breast surgeons should become adept.
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Affiliation(s)
- Ian Bennett
- Princess Alexandra Hospital, Brisbane, Australia. .,University of Queensland, Brisbane, Australia. .,Silverton Place, Suite 60, Level 5, 101 Wickham Terrace, Brisbane, QLD, 4000, Australia.
| | - Daniel de Viana
- Premion Place, Southport, Australia.,Breastscreen Queensland Gold Coast, Southport, Australia
| | - Michael Law
- Breast and Endocrine Surgery Unit, Eastern Health, Box Hill, VIC, Australia
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Clauser P, Kapetas P, Stöttinger A, Bumberger A, Rudas M, Baltzer PAT. A risk stratification algorithm for lesions of uncertain malignant potential diagnosed by vacuum-assisted breast biopsy (VABB) of mammographic microcalcifications. Eur J Radiol 2020; 135:109479. [PMID: 33370641 DOI: 10.1016/j.ejrad.2020.109479] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Revised: 11/28/2020] [Accepted: 12/13/2020] [Indexed: 11/17/2022]
Abstract
PURPOSE To investigate a risk stratification strategy for lesions of uncertain malignant potential (B3) diagnosed by vacuum-assisted breast biopsy (VABB) of mammographic microcalcifications. METHODS Patients who underwent VABB for microcalcification-only lesions with a diagnosis of B3 and subsequent surgery were included in this retrospective, IRB-approved study. Seventy-six B3-lesions (final histology: 66 benign, 10 malignant) were included (Tr). Data on B3 lesion type and presence of atypia, microcalcification characteristics (BI-RADS), removal at biopsy and concomitant lesions were collected. After univariate analysis (Chi-square test), data were combined into a risk stratification algorithm by using a ten-fold, cross-validated Classification and Regression Tree analysis (CRT). The algorithm was tested on a testing dataset (Te) of 23 B3-lesions (six malignant, 17 benign). RESULTS Malignancy was more frequent in women with a concomitant cancer (P < 0.001) and highly suspicious microcalcifications (P < 0.001). The CRT algorithm retained three characteristics: morphology; presence of atypia; presence of concomitant cancer. The algorithm identified 25/76 (32.9 %,Tr) and 6/23 (26.1 %,Te) lesions at low risk of malignancy. No malignant cases were identified at surgery (0/31). There were 3/76 (3.9 %,Tr) and 1/23 (4.3 %,Te) lesions assigned as high-risk by the algorithm and confirmed at surgery (4/4). In the remaining lesions (48/76, 63.1 %,Tr; 16/23, 69.6 %,Te), malignancy rates varied between 9% and 88.4 %; thus, surgery could not have been avoided. CONCLUSION We constructed and tested a risk stratification algorithm for B3 microcalcifications, including clinical, imaging, and pathological features, to assign probabilities of malignancy, which has the potential to reduce unnecessary surgeries.
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Affiliation(s)
- Paola Clauser
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, Austria
| | - Panagiotis Kapetas
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, Austria
| | - Alexander Stöttinger
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, Austria
| | - Alexander Bumberger
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, Austria
| | - Margaretha Rudas
- Department of Clinical Pathology, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, Austria
| | - Pascal A T Baltzer
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, Austria.
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Whitworth P, Hogan A, Ferko N, Son D, Wang F, Xiong Y, Suri H, Barclay B. Reduced Hospital Costs for Ultrasound-guided Vacuum-assisted Excision Compared with Open Surgery in Patients with Benign Breast Masses and High-risk Lesions. JOURNAL OF BREAST IMAGING 2020; 2:452-461. [PMID: 38424905 DOI: 10.1093/jbi/wbaa055] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Indexed: 03/02/2024]
Abstract
OBJECTIVE Benign breast masses represent a substantial proportion of breast cancer screening results and may require multiple follow-up visits and biopsy. Even with a preceding benign core biopsy, benign masses have been excised via open surgery for a variety of reasons. This study compared the procedural costs of US-guided vacuum-assisted excision (US-VAE) versus open surgical excisions for benign breast masses and high-risk lesions (HRL). METHODS In this retrospective cohort study, female outpatients receiving US-VAE or open excision of benign breast masses between 2015 and 2018 were identified within the Premier Healthcare Database. A secondary analysis was conducted for patients with HRLs. Propensity score matching and multivariate regression adjusted for patient demographics, encounter level covariates, and hospital characteristics. The total procedural costs were reported from a hospital perspective. RESULTS A total of 33 724 patients underwent excisions for benign breast masses (8481 US-VAE and 25 242 open surgery). Procedural costs were significantly lower in unmatched patients who received US-VAE ($1350) versus open surgery ($3045) (P < 0.0001). After matching, a total of 5499 discharges were included in each group, with similar findings for US-VAE ($1348) versus open surgery ($3101) (P < 0.0001). A secondary analysis of matched HRL patients (41 discharges in each group) also showed significantly lower procedural costs with US-VAE ($1620) versus open surgery ($3870) (P < 0.0001). CONCLUSION Among patients with benign breast masses or HRLs, US-VAE was associated with significantly lower procedural costs versus open surgery. If excision is performed and expected clinical outcomes are equal, US-VAE is preferable to reduce costs without compromising the quality of care.
