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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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2
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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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Laws A, Leonard S, Hershey E, Stokes S, Vincuilla J, Sharma E, Milliron K, Garber JE, Merajver SD, King TA, Pilewskie ML. Upgrade Rates and Breast Cancer Development Among Germline Pathogenic Variant Carriers with High-Risk Breast Lesions. Ann Surg Oncol 2024; 31:3120-3127. [PMID: 38261128 DOI: 10.1245/s10434-024-14947-0] [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: 07/10/2023] [Accepted: 01/04/2024] [Indexed: 01/24/2024]
Abstract
BACKGROUND High-risk lesions (HRL) of the breast are risk factors for future breast cancer development and may be associated with a concurrent underlying malignancy when identified on needle biopsy; however, there are few data evaluating HRLs in carriers of germline pathogenic variants (PVs) in breast cancer predisposition genes. METHODS We identified patients from two institutions with germline PVs in high- and moderate-penetrance breast cancer predisposition genes and an HRL in an intact breast, including atypical ductal hyperplasia (ADH), flat epithelial atypia (FEA), and lobular neoplasia (LN). We calculated upgrade rates at surgical excision and used Kaplan-Meier methods to characterize 3-year breast cancer risk in patients without upgrade. RESULTS Of 117 lesions in 105 patients, 65 (55.6%) were ADH, 48 (41.0%) were LN, and 4 (3.4%) were FEA. Most PVs (83.8%) were in the BRCA1/2, CHEK2 and ATM genes. ADH and FEA were excised in most cases (87.1%), with upgrade rates of 11.8% (95% confidence interval [CI] 5.5-23.4%) and 0%, respectively. LN was selectively excised (53.8%); upgrade rate in the excision group was 4.8% (95% CI 0.8-22.7%), and with 20 months of median follow-up, no same-site cancers developed in the observation group. Among those not upgraded, the 3-year risk of breast cancer development was 13.1% (95% CI 6.3-26.3%), mostly estrogen receptor-positive (ER +) disease (89.5%). CONCLUSIONS Upgrade rates for HRLs in patients with PVs in breast cancer predisposition genes appear similar to non-carriers. HRLs may be associated with increased short-term ER+ breast cancer risk in PV carriers, warranting strong consideration of surgical or chemoprevention therapies in this population.
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Affiliation(s)
- Alison Laws
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Saskia Leonard
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
- John A. Burns School of Medicine, University of Hawaii, Honolulu, HI, USA
| | - Emma Hershey
- Department of Surgery, Michigan Medicine, Ann Arbor, MI, USA
| | - Samantha Stokes
- Division of Cancer Genetics and Prevention, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Julie Vincuilla
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Eshita Sharma
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Kara Milliron
- Breast and Ovarian Cancer Risk Evaluation Program, Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI, USA
| | - Judy E Garber
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Division of Cancer Genetics and Prevention, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Sofia D Merajver
- Breast and Ovarian Cancer Risk Evaluation Program, Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI, USA
| | - Tari A King
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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4
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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 2024:14574969241234115. [PMID: 38414163 DOI: 10.1177/14574969241234115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [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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5
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Li JK, Jin ZY, Xu YJ, Fu NQ, Jiang Y, Li SY, Niu RL, Liu G, Wang ZL. Contrast-enhanced ultrasound to predict malignant upgrading of atypical ductal hyperplasia. Breast Cancer Res 2024; 26:27. [PMID: 38347651 PMCID: PMC10863177 DOI: 10.1186/s13058-024-01772-2] [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: 10/09/2023] [Accepted: 01/17/2024] [Indexed: 02/15/2024] Open
Abstract
BACKGROUND A malignancy might be found at surgery in cases of atypical ductal hyperplasia (ADH) diagnosed via US-guided core needle biopsy (CNB). The objective of this study was to investigate the diagnostic performance of contrast-enhanced ultrasound (CEUS) in predicting ADH diagnosed by US-guided CNB that was upgraded to malignancy after surgery. METHODS In this retrospective study, 110 CNB-diagnosed ADH lesions in 109 consecutive women who underwent US, CEUS, and surgery between June 2018 and June 2023 were included. CEUS was incorporated into US BI-RADS and yielded a CEUS-adjusted BI-RADS. The diagnostic performance of US BI-RADS and CEUS-adjusted BI-RADS for ADH were analyzed and compared. RESULTS The mean age of the 109 women was 49.7 years ± 11.6 (SD). The upgrade rate of ADH at CNB was 48.2% (53 of 110). The sensitivity, specificity, positive predictive value, and negative predictive value of CEUS for identification of malignant upgrading were 96.2%, 66.7%,72.9%, and 95.0%, respectively, based on BI-RADS category 4B threshold. The two false-negative cases were low-grade ductal carcinoma in situ. Compared with the US, CEUS-adjusted BI-RADS had better specificity for lesions smaller than 2 cm (76.7% vs. 96.7%, P = 0.031). After CEUS, 16 (10 malignant and 6 nonmalignant) of the 45 original US BI-RADS category 4A lesions were up-classified to BI-RADS 4B, and 3 (1 malignant and 2 nonmalignant) of the 41 original US BI-RADS category 4B lesions were down-classified to BI-RADS 4A. CONCLUSIONS CEUS is helpful in predicting malignant upgrading of ADH, especially for lesions smaller than 2 cm and those classified as BI-RADS 4A and 4B on ultrasound.
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Affiliation(s)
- Jun Kang Li
- Department of Ultrasound, The First Medical Center, Chinese PLA General Hospital, 28 Fuxing Road, Beijing, 100853, China
- Department of Ultrasound, Chinese PLA 63820 Hospital, Mianyang, Sichuan, China
| | - Zhi Ying Jin
- Department of Ultrasound, The First Medical Center, Chinese PLA General Hospital, 28 Fuxing Road, Beijing, 100853, China
| | - Yong Jie Xu
- Department of Ultrasound Diagnosis, Strategic Support Force Medical Center of Chinese PLA, Beijing, China
| | - Nai Qin Fu
- Department of Ultrasound, The First Medical Center, Chinese PLA General Hospital, 28 Fuxing Road, Beijing, 100853, China
| | - Ying Jiang
- Department of Ultrasound, The First Medical Center, Chinese PLA General Hospital, 28 Fuxing Road, Beijing, 100853, China
| | - Shi Yu Li
- Department of Ultrasound, The First Medical Center, Chinese PLA General Hospital, 28 Fuxing Road, Beijing, 100853, China
| | - Rui Lan Niu
- Department of Ultrasound, The First Medical Center, Chinese PLA General Hospital, 28 Fuxing Road, Beijing, 100853, China
| | - Gang Liu
- Department of Radiology, The First Medical Center, Chinese PLA General Hospital, Beijing, China.
| | - Zhi Li Wang
- Department of Ultrasound, The First Medical Center, Chinese PLA General Hospital, 28 Fuxing Road, Beijing, 100853, China.
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Rella R, Conti M, Borghetti A, Belli P, Morciano F, Rossati C, Caneva A, Di Leone A, Franceschini G, Gori E, Fornasa F, Tommasini O, Romanucci G. Atypical ductal hyperplasia on vacuum-assisted breast biopsy: a scoring system to predict the risk of upgrade to malignancy. LA RADIOLOGIA MEDICA 2024; 129:38-47. [PMID: 37874442 PMCID: PMC10808485 DOI: 10.1007/s11547-023-01740-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 10/05/2023] [Indexed: 10/25/2023]
Abstract
RATIONALE AND OBJECTIVES Our multicentric study analysed clinical, radiologic and pathologic features in patients with atypical ductal hyperplasia (ADH) diagnosed with vacuum-assisted biopsy (VAB), to identify factors associated with the risk of upgrade, to develop a scoring system to support decision making. MATERIALS AND METHODS Patients with ADH on VAB under stereotactic/tomosynthesis guidance (2012-2022) were eligible. Inclusion criteria were availability of surgical histopathological examination of the entire lesion or radiologic follow-up (FUP) ≥ 24 months. VAB results were compared with surgical pathological results or with imaging FUP evolution to assess upgrade. A backward stepwise linear regression was used to identify predictors of upgrade. The discriminatory power of the model was calculated through the area under the receiver operating curve (ROC-AUC); the Hosmer-Lemeshow test was used to assess model calibration. The points system was developed based on the selected risk factors, and the probability of upgrade associated with each point total was determined. RESULTS 112 ADH lesions were included: 91 (91/112, 81.3%) underwent surgical excision with 20 diagnosis of malignancy, while 21 (21/112, 18.7%) underwent imaging FUP with one interval change (mean FUP time 48 months). Overall upgrade rate was 18.7% (21/112). Age, menopausal status, concurrent breast cancer, BIRADS classification and number of foci of ADH were identified as risk factors for upgrade. Our model showed an AUC = 0.85 (95% CI 0.76-0.94). The points system showed that the risk of upgrade is < 2% when the total score is ≤ 1. CONCLUSION Our scoring system seemed a promising easy-to-use decision support tool for management of ADH, decreasing unnecessary surgeries, reducing patients' overtreatment and healthcare costs.
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Affiliation(s)
- Rossella Rella
- UOC Diagnostica per Immagini, Ospedale G.B. Grassi, Via Gian Carlo Passeroni, 28, 00122, Rome, Italy
| | - Marco Conti
- UOC di Radiologia Toracica e Cardiovascolare, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli 8, 00168, Rome, Italy.
| | - Alberto Borghetti
- UOC Malattie Infettive, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli 8, 00168, Rome, Italy
| | - Paolo Belli
- UOC di Radiologia Toracica e Cardiovascolare, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli 8, 00168, Rome, Italy
- Facoltà di Medicina e Chirurgia, Università Cattolica Sacro Cuore, Largo F. Vito 1, 00168, Rome, Italy
| | - Francesca Morciano
- Facoltà di Medicina e Chirurgia, Università Cattolica Sacro Cuore, Largo F. Vito 1, 00168, Rome, Italy
| | - Claudia Rossati
- UOSD Breast Unit ULSS9, Ospedale di Marzana, Piazzale Lambranzi, 1, 37142, Verona, Italy
| | - Andrea Caneva
- Divisione di Patologia, ULSS9 Scaligera, Ospedale G. Fracastoro, San Bonifacio, 37047, Verona, Italy
| | - Alba Di Leone
- Multidisciplinary Breast Centre, Dipartimento Scienze della Salute della Donna e del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168, Rome, Italy
| | - Gianluca Franceschini
- Multidisciplinary Breast Centre, Dipartimento Scienze della Salute della Donna e del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168, Rome, Italy
| | - Elisabetta Gori
- Facoltà di Medicina e Chirurgia, Università Cattolica Sacro Cuore, Largo F. Vito 1, 00168, Rome, Italy
| | - Francesca Fornasa
- UOSD Breast Unit ULSS9, Ospedale di Marzana, Piazzale Lambranzi, 1, 37142, Verona, Italy
| | - Oscar Tommasini
- UOC Diagnostica per Immagini, Ospedale G.B. Grassi, Via Gian Carlo Passeroni, 28, 00122, Rome, Italy
| | - Giovanna Romanucci
- UOSD Breast Unit ULSS9, Ospedale di Marzana, Piazzale Lambranzi, 1, 37142, Verona, Italy
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7
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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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8
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Miceli R, Mercado CL, Hernandez O, Chhor C. Active Surveillance for Atypical Ductal Hyperplasia and Ductal Carcinoma In Situ. JOURNAL OF BREAST IMAGING 2023; 5:396-415. [PMID: 38416903 DOI: 10.1093/jbi/wbad026] [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: 10/17/2022] [Indexed: 03/01/2024]
Abstract
Atypical ductal hyperplasia (ADH) and ductal carcinoma in situ (DCIS) are relatively common breast lesions on the same spectrum of disease. Atypical ductal hyperblasia is a nonmalignant, high-risk lesion, and DCIS is a noninvasive malignancy. While a benefit of screening mammography is early cancer detection, it also leads to increased biopsy diagnosis of noninvasive lesions. Previously, treatment guidelines for both entities included surgical excision because of the risk of upgrade to invasive cancer after surgery and risk of progression to invasive cancer for DCIS. However, this universal management approach is not optimal for all patients because most lesions are not upgraded after surgery. Furthermore, some DCIS lesions do not progress to clinically significant invasive cancer. Overtreatment of high-risk lesions and DCIS is considered a burden on patients and clinicians and is a strain on the health care system. Extensive research has identified many potential histologic, clinical, and imaging factors that may predict ADH and DCIS upgrade and thereby help clinicians select which patients should undergo surgery and which may be appropriate for active surveillance (AS) with imaging. Additionally, multiple clinical trials are currently underway to evaluate whether AS for DCIS is feasible for a select group of patients. Recent advances in MRI, artificial intelligence, and molecular markers may also have an important role to play in stratifying patients and delineating best management guidelines. This review article discusses the available evidence regarding the feasibility and limitations of AS for ADH and DCIS, as well as recent advances in patient risk stratification.
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Affiliation(s)
- Rachel Miceli
- NYU Langone Health, Department of Radiology, New York, NY, USA
| | | | | | - Chloe Chhor
- NYU Langone Health, Department of Radiology, New York, NY, USA
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9
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Grabenstetter A, Brennan SB, Sevilimedu V, Kuba MG, Giri DD, Wen HY, Morrow M, Brogi E. Is Surgical Excision of Focal Atypical Ductal Hyperplasia Warranted? Experience at a Tertiary Care Center. Ann Surg Oncol 2023; 30:4087-4094. [PMID: 36905438 PMCID: PMC10542905 DOI: 10.1245/s10434-023-13319-4] [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: 01/13/2023] [Accepted: 02/12/2023] [Indexed: 03/12/2023]
Abstract
BACKGROUND The core-needle biopsy (CNB) diagnosis of atypical ductal hyperplasia (ADH) generally mandates follow-up excision, but controversy exists on whether small foci of ADH require surgical management. This study evaluated the upgrade rate at excision of focal ADH (fADH), defined as 1 focus spanning ≤ 2 mm. METHODS We retrospectively identified in-house CNBs with ADH as the highest-risk lesion obtained between January 2013 and December 2017. A radiologist assessed radiologic-pathologic concordance. All CNB slides were reviewed by two breast pathologists, and ADH was classified as fADH and nonfocal ADH based on extent. Only cases with follow-up excision were included. The slides of excision specimens with upgrade were reviewed. RESULTS The final study cohort consisted of 208 radiologic-pathologic concordant CNBs, including 98 fADH and 110 nonfocal ADH. The imaging targets were calcifications (n = 157), a mass (n = 15), nonmass enhancement (n = 27), and mass enhancement (n = 9). Excision of fADH yielded seven (7%) upgrades (5 ductal carcinoma in situ (DCIS), 2 invasive carcinoma) versus 24 (22%) upgrades (16 DCIS, 8 invasive carcinoma) at excision of nonfocal ADH (p = 0.01). Both invasive carcinomas found at excision of fADH were subcentimeter tubular carcinomas away from the biopsy site and deemed incidental. CONCLUSIONS Our data show a significantly lower upgrade rate at excision of focal ADH than nonfocal ADH. This information can be valuable if nonsurgical management of patients with radiologic-pathologic concordant CNB diagnosis of focal ADH is being considered.
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Affiliation(s)
- Anne Grabenstetter
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| | - Sandra B Brennan
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Varadan Sevilimedu
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - M Gabriela Kuba
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Dilip D Giri
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Hannah Yong Wen
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Monica Morrow
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Edi Brogi
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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10
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Elfgen C, Leo C, Kubik-Huch RA, Muenst S, Schmidt N, Quinn C, McNally S, van Diest PJ, Mann RM, Bago-Horvath Z, Bernathova M, Regitnig P, Fuchsjäger M, Schwegler-Guggemos D, Maranta M, Zehbe S, Tausch C, Güth U, Fallenberg EM, Schrading S, Kothari A, Sonnenschein M, Kampmann G, Kulka J, Tille JC, Körner M, Decker T, Lax SF, Daniaux M, Bjelic-Radisic V, Kacerovsky-Strobl S, Condorelli R, Gnant M, Varga Z. Third International Consensus Conference on lesions of uncertain malignant potential in the breast (B3 lesions). Virchows Arch 2023:10.1007/s00428-023-03566-x. [PMID: 37330436 DOI: 10.1007/s00428-023-03566-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 05/01/2023] [Accepted: 05/17/2023] [Indexed: 06/19/2023]
Abstract
The heterogeneous group of B3 lesions in the breast harbors lesions with different malignant potential and progression risk. As several studies about B3 lesions have been published since the last Consensus in 2018, the 3rd International Consensus Conference discussed the six most relevant B3 lesions (atypical ductal hyperplasia (ADH), flat epithelial atypia (FEA), classical lobular neoplasia (LN), radial scar (RS), papillary lesions (PL) without atypia, and phyllodes tumors (PT)) and made recommendations for diagnostic and therapeutic approaches. Following a presentation of current data of each B3 lesion, the international and interdisciplinary panel of 33 specialists and key opinion leaders voted on the recommendations for further management after core-needle biopsy (CNB) and vacuum-assisted biopsy (VAB). In case of B3 lesion diagnosis on CNB, OE was recommended in ADH and PT, whereas in the other B3 lesions, vacuum-assisted excision was considered an equivalent alternative to OE. In ADH, most panelists (76%) recommended an open excision (OE) after diagnosis on VAB, whereas observation after a complete VAB-removal on imaging was accepted by 34%. In LN, the majority of the panel (90%) preferred observation following complete VAB-removal. Results were similar in RS (82%), PL (100%), and FEA (100%). In benign PT, a slim majority (55%) also recommended an observation after a complete VAB-removal. VAB with subsequent active surveillance can replace an open surgical intervention for most B3 lesions (RS, FEA, PL, PT, and LN). Compared to previous recommendations, there is an increasing trend to a de-escalating strategy in classical LN. Due to the higher risk of upgrade into malignancy, OE remains the preferred approach after the diagnosis of ADH.
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Affiliation(s)
- Constanze Elfgen
- Breast-Center Zurich, Zurich, Switzerland.
- University of Witten-Herdecke, Witten, Germany.
| | - Cornelia Leo
- Breast Center, Kantonsspital Baden, Baden, Switzerland
| | | | - Simone Muenst
- Institute of Medical Genetics and Pathology, University Hospital Basel, Basel, Switzerland
| | - Noemi Schmidt
- Department of Radiology, University Hospital Basel, Basel, Switzerland
| | - Cecily Quinn
- Irish National Breast Screening Program & Department of Histopathology, St. Vincent's University Hospital Dublin and School of Medicine, University College Dublin, Dublin, Ireland
| | - Sorcha McNally
- Radiology Department, St. Vincent University Hospital, Dublin, Ireland
| | - Paul J van Diest
- Department of Pathology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Ritse M Mann
- Department of Radiology, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Radiology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | | | - Maria Bernathova
- Department of Radiology and Nuclear Medicine, Medical University Vienna, Vienna, Austria
| | - Peter Regitnig
- Diagnostic and Research Institute of Pathology, Medical University Graz, Graz, Austria
| | - Michael Fuchsjäger
- Division of General Radiology, Department of Radiology, Medical University Graz, Graz, Austria
| | | | - Martina Maranta
- Department of Gynecology, County Hospital Chur, Chur, Switzerland
| | - Sabine Zehbe
- Radiology Section, Breast Center Stephanshorn, St. Gallen, Switzerland
| | | | - Uwe Güth
- Breast-Center Zurich, Zurich, Switzerland
| | - Eva Maria Fallenberg
- Department of Diagnostic and Interventional Radiology, School of Medicine & Klinikum Rechts der Isar, Technical University of Munich (TUM), Munich, Germany
| | - Simone Schrading
- Department of Radiology, County Hospital Lucerne, Lucerne, Switzerland
| | - Ashutosh Kothari
- Breast Surgery Unit, Guy's and St Thomas's NHS Foundation Trust, London, UK
| | | | - Gert Kampmann
- Centro di Radiologia e Senologia Luganese, Lugano, Switzerland
| | - Janina Kulka
- Department of Pathology, Forensic and Insurance Medicine, Semmelweis University Budapest, Budapest, Hungary
| | | | | | - Thomas Decker
- Breast Pathology, Reference Centers Mammography Münster, University Hospital Münster, Münster, Germany
| | - Sigurd F Lax
- Department of Pathology, Hospital Graz II, Graz, and School of Medicine, Johannes Kepler University Linz, Linz, Austria
| | - Martin Daniaux
- BrustGesundheitZentrum Tirol, University Hospital Innsbruck, Innsbruck, Austria
| | - Vesna Bjelic-Radisic
- University of Witten-Herdecke, Witten, Germany
- Breast Unit, Helios University Hospital, University Witten/Herdecke, Witten, Germany
| | | | | | - Michael Gnant
- Comprehensive Cancer Center, Medical University Vienna, Vienna, Austria
| | - Zsuzsanna Varga
- Department of Pathology and Molecular Pathology, University Hospital Zürich, Zürich, Switzerland
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11
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Han LK, Hussain A, Dodelzon K, Ginter PS, Towne WS, Marti JL. Active Surveillance of Atypical Ductal Hyperplasia of the Breast. Clin Breast Cancer 2023:S1526-8209(23)00130-1. [PMID: 37328333 DOI: 10.1016/j.clbc.2023.05.008] [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: 09/21/2022] [Revised: 04/25/2023] [Accepted: 05/17/2023] [Indexed: 06/18/2023]
Abstract
BACKGROUND When needle core biopsy (NCB) of the breast yields atypical ductal hyperplasia (ADH), excision is typically recommended. The natural history of ADH undergoing active surveillance (AS) is not well described. We investigate the rates of upgrade to malignancy of excised ADH and the rates of radiographic progression under AS. MATERIALS AND METHODS We retrospectively reviewed records of 220 cases of ADH on NCB. Of patients who had surgery within 6 months of NCB, we examined the malignancy upgrade rate. In the AS cohort, we examined rates of radiographic progression on interval imaging. RESULTS The malignancy upgrade rate among patients who underwent immediate excision (n = 185) was 15.7%: 14.1% (n = 26) ductal carcinoma in situ (DCIS) and 1.6% (n = 3) invasive ductal carcinoma (IDC). Upgrade to malignancy was less common in lesions <4 mm in size (0%) or with focal ADH (5%), and more common among lesions presenting with a radiographic mass (26%). Among the 35 patients who underwent AS, median follow-up was 20 months. Two lesions progressed on imaging (incidence 3.8% at 2 years). One patient without radiographic progression was found to have IDC at delayed surgery. The remaining lesions remained stable (46%), decreased in size (11%), or resolved (37%). CONCLUSIONS Our findings suggest that AS is a safe approach to managing ADH on NCB for most patients. This could spare many patients with ADH from unnecessary surgery. Given that AS is being investigated for low-risk DCIS in multiple international prospective trials, these results suggest that AS should also be investigated for ADH.
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Affiliation(s)
- Lynn K Han
- Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY
| | - Anum Hussain
- Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY
| | - Katerina Dodelzon
- Department of Radiology, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY
| | - Paula S Ginter
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, NY
| | - William S Towne
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, NY
| | - Jennifer L Marti
- Division of Breast Surgery, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, New York, NY.