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Affiliation(s)
| | | | | | | | - Faye Wang
- Becton, Dickinson and Company, Tempe, AZ
| | - Yan Xiong
- Becton, Dickinson and Company, Franklin Lakes, NJ
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Alvarado-Cabrero I, Valencia-Cedillo R, Estevez-Castro R. Preneoplasia of the Breast and Molecular Landscape. Arch Med Res 2020; 51:845-850. [PMID: 32972772 DOI: 10.1016/j.arcmed.2020.09.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 09/10/2020] [Indexed: 12/29/2022]
Abstract
The current model of human breast cancer progression proposes a linear multi-step process which initiates as flat epithelial atypia (FEA), progresses to atypical ductal hyperplasia (ADH), evolves into ductal carcinoma in situ (DCIS) and culminates in the potentially lethal stage of invasive ductal carcinoma. FEA commonly coexists with well-developed examples of ADH, low-grade DCIS, lobular neoplasia and tubular carcinoma. These findings and those of recent genetic studies suggest that FEA is a neoplastic lesion that may represent a precursor to or the earliest morphologic manifestation of ductal carcinoma in situ. At the same time, many of the genomic changes of ADH are also shared by common sporadic breast cancer, consistent with a high risk for future development of metachronous breast cancer.
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Affiliation(s)
- Isabel Alvarado-Cabrero
- Departamento de Patologia, Hospital de Oncología, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Ciudad de Mexico, Mexico.
| | - Raquel Valencia-Cedillo
- Departamento de Patologia, Hospital de Oncología, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Ciudad de Mexico, Mexico
| | - Rafael Estevez-Castro
- Departamento de Patologia, Hospital de Especialidades Dr. Bernardo Sepúlveda, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Ciudad de Mexico, Mexico
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McMahon MA, Haigh I, Chen Y, Millican-Slater RA, Sharma N. Role of vacuum assisted excision in minimising overtreatment of ductal atypias. Eur J Radiol 2020; 131:109258. [PMID: 32919262 DOI: 10.1016/j.ejrad.2020.109258] [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: 06/24/2020] [Revised: 08/23/2020] [Accepted: 08/25/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE B3 lesions are indeterminate lesions of uncertain malignant potential. They include lesions with and without epithelial atypia. Those with atypia include atypical intraductal epithelial proliferation (AIDEP)/atypical ductal hyperplasia (ADH) and flat epithelial atypia (FEA). They are traditionally managed with surgery. Vacuum assisted excision (VAE) allows larger samples to be obtained using a vacuum assisted biopsy (VAB) device, which equates to a surgical biopsy. We propose that VAE and mammographic surveillance is a safe alternative to surgery in managing the ductal atypias; (AIDEP/ADH and FEA). METHOD Retrospective analysis of prospectively collected data on B3 lesions (April 2009 - March 2016) from consecutive breast screening patients diagnosed with AIDEP/ADH or FEA on initial diagnostic core biopsy. Mammographic abnormality, breast density, size, management pathway and upgrade to cancer and types of cancer were also collected during the treatment pathway and 5 year surveillance period (April 2009 - April 2019). RESULTS 273 cases of ductal atypia were identified. 187/273 (68.5 %) cases were managed with VAE only as no upgrade to malignancy and then 5 year mammographic surveillance. 34/273 (12.5 %) cases had a VAE diagnosing malignancy. 24/273 (8.8 %) cases had a VAE and then a surgical biopsy due to radiological or pathological concern, 8/24 upgraded to malignancy. 22/273 (8%) cases had a surgical diagnostic biopsy, 9/22 (41 %) cases were upgraded to malignancy. In total 51/273 (19 %) cases were diagnosed with cancer on the new pathway (13 invasive (all ER positive and Her2 negative) and 38 non-invasive, (34 ductal carcinoma in situ (DCIS) and 4 cases of lobular carcinoma in situ (LCIS)). While 17/273 (6.2 %) cases developed malignancy (12 invasive (all HER2 negative) and 4 DCIS and 1 LCIS) during the 5 year surveillance period. CONCLUSIONS VAE is a safe alternative to surgery in managing ductal atypias. 187/273 (68.5 %) women avoided surgery. While 34/51 cancers (66.7 %) were diagnosed preoperatively using VAE, allowing the women to have a single therapeutic procedure.