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12
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Fraker JL, Clune CG, Sahni SK, Yaganti A, Vegunta S. Prevalence, Impact, and Diagnostic Challenges of Benign Breast Disease: A Narrative Review. Int J Womens Health 2023; 15:765-778. [PMID: 37223067 PMCID: PMC10202205 DOI: 10.2147/ijwh.s351095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 05/05/2023] [Indexed: 05/25/2023] Open
Abstract
Benign breast diseases, which are commonly seen in clinical practice, have various clinical presentations and implications, as well as management strategies. This article describes common benign breast lesions, presentations of these lesions, and typical radiographic and histologic findings. Also included in this review are the most recent data and guideline-based recommendations for the management of benign breast diseases at diagnosis, including surgical referral, medical management, and ongoing surveillance.
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Affiliation(s)
- Jessica L Fraker
- Division of Women’s Health Internal Medicine, Mayo Clinic, Scottsdale, AZ, USA
| | - Caroline G Clune
- Center for Breast Care, Mayo Clinic Health System — Southwest Wisconsin Region, La Crosse, WI, USA
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Sabrina K Sahni
- Jacoby Center for Breast Health, Mayo Clinic, Jacksonville, FL, USA
| | - Avani Yaganti
- Southern Illinois University School of Medicine, Springfield, IL, USA
| | - Suneela Vegunta
- Division of Women’s Health Internal Medicine, Mayo Clinic, Scottsdale, AZ, USA
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13
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Khadka VS, Nasu M, Deng Y, Jijiwa M. Circulating microRNA Biomarker for Detecting Breast Cancer in High-Risk Benign Breast Tumors. Int J Mol Sci 2023; 24:7553. [PMID: 37108716 PMCID: PMC10142546 DOI: 10.3390/ijms24087553] [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: 03/23/2023] [Revised: 04/13/2023] [Accepted: 04/18/2023] [Indexed: 04/29/2023] Open
Abstract
High-risk benign breast tumors are known to develop breast cancer at high rates. However, it is still controversial whether they should be removed during diagnosis or followed up until cancer development becomes evident. Therefore, this study sought to identify circulating microRNAs (miRNAs) that could serve as detection markers of cancers arising from high-risk benign tumors. Small RNA-seq was performed using plasma samples collected from patients with early-stage breast cancer (CA) and high-risk (HB), moderate-risk (MB), and no-risk (Be) benign breast tumors. Proteomic profiling of CA and HB plasma was performed to investigate the underlying functions of the identified miRNAs. Our findings revealed that four miRNAs, hsa-mir-128-3p, hsa-mir-421, hsa-mir-130b-5p, and hsa-mir-28-5p, were differentially expressed in CA vs. HB and had diagnostic power to discriminate CA from HB with AUC scores greater than 0.7. Enriched pathways based on the target genes of these miRNAs indicated their association with IGF-1. Furthermore, the Ingenuity Pathway Analysis performed on the proteomic data revealed that the IGF-1 signaling pathway was significantly enriched in CA vs. HB. In conclusion, these findings suggest that these miRNAs could potentially serve as biomarkers for detecting early-stage breast cancer from high-risk benign tumors by monitoring IGF signaling-induced malignant transformation.
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Affiliation(s)
| | | | - Youping Deng
- Department of Quantitative Health Sciences, John A. Burns School of Medicine, University of Hawaii, 651 Ilalo Street, Honolulu, HI 96813, USA; (V.S.K.); (M.N.)
| | - Mayumi Jijiwa
- Department of Quantitative Health Sciences, John A. Burns School of Medicine, University of Hawaii, 651 Ilalo Street, Honolulu, HI 96813, USA; (V.S.K.); (M.N.)
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14
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Breast MRI assists in decision-making for surgical excision of atypical ductal hyperplasia. Surgery 2023; 173:612-618. [PMID: 36202650 DOI: 10.1016/j.surg.2022.07.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Revised: 07/07/2022] [Accepted: 07/11/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND Atypical ductal hyperplasia diagnosed on percutaneous breast biopsy typically undergoes surgical excision, upgrading to invasive breast cancer or ductal carcinoma in situ in 10% to 53%. In efforts to limit excision to those with highest upgrade risk, we sought to determine if breast magnetic resonance imaging has value in predicting upgrade. In this study, we will describe magnetic resonance imaging presentation of atypical ductal hyperplasia and assess magnetic resonance imaging accuracy in predicting upgrade. METHODS All female patients ≥18 years with atypical ductal hyperplasia on percutaneous breast biopsy undergoing magnetic resonance imaging from 2008 to 2020 were included. Patient demographics, imaging presentation, magnetic resonance imaging enhancement kinetic curves, and pathology features were captured. Categorical variables were analyzed using Fisher exact to test for association between variables and upgrade. Continuous variables were analyzed using t tests. RESULTS Magnetic resonance imaging was performed for 125 percutaneous breast biopsy with atypical ductal hyperplasia: 67 after and 58 before atypical ductal hyperplasia diagnosis. On magnetic resonance imaging, atypical ductal hyperplasia site had no enhancement in 45 (36%), nonmass enhancement in 50 (40%), and mass enhancement in 30 (24%). In total, 28% had atypical ductal hyperplasia diagnosed by magnetic resonance imaging-guided percutaneous breast biopsy. Surgical excision was performed for 96 (76.8%) and 15 (15.6%) upgraded (11 ductal carcinoma in situ, 4 invasive breast cancer). All 15 upgrades had enhancement. Any kinetic pattern enhancement was significantly associated with upgrade (P = .009) with upgrade most strongly associated with type III washout. The lowest risk for upgrade was pure atypical ductal hyperplasia and no magnetic resonance imaging enhancement (0%, n = 25). CONCLUSIONS Active monitoring may be safely offered to women with pure atypical ductal hyperplasia on percutaneous breast biopsy when magnetic resonance imaging shows no enhancement. Any enhancement at atypical ductal hyperplasia site, particularly type III washout kinetics, should continue to undergo excision.
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15
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Safety of de-escalation of surgical intervention for atypical ductal hyperplasia on percutaneous biopsy: One size does not fit all. Am J Surg 2023; 225:21-25. [PMID: 36180303 DOI: 10.1016/j.amjsurg.2022.09.044] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Revised: 07/23/2022] [Accepted: 09/20/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Oncologic safety of active monitoring (AM) for atypical ductal hyperplasia (ADH) on core-needle biopsy (CNB) is not well defined. We sought to define oncologic outcomes for AM to manage ADH meeting institutional predefined low-risk criteria (LOW). METHODS ADH was diagnosed on CNB from 10/2015-03/2020. LOW (pure ADH, size <1 cm, >50% removed by CNB, <3 foci, and no necrosis) patients were offered AM; all others were recommended for surgical excision. Oncologic outcomes were compared for AM and surgery. RESULTS 111 were included, 21 (19%) meeting LOW. AM occurred in 18 (86%) while 3 elected for excision (with 0% upgrade). Of the 18 LOW in AM, 2 required additional CNB (none at ADH site): 0% were diagnosed with cancer over median 23 month follow-up. CONCLUSIONS There were no missed cancers at ADH site during AM for LOW, confirming the oncologic safety of AM in this select group.
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16
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Varga Z, Sinn P, Lebeau A. [B3 lesions of the breast: histological, clinical, and epidemiological aspects : Update]. PATHOLOGIE (HEIDELBERG, GERMANY) 2023; 44:5-16. [PMID: 36635403 PMCID: PMC9877091 DOI: 10.1007/s00292-022-01180-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 12/22/2022] [Indexed: 01/14/2023]
Abstract
B3 lesions of the breast are a heterogeneous group of lesions with uncertain malignant potential encompassing a broad spectrum of histologically distinct alterations that often pose challenging decisions if diagnosed on the preoperative core or vacuum biopsies. B3 lesions are mostly detected due to mammographic calcifications or mass lesions and, in most cases, encompass a spectrum of atypical lesions such as atypical ductal hyperplasia, classic lobular neoplasia, flat epithelial atypia, papillomas, fibroepithelial tumors, and rarely other lesions such as mucocele-like lesions, atypical apocrine lesions, and rare stromal proliferations. The use of immunohistochemical stains (estrogen receptors, basal cytokeratin, myoepithelial markers, and stromal marker panel) is useful in the differentiation of these lesions and allowing proper classification. Regarding clinical management of B3 lesions, the radiological-pathological correlation of the given entity plays the most important key element for the proper next diagnostic and therapeutic step.
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Affiliation(s)
- Zsuzsanna Varga
- Institut für Pathologie und Molekularpathologie, Universitätsspital Zürich, Schmelzbergstr. 12, 8091 Zürich, Schweiz
| | - Peter Sinn
- Pathologisches Institut, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - Annette Lebeau
- Institut für Pathologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland ,Gemeinschaftspraxis für Pathologie, Lübeck, Deutschland
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17
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Record S, Chiba A. ADH: To excise or not to excise, that is the question. Am J Surg 2023; 225:20. [PMID: 36437122 DOI: 10.1016/j.amjsurg.2022.10.055] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 10/25/2022] [Indexed: 11/13/2022]
Affiliation(s)
| | - Akiko Chiba
- Department of Surgery, Duke University Medical Center, Durham, NC, USA; Duke Cancer Institute, Durham, NC, USA; Department of Surgery, Durham VA Medical Center, Durham, NC, USA.
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18
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Harbhajanka A, Gilmore HL, Calhoun BC. High-risk and selected benign breast lesions diagnosed on core needle biopsy: Evidence for and against immediate surgical excision. Mod Pathol 2022; 35:1500-1508. [PMID: 35654997 DOI: 10.1038/s41379-022-01092-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 04/18/2022] [Accepted: 04/18/2022] [Indexed: 11/09/2022]
Abstract
The vast majority of image-detected breast abnormalities are diagnosed by percutaneous core needle biopsy (CNB) in contemporary practice. For frankly malignant lesions diagnosed by CNB, the standard practice of excision and multimodality therapy have been well-defined. However, for high-risk and selected benign lesions diagnosed by CNB, there is less consensus on optimal patient management and the need for immediate surgical excision. Here we outline the arguments for and against the practice of routine surgical excision of commonly encountered high-risk and selected benign breast lesions diagnosed by CNB. The entities reviewed include atypical ductal hyperplasia, atypical lobular hyperplasia, lobular carcinoma in situ, intraductal papillomas, and radial scars. The data in the peer-reviewed literature confirm the benefits of a patient-centered, multidisciplinary approach that moves away from the reflexive "yes" or "no" for routine excision for a given pathologic diagnosis.
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Affiliation(s)
- Aparna Harbhajanka
- Department of Pathology, Case Western University School of Medicine, Cleveland, OH, 44106, USA
| | - Hannah L Gilmore
- Department of Pathology, Case Western University School of Medicine, Cleveland, OH, 44106, USA
| | - Benjamin C Calhoun
- Department of Pathology and Laboratory Medicine, The University of North Carolina School of Medicine, Chapel Hill, NC, 27599, USA.
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19
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Pleasant V. Management of breast complaints and high-risk lesions. Best Pract Res Clin Obstet Gynaecol 2022; 83:46-59. [PMID: 35570155 DOI: 10.1016/j.bpobgyn.2022.03.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Revised: 03/24/2022] [Accepted: 03/28/2022] [Indexed: 11/02/2022]
Abstract
Benign breast disease including palpable breast mass, mastalgia, skin changes, and nipple discharge are common gynecologic symptoms. Practitioners should be well versed in the components of clinical breast care. Workup begins with taking a thorough medical and family history to assess risk and performing a clinical breast examination. Breast imaging is often indicated for further evaluation. A structured approach to the evaluation and management of these breast conditions is critical to distinguish benign disease from malignancy. High-risk breast lesions such as atypical hyperplasia and lobular carcinoma in situ are also frequently encountered, and while benign, they do increase the future risk of breast cancer and patients should be offered intensive surveillance and chemoprevention.
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Affiliation(s)
- Versha Pleasant
- University of Michigan, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA.
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20
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Sanders ME, Podoll MB. Atypical Ductal Hyperplasia-Ductal Carcinoma In Situ Spectrum: Diagnostic Considerations and Treatment Impact in the Era of Deescalation. Surg Pathol Clin 2022; 15:95-103. [PMID: 35236636 DOI: 10.1016/j.path.2021.11.006] [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: 06/14/2023]
Abstract
As the first node in treatment algorithms for breast disease, pathologists have the potential to play a critical role in refining appropriate therapy for lesions in the atypical ducal hyperplasia-ductal carcinoma in situ (ADH-DCIS) spectrum by conservatively approaching diagnosis of lesions limited in size on core needle biopsy. Appropriate efforts to downgrade the diagnosis of lesions at the borderline of ADH and DCIS will certainly lead to more breast conservation and avoid the common morbidities of mastectomy, sentinel node biopsy, and radiation therapy. Whether results of clinical trials of active surveillance will successfully identify a subset of women who may successfully forgo even limited breast-conserving surgery is eagerly anticipated. Given the increasing concern that a significant number of women with DCIS are overtreated, identification of patients at very low risk for progression who may forgo surgery and radiation therapy safely is of significant interest.
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Affiliation(s)
- Melinda E Sanders
- Vanderbilt University Medical Center, 1301 Medical Center Drive, 4918A TVC Blg, Nashville, TN 37215.
| | - Mirna B Podoll
- Vanderbilt University Medical Center, 1301 Medical Center Drive, 4918A TVC Blg, Nashville, TN 37215
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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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22
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Bong TSH, Tan JKT, Ho JTS, Tan PH, Lau WS, Tan TM, Wong JSL, Tan VKM, Tan BKT, Madhukumar P, Yong WS, Lim SZ, Wong CY, Ong KW, Sim Y. Atypical Ductal Hyperplasia of the Breast on Core Needle Biopsy: Risk of Malignant Upgrade On Surgical Excision. J Breast Cancer 2022; 25:37-48. [PMID: 35199500 PMCID: PMC8876544 DOI: 10.4048/jbc.2022.25.e7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 11/06/2021] [Accepted: 02/02/2022] [Indexed: 11/30/2022] Open
Abstract
Purpose This study identified factors predicting malignant upgrade for atypical ductal hyperplasia (ADH) diagnosed on core-needle biopsy (CNB) and developed a nomogram to facilitate evidence-based decision making. Methods This retrospective analysis included women diagnosed with ADH at the National Cancer Centre Singapore (NCCS) in 2010–2015. Cox proportional hazards regression was used to identify clinical, radiological, and histological factors associated with malignant upgrade. A nomogram was constructed using variables with the strongest associations in multivariate analysis. Multivariable logistic regression coefficients were used to estimate the predicted probability of upgrade for each factor combination. Results Between 2010 and 2015, 238,122 women underwent mammographic screening under the National Breast Cancer Screening Program. Among 29,564 women recalled, 5,971 CNBs were performed. Of these, 2,876 underwent CNBs at NCCS, with 88 patients (90 lesions) diagnosed with ADH and 26 lesions upgraded to breast malignancy on excision biopsy. In univariate analysis, factors associated with malignant upgrade were the presence of a mass on ultrasound (p = 0.018) or mammography (p = 0.026), microcalcifications (p = 0.047), diffuse microcalcification distribution (p = 0.034), mammographic parenchymal density (p = 0.008). and ≥ 3 separate ADH foci found on biopsy (p = 0.024). Mammographic parenchymal density (hazard ratio [HR], 0.04; 95% confidence interval [CI], 0.005–0.35; p = 0.014), presence of a mass on ultrasound (HR, 10.50; 95% CI, 9.21–25.2; p = 0.010), and number of ADH foci (HR, 1.877; 95% CI, 1.831–1.920; p = 0.002) remained significant in multivariate analysis and were included in the nomogram. Conclusion Our model provided good discrimination of breast cancer risk prediction (C-statistic of 0.81; 95% CI, 0.74–0.88) and selected for a subset of women at low risk (2.1%) of malignant upgrade, who may avoid surgical excision following a CNB diagnosis of ADH.
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Affiliation(s)
- Tiffany Sin Hui Bong
- Department of Breast Surgery, Division of Surgery and Surgical Oncology, National Cancer Centre Singapore, Singapore
| | - Jun Kiat Thaddaeus Tan
- Department of Breast Surgery, Division of Surgery and Surgical Oncology, National Cancer Centre Singapore, Singapore
| | | | - Puay Hoon Tan
- Division of Pathology, Singapore General Hospital, Singapore
| | - Wing Sze Lau
- Department of Clinical Laboratory, Gleneagles Hospital Hong Kong, Hong Kong
| | - Tuan Meng Tan
- Department of Statistics and Applied Probability, National University of Singapore, Singapore
| | - Jill Su Lin Wong
- Division of Oncologic Imaging, National Cancer Centre Singapore, Singapore
| | - Veronique Kiak Mien Tan
- Department of Breast Surgery, Division of Surgery and Surgical Oncology, National Cancer Centre Singapore, Singapore
- Department of Breast Surgery, Division of Surgery and Surgical Oncology, Singapore General Hospital, Singapore
- SingHealth Duke-NUS Breast Centre, Singapore
| | - Benita Kiat Tee Tan
- Department of Breast Surgery, Division of Surgery and Surgical Oncology, National Cancer Centre Singapore, Singapore
- Department of Breast Surgery, Division of Surgery and Surgical Oncology, Singapore General Hospital, Singapore
- SingHealth Duke-NUS Breast Centre, Singapore
- Department of General Surgery, Sengkang General Hospital, Singapore
| | - Preetha Madhukumar
- Department of Breast Surgery, Division of Surgery and Surgical Oncology, National Cancer Centre Singapore, Singapore
- Department of Breast Surgery, Division of Surgery and Surgical Oncology, Singapore General Hospital, Singapore
- SingHealth Duke-NUS Breast Centre, Singapore
| | - Wei Sean Yong
- Department of Breast Surgery, Division of Surgery and Surgical Oncology, National Cancer Centre Singapore, Singapore
- Department of Breast Surgery, Division of Surgery and Surgical Oncology, Singapore General Hospital, Singapore
- SingHealth Duke-NUS Breast Centre, Singapore
| | - Sue Zann Lim
- Department of Breast Surgery, Division of Surgery and Surgical Oncology, National Cancer Centre Singapore, Singapore
- Department of Breast Surgery, Division of Surgery and Surgical Oncology, Singapore General Hospital, Singapore
- SingHealth Duke-NUS Breast Centre, Singapore
| | - Chow Yin Wong
- Department of Breast Surgery, Division of Surgery and Surgical Oncology, Singapore General Hospital, Singapore
- SingHealth Duke-NUS Breast Centre, Singapore
| | - Kong Wee Ong
- Department of Breast Surgery, Division of Surgery and Surgical Oncology, National Cancer Centre Singapore, Singapore
- Department of Breast Surgery, Division of Surgery and Surgical Oncology, Singapore General Hospital, Singapore
- SingHealth Duke-NUS Breast Centre, Singapore
| | - Yirong Sim
- Department of Breast Surgery, Division of Surgery and Surgical Oncology, National Cancer Centre Singapore, Singapore
- Department of Breast Surgery, Division of Surgery and Surgical Oncology, Singapore General Hospital, Singapore
- SingHealth Duke-NUS Breast Centre, Singapore
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23
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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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Nicosia L, Latronico A, Addante F, De Santis R, Bozzini AC, Montesano M, Frassoni S, Bagnardi V, Mazzarol G, Pala O, Lazzeroni M, Lissidini G, Mastropasqua MG, Cassano E. Atypical Ductal Hyperplasia after Vacuum-Assisted Breast Biopsy: Can We Reduce the Upgrade to Breast Cancer to an Acceptable Rate? Diagnostics (Basel) 2021; 11:diagnostics11061120. [PMID: 34205428 PMCID: PMC8259513 DOI: 10.3390/diagnostics11061120] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Revised: 06/16/2021] [Accepted: 06/17/2021] [Indexed: 12/02/2022] Open
Abstract
(1) Background: to evaluate which factors can reduce the upgrade rate of atypical ductal hyperplasia (ADH) to in situ or invasive carcinoma in patients who underwent vacuum-assisted breast biopsy (VABB) and subsequent surgical excision. (2) Methods: 2955 VABBs were reviewed; 141 patients with a diagnosis of ADH were selected for subsequent surgical excision. The association between patients’ characteristics and the upgrade rate to breast cancer was evaluated in both univariate and multivariate analyses. (3) Results: the upgrade rates to ductal carcinoma in situ (DCIS) and invasive carcinoma (IC) were, respectively, 29.1% and 7.8%. The pooled upgrade rate to DCIS or IC was statistically lower at univariate analysis, considering the following parameters: complete removal of the lesion (p-value < 0.001); BIRADS ≤ 4a (p-value < 0.001); size of the lesion ≤15 mm (p-value: 0.002); age of the patients <50 years (p-value: 0.035). (4) Conclusions: the overall upgrade rate of ADH to DCIS or IC is high and, as already known, surgery should be recommended. However, ADH cases should always be discussed in multidisciplinary meetings: some parameters appear to be related to a lower upgrade rate. Patients presenting these parameters could be strictly followed up to avoid overtreatment.
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Affiliation(s)
- Luca Nicosia
- Department of Breast Radiology, IEO European Institute of Oncology, IRCCS, 20141 Milan, Italy; (L.N.); (A.L.); (A.C.B.); (M.M.); (E.C.)
| | - Antuono Latronico
- Department of Breast Radiology, IEO European Institute of Oncology, IRCCS, 20141 Milan, Italy; (L.N.); (A.L.); (A.C.B.); (M.M.); (E.C.)
| | - Francesca Addante
- Department of Emergency and Organ Transplantation, Section of Anatomic Pathology, School of Medicine, University “Aldo Moro”, 70124 Bari, Italy;
| | - Rossella De Santis
- Postgraduate School in Radiology, University of Milan, 20122 Milan, Italy;
| | - Anna Carla Bozzini
- Department of Breast Radiology, IEO European Institute of Oncology, IRCCS, 20141 Milan, Italy; (L.N.); (A.L.); (A.C.B.); (M.M.); (E.C.)
| | - Marta Montesano
- Department of Breast Radiology, IEO European Institute of Oncology, IRCCS, 20141 Milan, Italy; (L.N.); (A.L.); (A.C.B.); (M.M.); (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.)
| | - Giovanni Mazzarol
- Division of Pathology and Laboratory Medicine, IEO European Institute of Oncology, IRCCS, 20141 Milan, Italy; (G.M.); (O.P.)
| | - Oriana Pala
- Division of Pathology and Laboratory Medicine, IEO European Institute of Oncology, IRCCS, 20141 Milan, Italy; (G.M.); (O.P.)
| | - Matteo Lazzeroni
- Division of Cancer Prevention and Genetics, IEO European Institute of Oncology IRCCS, 20141 Milan, Italy;
| | - Germana Lissidini
- Division of Breast Surgery, IEO European Institute of Oncology, IRCCS, 20141 Milan, Italy;
| | - Mauro Giuseppe Mastropasqua
- Department of Emergency and Organ Transplantation, Section of Anatomic Pathology, School of Medicine, University “Aldo Moro”, 70124 Bari, Italy;
- Correspondence: ; Tel.: +39-0805594414
| | - Enrico Cassano
- Department of Breast Radiology, IEO European Institute of Oncology, IRCCS, 20141 Milan, Italy; (L.N.); (A.L.); (A.C.B.); (M.M.); (E.C.)