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Affiliation(s)
- M A McMahon
- Department of Breast Radiology, Leeds Teaching Hospitals NHS Trust, United Kingdom
| | - I Haigh
- Department of Breast Radiology, Leeds Teaching Hospitals NHS Trust, United Kingdom
| | - Y Chen
- Division of Cancer and Stem Cell, School of Medicine at University of Nottingham, United Kingdom
| | | | - N Sharma
- Department of Breast Radiology, Leeds Teaching Hospitals NHS Trust, United Kingdom.
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Lucioni M, Rossi C, Lomoro P, Ballati F, Fanizza M, Ferrari A, Garcia-Etienne CA, Boveri E, Meloni G, Sommaruga MG, Ferraris E, Lasagna A, Bonzano E, Paulli M, Sgarella A, Di Giulio G. Positive predictive value for malignancy of uncertain malignant potential (B3) breast lesions diagnosed on vacuum-assisted biopsy (VAB): is surgical excision still recommended? Eur Radiol 2020; 31:920-927. [PMID: 32816199 DOI: 10.1007/s00330-020-07161-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 06/20/2020] [Accepted: 08/06/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE Breast lesions classified as of "uncertain malignant potential" represent a heterogeneous group of abnormalities with an increased risk of associated malignancy. Clinical management of B3 lesions diagnosed on vacuum-assisted breast biopsy (VABB) is still challenging: surgical excision is no longer the only available treatment and VABB may be sufficient for therapeutic excision. The aim of the present study is to evaluate the positive predictive value (PPV) for malignancy in B3 lesions that underwent surgical excision, identifying possible upgrading predictive factors and characterizing the malignant lesions eventually diagnosed. These results are compared with a subset of patients with B3 lesions who underwent follow-up. METHODS A total of 1250 VABBs were performed between January 2006 and December 2017 at our center. In total, 150 B3 cases were diagnosed and 68 of them underwent surgical excision. VABB findings were correlated with excision histology. A PPV for malignancy for each B3 subtype was derived. RESULTS The overall PPV rate was 28%, with the highest upgrade rate for atypical ductal hyperplasia (41%), followed by classical lobular neoplasia (29%) and flat epithelial atypia (11%). Only two cases of carcinoma were detected in the follow-up cohort, both associated with atypical ductal hyperplasia at VABB. CONCLUSION Open surgery is recommended in case of atypical ductal hyperplasia while, for other B3 lesions, excision with VABB only may be an acceptable alternative if radio-pathological correlation is assessed, if all microcalcifications have been removed by VABB, and if the lesion lacks high-risk cytological features. KEY POINTS • Surgical treatment is strongly recommended in case of ADH, while the upgrade rate in case of pure FEA, especially following complete microcalcification removal by VABB, may be sufficiently low to advice surveillance as a management strategy. • The use of 11-G- or 8-G-needle VABB, resulting in possible complete diagnostic excision of the lesion, can be an acceptable alternative in case of RS, considering open surgery only for selected high-risk patients. • LN management is more controversial: surgical excision may be recommended following classical LN diagnosis on breast biopsy if an additional B3 lesion is concurrently detected while in the presence of isolated LN with adequate radiological-pathological correlation follow-up alone could be an acceptable option.
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Affiliation(s)
- Marco Lucioni
- Anatomic Pathology Section, Department of Human Pathology, University of Pavia, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Chiara Rossi
- Anatomic Pathology Section, Department of Human Pathology, University of Pavia, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Pascal Lomoro
- Breast Imaging Department, Valduce Hospital, Via Dante Alighieri 11, 22100, Como, Italy.
| | - Francesco Ballati
- Breast Imaging Department, University of Pavia, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Marianna Fanizza
- Breast Imaging Department, University of Pavia, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Alberta Ferrari
- Breast Surgery Department, Fondazione IRCCS Policlinico San Matteo, Università degli Studi di Pavia, Pavia, Italy
| | - Carlos A Garcia-Etienne
- Breast Surgery Department, Fondazione IRCCS Policlinico San Matteo, Università degli Studi di Pavia, Pavia, Italy
| | - Emanuela Boveri
- Anatomic Pathology Section, Department of Human Pathology, University of Pavia, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Giulia Meloni
- Breast Imaging Department, University of Pavia, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Maria Grazia Sommaruga
- Breast Imaging Department, University of Pavia, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Elisa Ferraris
- Medical Oncology, Fondazione IRCCS Policlinico San Matteo and, Università degli Studi, Pavia, Italy
| | - Angioletta Lasagna
- Medical Oncology, Fondazione IRCCS Policlinico San Matteo and, Università degli Studi, Pavia, Italy
| | - Elisabetta Bonzano
- University of Pavia and Department of Radiation Oncology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Marco Paulli
- Anatomic Pathology Section, Department of Human Pathology, University of Pavia, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Adele Sgarella
- Breast Surgery Department, Fondazione IRCCS Policlinico San Matteo, Università degli Studi di Pavia, Pavia, Italy
| | - Giuseppe Di Giulio
- Breast Imaging Department, University of Pavia, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
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