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25
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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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26
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Upgrade Rate of Atypical Ductal Hyperplasia: Ten Years Experience and Predictive Factors. J Surg Res 2021; 266:311-318. [PMID: 34044175 DOI: 10.1016/j.jss.2021.03.063] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 01/13/2021] [Accepted: 03/26/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Atypical ductal hyperplasia (ADH) is a benign epithelial proliferative lesion with histologic features resembling those seen in low grade ductal carcinoma in situ (DCIS). Surgical excision of the biopsy site is the standard management approach. The objective of this study was to determine the upgrade rate from ADH on stereotactic breast biopsies to DCIS or invasive carcinoma (IC) in our institution. We also sought to identify clinical, pathologic and radiologic predictive factors associated with risk of upgrade. MATERIALS AND METHODS Clinical charts, mammograms and pathology reports were reviewed for all women with a stereotactic breast biopsy showing ADH and subsequent surgery at our institution between 2008 and 2018. When available, mammograms were re-reviewed by a radiologist for this study. RESULTS 295 biopsies were analyzed in 290 patients. Mean age was 56 y old. Upgrade rate was 10.5% of which 7.5% were DCIS and 3.1% IC. Mammograms were reviewed by a radiologist in 161 patients from 2013 to 2018. In this subset of patients, the rate of upgrade was 8.7% (4.35% DCIS and 4.35% IC). A statistically significant difference he largest size of the microcalcification clusters on mammogram was observed between the upgraded and the non-upgraded subgroups (14.2 mm versus 8.9 mm, P = 0.03) CONCLUSIONS: The evaluation of the largest size of microcalcification clusters on mammogram as a cut-off feature could be considered to choose between an observational versus a surgical approach. This large series provides contemporary data to assist informed decision making regarding the treatment of our patients.
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27
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Sun T, Zhang H, Gao W, Yang Q. The appropriate number of preoperative core needle biopsy specimens for analysis in breast cancer. Medicine (Baltimore) 2021; 100:e25400. [PMID: 33832135 PMCID: PMC8036035 DOI: 10.1097/md.0000000000025400] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 03/14/2021] [Indexed: 01/05/2023] Open
Abstract
Ultrasound (US)-guided core needle biopsy (CNB) has been recognized as a crucial diagnostic tool for breast cancer. However, there is a lack of guidance for hospitals that are not equipped with adjunctive US. The aim of this study was to assess the sensitivity, specificity, and experience of freehanded CNB in the outpatient department, and to determine the minimum number of tissue strips required to obtain concordance for estrogen receptor (ER), progesterone receptor (PR), human epidermal growth factor receptor-2 (HER2), and tumor grade with the excised specimen.A prospective study was performed on 95 patients undergoing CNB and subsequent surgical procedures. The reliability of immunohistochemical assessments of the pathological type, tumor grade, ER, PR, and HER2 status in CNBs was compared with that of surgical specimens. Concordance between the CNBs and surgical samples was estimated as a percentage agreement, and analyzed using the chi-square test. A P < .05 was considered significant.The concordance rates of ER, PR, and HER2 status and tumor grade status between CNBs and surgically excised specimens were 97.9%, 91.6%, 82.1%, and 84.2%, respectively. The reliability of taking 2 tissue strips was similar to that of taking six tissue strips in distinguishing malignancy from benignancy, and determining the pathological type without the aid of US. Four tissue strips obtained by CNB showed good accuracy comparable to those obtained by surgical specimens in assessing ER, PR, and HER2 status and tumor grade.Two tissue strips obtained by CNB showed good accuracy in differentiating malignancy from benignancy, while at least 4 strips are recommended to obtain overall conformity of pathological biomarkers.
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Affiliation(s)
- Tao Sun
- Department of Breast Surgery, General Surgery, Qilu Hospital of Shandong University
- Department of Breast and Thyroid Surgery
| | - Hanwen Zhang
- Department of Breast Surgery, General Surgery, Qilu Hospital of Shandong University
| | - Wei Gao
- Department of Pathology, Jinan Central Hospital Affiliated to Shandong University, Jinan, Shandong
| | - Qifeng Yang
- Department of Breast Surgery, General Surgery, Qilu Hospital of Shandong University
- Pathology Tissue Bank, Qilu Hospital of Shandong University
- Research Institute of Breast Cancer, Shandong University, China
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28
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Huang YX, Chen YL, Li SP, Shen JP, Zuo K, Zhou SC, Chang C. Development and Validation of a Simple-to-Use Nomogram for Predicting the Upgrade of Atypical Ductal Hyperplasia on Core Needle Biopsy in Ultrasound-Detected Breast Lesions. Front Oncol 2021; 10:609841. [PMID: 33868984 PMCID: PMC8044403 DOI: 10.3389/fonc.2020.609841] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 12/16/2020] [Indexed: 11/19/2022] Open
Abstract
Background The rate of carcinoma upgrade for atypical ductal hyperplasia (ADH) diagnosed on core needle biopsy (CNB) is variable on open excision. The purpose of the present study was to develop and validate a simple-to-use nomogram for predicting the upgrade of ADH diagnosed with ultrasound (US)-guided core needle biopsy in patients with US-detected breast lesions. Methods Two retrospective sets, the training set (n = 401) and the validation set (n = 186), from Fudan University Shanghai Cancer Center between January 2014 and December 2019 were retrospectively analyzed. Clinicopathological and US features were selected using univariate and multivariable logistic regression, and the significant features were incorporated to build a nomogram model. Model discrimination and calibration were assessed in the training set and validation set. Results Of the 587 ADH biopsies, 67.7% (training set: 267/401, 66.6%; validation set: 128/186, 68.8%) were upgraded to cancers. In the multivariable analysis, the risk factors were age [odds ratio (OR) 2.739, 95% confidence interval (CI): 1.525–5.672], mass palpation (OR 3.008, 95% CI: 1.624–5.672), calcifications on US (OR 4.752, 95% CI: 2.569–9.276), ADH extent (OR 3.150, 95% CI: 1.951–5.155), and suspected malignancy (OR 4.162, CI: 2.289–7.980). The model showed good discrimination, with an area under curve (AUC) of 0.783 (95% CI: 0.736–0.831), and good calibration (p = 0.543). The application of the nomogram in the validation set still had good discrimination (AUC = 0.753, 95% CI: 0.666–0.841) and calibration (p = 0.565). Instead of surgical excision of all ADHs, if those categorized with the model to be at low risk for upgrade were surveillanced and the remainder were excised, then 63.7% (37/58) of surgeries of benign lesions could have been avoided and 78.1% (100/128) malignant lesions could be treated in time. Conclusions This study developed a simple-to-use nomogram by incorporating clinicopathological and US features with the overarching goal of predicting the probability of upgrade in women with ADH. The nomogram could be expected to decrease unnecessary surgery by nearly two-third and to identify most of the malignant lesions, helping guide clinical decision making with regard to surveillance versus surgical excision of ADH lesions.
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Affiliation(s)
- Yun-Xia Huang
- Department of Ultrasonography, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Ya-Ling Chen
- Department of Ultrasonography, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Shi-Ping Li
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China.,Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Ju-Ping Shen
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China.,Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Ke Zuo
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China.,Department of Pathology, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Shi-Chong Zhou
- Department of Ultrasonography, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Cai Chang
- Department of Ultrasonography, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
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Abstract
High-risk breast lesions (HRLs) are a group of heterogeneous lesions that can be associated with a synchronous or adjacent breast cancer and that confer an elevated lifetime risk of breast cancer. Management of HRLs after core needle biopsy may include close imaging and clinical follow-up or excisional biopsy to evaluate for cancer. This article reviews histologic features and clinical presentation of each of the HRLs, current evidence with regard to management, and guidelines from the American Society of Breast Surgeons and National Comprehensive Cancer Network. In addition, imaging surveillance and risk-reduction strategies for women with HRLs are discussed.
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30
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Li X, Ma Z, Styblo TM, Arciero CA, Wang H, Cohen MA. Management of high-risk breast lesions diagnosed on core biopsies and experiences from prospective high-risk breast lesion conferences at an academic institution. Breast Cancer Res Treat 2020; 185:573-581. [PMID: 33068196 DOI: 10.1007/s10549-020-05977-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 10/08/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND The management of high-risk breast lesions diagnosed on image-guided core biopsy remains controversial. We implemented a high-risk breast conference attended by breast pathologists, imagers, and surgeons to prospectively review all contemporary cases in order to provide a consensus recommendation to either surgically excise or follow on imaging at 6-month intervals for a minimum of 2 years. METHODS Between May, 2015 and June, 2019, 127 high-risk lesions were discussed. Of these 127 cases, 116 had concordant radiology-pathology (rad-path) findings. The remaining 11 patients had discordant rad-path findings. Of the 116 concordant cases, 6 were excluded due to lack of the first imaging follow-up until analysis. Of the remaining 110 patients, 43 had atypical ductal hyperplasia (ADH), 12 had lobular carcinoma in situ (LCIS), 19 had atypical lobular hyperplasia (ALH), 33 had radial scar (RS), 2 had flat epithelial atypia (FEA), and 1 had mucocele-like lesion (ML). We recommended excision for ADH if there were > 2 ADH foci or < 90% of the associated calcifications were removed. For patients with LCIS or ALH, we recommended excision if the LCIS or ALH was associated with microcalcifications or the LCIS was extensive. We recommended excision of RS when < 1/2 of the lesion was biopsied. We recommended all patients with FEA and ML for 6-month follow-up. RESULTS Following conference-derived consensus for excision, of the 27 ADH excised, 9 were upgraded to invasive carcinoma or ductal carcinoma in situ. Of the six LCIS cases recommended for excision, none were upgraded. Nine excised radial scars revealed no upgrades. Additionally, 3 patients with ADH, 2 with ALH, 1 with LCIS, and 2 with RS underwent voluntary excision, and none were upgraded. All other patients (13 with ADH, 5 LCIS, 17 ALH, 22 RS, 2 FEA and 1 ML) were followed with imaging, and none revealed evidence of disease progression during follow-up (187-1389 days). All 11 rad-path discordant cases were excised with 2 upgraded to carcinoma. CONCLUSIONS The results of this prospective study indicate that high-risk breast lesions can be successfully triaged to surgery versus observation following establishment of predefined firm guidelines and performance of rigorous rad-path correlation.
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Affiliation(s)
- Xiaoxian Li
- Department of Pathology and Laboratory Medicine, Emory University, 1364 Clifton Road, Atlanta, GA, 30322, USA.
| | - Zhongliang Ma
- Breast Disease Center, The Affiliated Hospital of Qingdao University, Qingdao, China
| | | | | | - Haibo Wang
- Breast Disease Center, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Michael A Cohen
- Department of Radiology and Imaging Sciences, Emory University, 1364 Clifton Road, Atlanta, GA, 30322, USA.
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Polat DS, Schopp JG, Arjmandi F, Porembka J, Sarode V, Farr D, Xi Y, Dogan BE. Performance of a clinical and imaging-based multivariate model as decision support tool to help save unnecessary surgeries for high-risk breast lesions. Breast Cancer Res Treat 2020; 185:479-494. [PMID: 33010022 DOI: 10.1007/s10549-020-05947-1] [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: 06/01/2020] [Accepted: 09/21/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE To investigate the performance of an imaging and biopsy parameters-based multivariate model in decreasing unnecessary surgeries for high-risk breast lesions. METHODS In an IRB-approved study, we retrospectively reviewed all high-risk lesions (HRL) identified at imaging-guided biopsy in our institution between July 1, 2014-July 1, 2017. Lesions were categorized high-risk-I (HR-I = atypical ductal hyperplasia, atypical lobular hyperplasia, lobular carcinoma in situ and atypical papillary lesion) and II (HR-II = Flat epithelial atypia, radial scar, benign papilloma). Patient risk factors, lesion features, detection and biopsy modality, excision and cancer upgrade rates were collected. Reference standard for upgrade was either excision or at least 2-year imaging follow-up. Multiple logistic regression analysis was performed to develop a multivariate model using HRL type, lesion and biopsy needle size for surgical cancer upgrade with performance assessed using ROC analysis. RESULTS Of 699 HRL in 652 patients, 525(75%) had reference standard available, and 48/525(9.1%) showed cancer at surgical excision. Excision (84.5% vs 51.1%) and upgrade (17.6%vs1.8%) rates were higher in HR-I compared to HR-II (p < 0.01). In HR-I, small needle size < 12G vs ≥ 12G [32.1% vs 13.2%, p < 0.01] and less cores [< 6 vs ≥ 6, 28.6%vs13.7%, p = 0.01] were significantly associated with higher cancer upgrades. Our multivariate model had an AUC = 0.87, saving 28.1% of benign surgeries with 100% sensitivity, based on HRL subtype, lesion size(mm, continuous), needle size (< 12G vs ≥ 12G) and biopsy modality (US vs MRI vs stereotactic) CONCLUSION: Our multivariate model using lesion size, needle size and patient age had a high diagnostic performance in decreasing unnecessary surgeries and shows promise as a decision support tool.
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Affiliation(s)
- Dogan S Polat
- Department of Diagnostic Radiology, University of Texas Southwestern Medical Center, Dallas, TX, USA.
| | - Jennifer G Schopp
- Department of Diagnostic Radiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Firouzeh Arjmandi
- Department of Diagnostic Radiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Jessica Porembka
- Department of Diagnostic Radiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Venetia Sarode
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Deborah Farr
- Department of Surgery, Surgical Oncology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Yin Xi
- Department of Diagnostic Radiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Basak E Dogan
- Department of Diagnostic Radiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
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32
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Huang YY, Park H, McLaren S, Thirunavukkarasu P, Lin JTW, Rajakaruna R, Dhillon R, Ponniah AK. B3 lesion upgrade rates in a tertiary Australian breast centre: a 8-year experience (2012-2019). ANZ J Surg 2020; 90:2521-2526. [PMID: 32969161 DOI: 10.1111/ans.16315] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 08/29/2020] [Accepted: 09/03/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND B3 breast lesions identified on core needle biopsy have uncertain malignant potential. Traditional management of these lesions has been surgical excision, but there is growing interest in less invasive and more cost-effective alternatives such as vacuum-assisted excisional biopsy (VAEB). Determining the rate of malignant upgrade for B3 lesions is important as it may identify low-risk lesions where VAEB could be considered. METHODS A retrospective study was conducted of women undergoing an elective excisional biopsy for a B3 lesion identified on core needle biopsy at a tertiary Australian breast centre. The pre-operative biopsy diagnosis and subsequent excisional biopsy diagnosis were used to calculate the proportion of cases where the diagnosis was upgraded to malignancy. RESULTS A total of 299 eligible patients were identified. Pre-operative diagnosis of papillary lesion with atypia was associated with the highest upgrade rate (50%, n = 12). The next highest upgrade rates occurred in those with flat epithelial atypia (37.50%, n = 8); atypical ductal hyperplasia (24.71%, n = 85); lobular carcinoma in situ (LCIS)/atypical lobular hyperplasia with calcification (17.65%, n = 17); and papillary lesion without atypia (4.72%, n = 106). Patients with radial scar (n = 51), classical LCIS without calcification (n = 7) and mucocoele-like lesion (n = 8) had a 0% upgrade rate. CONCLUSION VAEB may be appropriate for low malignant risk lesions such as papillary lesion without atypia, mucocoele-like lesion and radial scar lesion without atypia. Open-surgical-excisional biopsy remains appropriate for high upgrade lesions such as atypical ductal hyperplasia, papillary lesion with atypia, flat epithelial atypia and classical LCIS with calcification. Long-term prospective randomized multicentre studies and continuing multidisciplinary approach is recommended for future clinical implementation.
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Affiliation(s)
- Yang Y Huang
- Department of Breast Surgery, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Hyerin Park
- Department of Surgery, The University of Western Australia, Faculty of Medicine, Dentistry and Health Sciences, Perth, Western Australia, Australia
| | - Sally McLaren
- Department of Anatomical Pathology, PathWest Laboratory Medical WA, Perth, Western Australia, Australia
| | - Palan Thirunavukkarasu
- Department of Breast Surgery, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Joshua T W Lin
- Department of Breast Surgery, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Ramela Rajakaruna
- Department of Anatomical Pathology, PathWest Laboratory Medical WA, Perth, Western Australia, Australia
| | - Ravinder Dhillon
- Department of Radiology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Ananda K Ponniah
- Department of Breast Surgery, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
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Uzan C, Mazouni C, Rossoni C, De Korvin B, de Lara CT, Cohen M, Chabbert N, Zilberman S, Boussion V, Vincent Salomon A, Espie M, Coutant C, Marchal F, Salviat F, Boulanger L, Doutriaux-Dumoulin I, Jouve E, Mathelin C, de Saint Hilaire P, Mollard J, Balleyguier C, Joyon N, Triki ML, Delaloge S, Michiels S. Prospective Multicenter Study Validate a Prediction Model for Surgery Uptake Among Women with Atypical Breast Lesions. Ann Surg Oncol 2020; 28:2138-2145. [PMID: 32920723 DOI: 10.1245/s10434-020-09107-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 08/18/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Diagnosis of atypical breast lesions (ABLs) leads to unnecessary surgery in 75-90% of women. We have previously developed a model including age, complete radiological target excision after biopsy, and focus size that predicts the probability of cancer at surgery. The present study aimed to validate this model in a prospective multicenter setting. - METHODS Women with a recently diagnosed ABL on image-guided biopsy were recruited in 18 centers, before wire-guided localized excisional lumpectomy. Primary outcome was the negative predictive value (NPV) of the model. RESULTS The NOMAT model could be used in 287 of the 300 patients included (195 with ADH). At surgery, 12 invasive (all grade 1), and 43 in situ carcinomas were identified (all ABL: 55/287, 19%; ADH only: 49/195, 25%). The area under the receiving operating characteristics curve of the model was 0.64 (95% CI 0.58-0.69) for all ABL, and 0.63 for ADH only (95% CI 0.56-0.70). For the pre-specified threshold of 20% predicted probability of cancer, NPV was 82% (77-87%) for all ABL, and 77% (95% CI 71-83%) for patients with ADH. At a 10% threshold, NPV was 89% (84-94%) for all ABL, and 85% (95% CI 78--92%) for the ADH. At this threshold, 58% of the whole ABL population (and 54% of ADH patients) could have avoided surgery with only 2 missed invasive cancers. CONCLUSION The NOMAT model could be useful to avoid unnecessary surgery among women with ABL, including for patients with ADH. CLINICAL TRIAL REGISTRATION NCT02523612.
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Affiliation(s)
- Catherine Uzan
- AP-HP (Assistance Publique des Hôpitaux de Paris), Department of Gynecological and Breast Surgery and Oncology, Pitié-Salpêtrière University Hospital, Paris, France. .,Sorbonne University, INSERM UMR_S_938, "Cancer Biology and Therapeutics", Centre de Recherche Saint-Antoine (CRSA), Paris, France. .,Institut Universitaire de Cancérologie (IUC), Paris, France.
| | | | | | | | | | | | | | | | | | - Anne Vincent Salomon
- Institut Curie, Université Paris-Sciences Lettres, INSERM U934, Département de Médecine Diagnostique et Théranostique, Paris, France
| | - Marc Espie
- University of Paris, Hôpital Saint Louis, APHP, Paris, France
| | | | - Frederic Marchal
- Institut de Cancérologie de Lorraine, Vandœuvre-lès-Nancy, France
| | - Flore Salviat
- Service de Biostatistique et d'Épidémiologie, Gustave Roussy, Villejuif, France.,CESP INSERM U1018, Université Paris-Sud, Université Paris-Saclay, Villejuif, France
| | | | | | - Eva Jouve
- Institut Claudius Regaud-Oncopole, Toulouse, France
| | - Carole Mathelin
- Les Hôpitaux universitaires de Strasbourg, Strasbourg, France
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Lustig DB, Guo M, Liu C, Warburton R, Dingee CK, Pao JS, Kuusk U, Chen L, McKevitt EC. Development and Prospective Validation of a Risk Calculator That Predicts a Low Risk Cohort for Atypical Ductal Hyperplasia Upstaging to Malignancy: Evidence for a Watch and Wait Strategy of a High-Risk Lesion. Ann Surg Oncol 2020; 27:4622-4627. [PMID: 32710273 DOI: 10.1245/s10434-020-08881-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 05/04/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Guidelines recommend surgical excision of atypical ductal hyperplasia (ADH) due to the concern of undersampling a potential malignancy on core needle biopsy (CNB). The purpose of this study was to determine clinical, radiological and pathological variables associated with ADH upstaging to cancer and to develop a predictive risk calculator capable of identifying women who have a low oncological risk of upstaging. METHODS A prospectively collected database from a tertiary breast referral center was analyzed for women diagnosed with ADH on CNB between January 2013 to December 2017 who underwent surgical excision. CNB and surgical pathology reports were examined to determine rate of upstaging. The association between clinical, radiological and pathological variables were evaluated using regression analysis to determine predictors of ADH upstaging to cancer. Significant variables (p ≤ 0.05) identified on univariate analysis were assigned a score of "1" and were included in the ADH upstaging risk calculator. RESULTS A total of 1986 patients underwent surgery for a high-risk lesion. We identified 318 (16.0%) patients who had ADH identified on their CNB who underwent surgery-of which 290 were included in our study. The upstage rate was 24.8%. Five variables were associated with upstaging and included in our calculator: (1) lesion > 5 mm on ultrasound; (2) lesion > 5 mm on mammogram; (3) one or more "high-risk" lesion(s) on CNB; (4) pathological suspicion for cancer and; (5) incomplete removal of calcifications on CNB. Patients with a score of 0 had a 2% risk of being upstaged to cancer and were deemed low risk with 17.2% of patients falling within this category. CONCLUSIONS Patients with ADH on CNB can be stratified into a low oncological cohort who have a 2% risk of being upstaged to carcinoma. In the future, these select patients may be counselled and potentially offered observation as an alternative to surgery.
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Affiliation(s)
- Daniel Ben Lustig
- Department of Surgery, Vancouver Coastal Health, 2775 Laurel Street, 11th Floor, Vancouver, BC, V5Z 1M9, Canada. .,University of British Columbia, Vancouver, Canada.
| | - Michael Guo
- University of British Columbia, Vancouver, Canada
| | - Claire Liu
- University of British Columbia, Vancouver, Canada
| | - Rebecca Warburton
- University of British Columbia, Vancouver, Canada.,Providence Health Care, Vancouver, Canada
| | - Carol K Dingee
- University of British Columbia, Vancouver, Canada.,Providence Health Care, Vancouver, Canada
| | - Jin-Si Pao
- University of British Columbia, Vancouver, Canada.,Providence Health Care, Vancouver, Canada
| | - Urve Kuusk
- University of British Columbia, Vancouver, Canada.,Providence Health Care, Vancouver, Canada
| | - Leo Chen
- University of British Columbia, Vancouver, Canada
| | - Elaine C McKevitt
- University of British Columbia, Vancouver, Canada.,Providence Health Care, Vancouver, Canada
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35
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Amin AL, Fan F, Winblad OD, Larson KE, Wagner JL. Ipsilateral and Concurrent Breast Cancer and Atypical Ductal Hyperplasia: Does Atypia Also Need Surgical Excision? Ann Surg Oncol 2020; 27:4786-4794. [PMID: 32705514 DOI: 10.1245/s10434-020-08896-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 06/27/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Standard-of-care management of atypical ductal hyperplasia (ADH) is surgical excision. Multiple studies have identified features of ADH in patients at low risk for upgrade who may benefit from omission of surgical excision. Patients with an ipsilateral breast cancer have been excluded from studies investigating observation for the management of ADH. METHODS This was a retrospective review of women with both a breast cancer and an ipsilateral separate site of ADH diagnosed on percutaneous biopsy, who underwent excision of both sites from 2008 to 2018. Radiographic and pathologic features of ADH and cancer were analyzed, including imaging size, biopsy modality, distance between sites, cancer subtype, grade, prognostic markers, ADH foci, and presence of necrosis or micropapillary features. Final pathology at the ADH site was used to determine upgrade. Multivariable logistic regression was performed to identify variables significantly associated with ADH upgrade to malignancy. RESULTS Among 62 women meeting the inclusion criteria, 11 (17.7%) upgraded to malignancy [9 ductal carcinoma in situ (DCIS), 2 invasive cancer] at the site of ADH. Upgrade was significantly higher with ipsilateral DCIS (p = 0.03), ultrasound biopsy at the ADH site (p = 0.01), and ADH with necrosis (p = 0.04). The group at lowest risk for upgrade had stereotactic biopsy and ADH without necrosis (0% upgrade). CONCLUSION The presence of breast cancer does not significantly increase the likelihood for upgrade at a separate site of ipsilateral concurrent ADH above contemporary reported upgrade rates of ADH alone (10-30%). When considering breast conservation for breast cancer, omitting excision of the site of ADH can be considered when low-risk features are present.
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Affiliation(s)
- Amanda L Amin
- Department of Surgery, The University of Kansas Health System, Kansas City, KS, USA.
| | - Fang Fan
- Department of Pathology, The University of Kansas Health System, Kansas City, KS, USA
| | - Onalisa D Winblad
- Department of Radiology, The University of Kansas Health System, Kansas City, KS, USA
| | - Kelsey E Larson
- Department of Surgery, The University of Kansas Health System, Kansas City, KS, USA
| | - Jamie L Wagner
- Department of Surgery, The University of Kansas Health System, Kansas City, KS, USA
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36
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Ma Z, Arciero CA, Styblo TM, Wang H, Cohen MA, Li X. Patients with benign papilloma diagnosed on core biopsies and concordant pathology-radiology findings can be followed: experiences from multi-specialty high-risk breast lesion conferences in an academic center. Breast Cancer Res Treat 2020; 183:577-584. [PMID: 32705378 DOI: 10.1007/s10549-020-05803-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Accepted: 07/11/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND To determine whether patients with benign papilloma diagnosed on core biopsy can be spared from surgery. METHODS We prospectively reviewed 150 consecutive core biopsy-diagnosed papilloma cases at a multi-specialty high-risk breast lesion conference to determine whether surgical excision was necessary. Of these 150 cases, 148 had concordant radiologic-pathologic features. Six were excluded due to lack of the first imaging follow-up until analysis. 112 were benign papillomas; 17 were papillomas involved by atypical ductal hyperplasia (atypical papilloma); 6 papillomas had ADH in adjacent tissue but not involving the papilloma; 2 papillomas were involved by atypical lobular hyperplasia (ALH); and 5 papillomas had ALH in adjacent tissue. Two were radiology-pathology (rad-path) discordant. RESULTS Thirty-nine of the 112 benign papillomas were excised with no upgrade to carcinoma; 73 were followed with no disease progression during follow-up (185-1279 days). Fifteen of 17 atypical papillomas were surgically excised with 4 (26.7%) upgraded to carcinoma. Four of the 6 patients with ADH adjacent to a benign papilloma underwent excision with 2 upgrades to carcinoma. None of the patients with papilloma, which was either involved by ALH or had ALH in adjacent tissue had upgrade or disease progression during follow-up (204-1159 days). Finally, the two cases with discordant path-rad discordant were excised with no upgrade. CONCLUSIONS Our data confirm that rad-path concordant benign papillomas diagnosed on core biopsy do not require surgery. It also supports the value of a formal multi-specialty review of all benign papilloma cases to create a consensus management plan.
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Affiliation(s)
- Zhongliang Ma
- Breast Disease Center, The Affiliated Hospital of Qingdao University, Qingdao, China
| | | | | | - Haibo Wang
- Breast Disease Center, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Michael A Cohen
- Department of Radiology and Imaging Sciences, Emory University, 1364 Clifton Road, Atlanta, GA, USA.
| | - Xiaoxian Li
- Department of Pathology and Laboratory Medicine, Emory University, 1364 Clifton Road, Atlanta, GA, 30322, USA.
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Yu CC, Cheung YC, Ueng SH, Chen SC. Impact of Non-Calcified Specimen Pathology on the Underestimation of Malignancy for the Incomplete Retrieval of Suspicious Calcifications Diagnosed as Flat Epithelial Atypia or Atypical Ductal Hyperplasia by Stereotactic Vacuum-Assisted Breast Biopsy. Korean J Radiol 2020; 21:1220-1229. [PMID: 32729266 PMCID: PMC7462764 DOI: 10.3348/kjr.2019.0786] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Revised: 04/10/2020] [Accepted: 04/14/2020] [Indexed: 11/15/2022] Open
Abstract
Objective Stereotactic vacuum-assisted breast biopsy (VABB) is considered a reliable alternative to surgical biopsy for suspicious calcifications. In most cases, the management of flat epithelial atypia (FEA) and atypical ductal hyperplasia (ADH) after VABB with residual calcifications requires surgical excision. This study aimed to evaluate the impact of pathology of non-calcified specimens on the underestimation of malignancy. Materials and Methods We retrospectively reviewed 1147 consecutive cases of stereotactic VABB of suspicious calcifications without mass from January 2010 to December 2016 and identified 46 (4.0%) FEA and 52 (4.5%) ADH cases that were surgically excised for the retrieval of residual calcifications. Mammographic features and pathology of the calcified and non-calcified specimens were reviewed. Results Seventeen specimens (17.3%) were upgraded to malignancy. Mammographic features associated with the underestimation of malignancy were calcification extent (> 34.5 mm: odds ratio = 6.059, p = 0.026). According to the pathology of calcified versus non-calcified specimens, four risk groups were identified: Group A (ADH vs. high-risk lesions), Group B (ADH vs. non-high-risk lesions), Group C (FEA vs. high-risk lesions), and Group D (FEA vs. non-high-risk lesions). The lowest underestimation rate was observed in Group D (Group A vs. Group B vs. Group C vs. Group D: 35.0% vs. 20.0% vs. 15.0% vs. 3.6%, p = 0.041, respectively). Conclusion Considering that the calcification extent and pathology of non-calcified specimens may be beneficial in determining the likelihood of malignancy underestimation, excision after FEA or ADH diagnosis by VABB is required, except for the diagnoses of FEA coexisting without atypia lesions in non-calcified specimens.
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Affiliation(s)
- Chi Chang Yu
- Department of Surgery, Chang Gung Memorial Hospital, Chang Gung University Medical College, Taoyuan, Taiwan.
| | - Yun Chung Cheung
- Department of Diagnostic Radiology, Chang Gung Memorial Hospital, Chang Gung University Medical College, Taoyuan, Taiwan
| | - Shir Hwa Ueng
- Department of Pathology, Chang Gung Memorial Hospital, Chang Gung University Medical College, Taoyuan, Taiwan
| | - Shin Cheh Chen
- Department of Surgery, Chang Gung Memorial Hospital, Chang Gung University Medical College, Taoyuan, Taiwan
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38
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Yoon JH, Koo JS, Lee HS, Kim EK, Kim MJ, Park VY, Moon HJ. Factors Predicting Breast Cancer Development in Women During Surveillance After Surgery for Atypical Ductal Hyperplasia of the Breast: Analysis of Clinical, Radiologic, and Histopathologic Features. Ann Surg Oncol 2020; 27:3614-3622. [PMID: 32314161 DOI: 10.1245/s10434-020-08476-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Indexed: 01/21/2023]
Abstract
BACKGROUND This study aimed to evaluate the risk of breast cancer development for women under surveillance after surgery for atypical ductal hyperplasia (ADH), as well as the clinical and pathologic factors associated with breast cancer development. METHODS From November 2003 to December 2014, the study included 205 women (mean age, 47.1 ± 11.2 years; range 18-73 years) with a pathologic diagnosis of ADH at surgical excision who had preoperative mammography and ultrasonography (US) images and pathology slides available for review. The patients were classified into three groups according to the detection method as follows: negative group (with ADH occult on imaging), mammography group (with ADH detected on mammography), and US group (with ADH detected on US only). Clinical, radiologic, and histopathologic factors associated with breast cancer development after ADH surgery were evaluated. RESULTS Breast cancer developed in 15 patients (7.3%) during surveillance after ADH surgery (follow-up period, 63.9 ± 40.8 months). Palpable lesions had significantly higher rates of breast cancer development after ADH surgery (26.7% vs 6.8%; P = 0.045). Breast cancer development after ADH surgery did not differ according to the detection method (P = 0.654). Palpability was significantly associated with breast cancer development during surveillance after ADH surgery (hazard ratio, 3.579; 95% confidence interval 1.048-12.220; P = 0.042). CONCLUSION The breast cancer development rate for women under surveillance after ADH surgery was 7.3%. Palpability at the time of ADH diagnosis was significantly associated with breast cancer development.
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Affiliation(s)
- Jung Hyun Yoon
- Department of Radiology, Severance Hospital, Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul, Korea
| | - Ja Seung Koo
- Department of Pathology, Yonsei University College of Medicine, Seoul, Korea
| | - Hye Sun Lee
- Biostatistics Collaboration Unit, Yonsei University College of Medicine, Seoul, Korea
| | - Eun-Kyung Kim
- Department of Radiology, Severance Hospital, Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul, Korea
| | - Min Jung Kim
- Department of Radiology, Severance Hospital, Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul, Korea
| | - Vivian Youngjean Park
- Department of Radiology, Severance Hospital, Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul, Korea
| | - Hee Jung Moon
- Department of Radiology, Severance Hospital, Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul, Korea.
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Kim WG, Cummings MC, Lakhani SR. Pitfalls and controversies in pathology impacting breast cancer management. Expert Rev Anticancer Ther 2020; 20:205-219. [PMID: 32174198 DOI: 10.1080/14737140.2020.1738222] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Introduction: Breast cancer is a heterogeneous disease, at morphological, molecular, and clinical levels and this has significant implications for the diagnosis and management of the disease. The introduction of breast screening, and the use of small tissue sampling for diagnosis, the recognition of new morphological and molecular subtypes, and the increasing use of neoadjuvant therapies have created challenges in pathological diagnosis and classification.Areas covered: Areas of potential difficulty include columnar cell lesions, particularly flat epithelial atypia, atypical ductal hyperplasia, lobular neoplasia and its variants, and a range of papillary lesions. Fibroepithelial, sclerosing, mucinous, and apocrine lesions are also considered. Established and newer prognostic and predictive markers, such as immune infiltrates, PD-1 and PD-L1 and gene expression assays are evaluated. The unique challenges of pathology assessment post-neoadjuvant systemic therapy are also explored.Expert opinion: Controversies in clinical management arise due to incomplete and sometimes conflicting data on clinicopathological associations, prognosis, and outcome. The review will address some of these challenges.
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Affiliation(s)
- Woo Gyeong Kim
- Department of Pathology, University of Inje College of Medicine, Busan, Korea.,University of Queensland Centre for Clinical Research, Brisbane, Australia
| | - Margaret C Cummings
- University of Queensland Centre for Clinical Research, Brisbane, Australia.,Department of Anatomical Pathology, Pathology Queensland, Brisbane, Australia
| | - Sunil R Lakhani
- University of Queensland Centre for Clinical Research, Brisbane, Australia.,Department of Anatomical Pathology, Pathology Queensland, Brisbane, Australia
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Khoury T, Jabbour N, Peng X, Yan L, Quinn M. Atypical Ductal Hyperplasia and Those Bordering on Ductal Carcinoma In Situ Should Be Included in the Active Surveillance Clinical Trials. Am J Clin Pathol 2020; 153:131-138. [PMID: 31602455 DOI: 10.1093/ajcp/aqz143] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVES Women with atypical ductal hyperplasia (ADH), unlike those with ductal carcinoma in situ (DCIS), are denied eligibility for active surveillance clinical trials. METHODS We applied the inclusion criteria of the Comparison of Operative to Monitoring and Endocrine Therapy (COMET) trial to the cases of women (n = 165) at the Roswell Park Cancer Institute who had a diagnosis of ADH, ADH bordering on DCIS, or low- to intermediate-grade DCIS on core biopsy taken during screening mammography. Upgrade of lesions to high risk was based on invasive carcinoma, high-grade DCIS, or DCIS with comedo necrosis. RESULTS In total, nine (5.5%) lesions were upgraded: two (1.7%) reported ADH, one (5.9%) reported ADH bordering on DCIS, and six (19.4%) reported DCIS (P = .002); and two (1.6%) reclassified ADH vs seven (17.1%) reclassified DCIS (P < .001). In multivariate analysis, only increased number of foci had the potential to predict high risk (odds ratio: 1.39; P = .06). CONCLUSIONS We conclude that ADH and ADH bordering on DCIS have lower upgrade rates than DCIS. We recommend opening an active surveillance clinical trial for women with these diagnoses.
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Affiliation(s)
- Thaer Khoury
- Department of Pathology, Roswell Park Cancer Institute, Buffalo, NY
| | - Nashwan Jabbour
- Department of Pathology, Roswell Park Cancer Institute, Buffalo, NY
| | - Xuan Peng
- Department of Biostatics, Roswell Park Cancer Institute, Buffalo, NY
| | - Li Yan
- Department of Biostatics, Roswell Park Cancer Institute, Buffalo, NY
| | - Marie Quinn
- Department of Radiology, Roswell Park Cancer Institute, Buffalo, NY
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Alipour S, Omranipour R, Amant F, Eslami B. Atypical Lesions of the Breast and Lobular Carcinoma in Situ in Pregnancy - Surgeons' Practice. Eur J Breast Health 2020; 16:16-21. [PMID: 31912009 DOI: 10.5152/ejbh.2019.5158] [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: 06/18/2019] [Accepted: 10/07/2019] [Indexed: 11/22/2022]
Abstract
Objective Approach to precancerous and high-risk breast lesions occurring in pregnancy has received little attention in the literature. We carried out a study to investigate the practice of surgeons in the management of these cases. Materials and Methods A short survey was sent to surgeons, including a multiple-choice questionnaire about their practice for atypical hyperplasia or lobular carcinoma in situ presenting in each trimester of pregnancy or at time of breastfeeding. Answer options included observation, immediate vacuum biopsy, immediate surgery, surgery in next trimester, surgery after delivery, and surgery after end of breastfeeding; based on the time of presentation. Results Out of the 671 practitioners invited, 97(14.5 %) responded to the survey. Participants were from 23 countries. Answers showed that management of gestational Atypical Ductal Hyperplasia (ADH) and Lobular Neoplasia (LN) was readily postponed by surgeons in favor of fetus safety while being cautious about risks of conservative management alone. Conclusion Various methods of treatment are selected by surgeons for managing high-risk breast lesions during pregnancy. In the absence of relevant literature, decision making in a multidisciplinary team would be the best approach in these cases.
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Affiliation(s)
- Sadaf Alipour
- Breast Disease Research Center (BDRC), Tehran University of Medical Sciences, Tehran, Iran.,Department of Surgery, Arash Women's Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Ramesh Omranipour
- Breast Disease Research Center (BDRC), Tehran University of Medical Sciences, Tehran, Iran.,Department of Surgical Oncology, Tehran University of Medical Sciences, Tehran, Iran
| | - Frederic Amant
- Department of Oncology, KU Leuven, Leuven, Belgium.,Center for Gynecologic Oncology Amsterdam, Netherlands Cancer Institute and Amsterdam University Medical Centers, Amsterdam, Netherlands
| | - Bita Eslami
- Breast Disease Research Center (BDRC), Tehran University of Medical Sciences, Tehran, Iran
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Atypical Ductal Hyperplasia and Lobular Neoplasia: Update and Easing of Guidelines. AJR Am J Roentgenol 2019; 214:265-275. [PMID: 31825261 DOI: 10.2214/ajr.19.21991] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE. Atypical ductal hyperplasia (ADH), atypical lobular hyperplasia (ALH), and lobular carcinoma in situ (LCIS) are among high-risk lesions that have been previously recommended for surgical excision when diagnosed on core needle biopsy. Recent studies have examined whether imaging surveillance is a reasonable alternative to surgical management for these lesions. This article synthesizes the evidence regarding management of atypical hyperplasia and LCIS diagnosed on core needle biopsy and clinical implications of these diagnoses on future breast cancer risk as well as highlights areas of further research needed to improve practice guidelines for these high-risk lesions. CONCLUSION. Although surgical excision is still recommended after diagnosis of ADH on core needle biopsy, in specific circumstances ALH and LCIS can safely be managed by imaging surveillance.
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Harrington L, diFlorio-Alexander R, Trinh K, MacKenzie T, Suriawinata A, Hassanpour S. Prediction of Atypical Ductal Hyperplasia Upgrades Through a Machine Learning Approach to Reduce Unnecessary Surgical Excisions. JCO Clin Cancer Inform 2019; 2:1-11. [PMID: 30652620 PMCID: PMC6874044 DOI: 10.1200/cci.18.00083] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Surgical excision is currently recommended for all occurrences of atypical ductal hyperplasia (ADH) found on core needle biopsies for malignancy diagnoses and treatment of lesions. The excision of all ADH lesions may lead to overtreatment, which results in invasive surgeries for benign lesions in many women. A machine learning method to predict ADH upgrade may help clinicians and patients decide whether combined active surveillance and hormonal therapy is a reasonable alternative to surgical excision. METHODS The following six machine learning models were developed to predict ADH upgrade from core needle biopsy: gradient-boosting trees, random forest, radial support vector machine (SVM), weighted K-nearest neighbors (KNN), logistic elastic net, and logistic regression. The study cohort consisted of 128 lesions from 124 women at a tertiary academic care center in New Hampshire who had ADH on core needle biopsy and who underwent an associated surgical excision from 2011 to 2017. RESULTS The best-performing models were gradient-boosting trees (area under the curve [AUC], 68%; accuracy, 78%) and random forest (AUC, 67%; accuracy, 77%). The top five most important features that determined ADH upgrade were age at biopsy, lesion size, number of biopsies, needle gauge, and personal and family history of breast cancer. Using the random forest model, 98% of all malignancies would have been diagnosed through surgical biopsies, whereas 16% of unnecessary surgeries on benign lesions could have been avoided (ie, 87% sensitivity at 45% specificity). CONCLUSION These results add to the growing body of support for machine learning models as useful aids for clinicians and patients in decisions about the clinical management of ADH.
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Affiliation(s)
- Lia Harrington
- Lia Harrington, Todd MacKenzie, and Saeed Hassanpour, Geisel School of Medicine at Dartmouth College, Hanover; Roberta diFlorio-Alexander, Katherine Trinh, and Arief Suriawinata, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Roberta diFlorio-Alexander
- Lia Harrington, Todd MacKenzie, and Saeed Hassanpour, Geisel School of Medicine at Dartmouth College, Hanover; Roberta diFlorio-Alexander, Katherine Trinh, and Arief Suriawinata, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Katherine Trinh
- Lia Harrington, Todd MacKenzie, and Saeed Hassanpour, Geisel School of Medicine at Dartmouth College, Hanover; Roberta diFlorio-Alexander, Katherine Trinh, and Arief Suriawinata, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Todd MacKenzie
- Lia Harrington, Todd MacKenzie, and Saeed Hassanpour, Geisel School of Medicine at Dartmouth College, Hanover; Roberta diFlorio-Alexander, Katherine Trinh, and Arief Suriawinata, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Arief Suriawinata
- Lia Harrington, Todd MacKenzie, and Saeed Hassanpour, Geisel School of Medicine at Dartmouth College, Hanover; Roberta diFlorio-Alexander, Katherine Trinh, and Arief Suriawinata, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Saeed Hassanpour
- Lia Harrington, Todd MacKenzie, and Saeed Hassanpour, Geisel School of Medicine at Dartmouth College, Hanover; Roberta diFlorio-Alexander, Katherine Trinh, and Arief Suriawinata, Dartmouth-Hitchcock Medical Center, Lebanon, NH
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Sergesketter AR, Thomas SM, Fayanju OM, Menendez CS, Rosenberger LH, Greenup RA, Hyslop T, Parrilla Castellar ER, Hwang ES, Plichta JK. The Influence of Age on the Histopathology and Prognosis of Atypical Breast Lesions. J Surg Res 2019; 241:188-198. [PMID: 31028940 PMCID: PMC6571073 DOI: 10.1016/j.jss.2019.03.047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2018] [Revised: 03/08/2019] [Accepted: 03/22/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Although several prognostic variables and risk factors for breast cancer are age-related, the association between age and risk of cancer with breast atypia is controversial. This study aimed to compare the type of breast atypia and risk of underlying or subsequent breast cancer by age. METHODS Adult women with breast atypia (atypical ductal hyperplasia, atypical lobular hyperplasia, and lobular carcinoma in situ) at a single institution from 2008 to 2017 were stratified by age at initial diagnosis: <50 y, 50-70 y, and >70 y. Regression modeling was used to estimate the association of age with risk of underlying carcinoma or subsequent cancer diagnosis. RESULTS A total of 530 patients with atypia were identified: 31.1% < 50 y (n = 165), 58.1% 50-70 y (n = 308), and 10.8% > 70 y (n = 57). The proportion of women with atypical ductal hyperplasia steadily increased with age, compared with atypical lobular proliferations (P = 0.04). Of those with atypia on needle biopsy, the overall rate of underlying carcinoma was 17.5%. After adjustment, older age was associated with a greater risk of underlying carcinoma (odds ratio: 1.028, 95% confidence interval: 1.003-1.053; P = 0.03). Of those confirmed to have atypia on surgical excision, the overall rate of a subsequent cancer diagnosis was 15.7%. Age was not associated with a long-term risk for breast cancer (P = 0.48) or the time to a subsequent diagnosis of carcinoma (log-rank P = 0.41). CONCLUSIONS Although atypia diagnosed on needle biopsy may be sufficient to warrant surgical excision, older women may be at a greater risk for an underlying carcinoma, albeit the long-term risk for malignancy associated with atypia does not appear to be affected by age.
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Affiliation(s)
| | - Samantha M Thomas
- Duke Cancer Institute, Durham, North Carolina; Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina
| | - Oluwadamilola M Fayanju
- Department of Surgery, Duke University Medical Center, Durham, North Carolina; Duke Cancer Institute, Durham, North Carolina
| | - Carolyn S Menendez
- Department of Surgery, Duke University Medical Center, Durham, North Carolina; Duke Cancer Institute, Durham, North Carolina
| | - Laura H Rosenberger
- Department of Surgery, Duke University Medical Center, Durham, North Carolina; Duke Cancer Institute, Durham, North Carolina
| | - Rachel A Greenup
- Department of Surgery, Duke University Medical Center, Durham, North Carolina; Duke Cancer Institute, Durham, North Carolina
| | - Terry Hyslop
- Duke Cancer Institute, Durham, North Carolina; Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina
| | - Edgardo R Parrilla Castellar
- Department of Surgery, Duke University Medical Center, Durham, North Carolina; Department of Pathology, Duke University Medical Center, Durham, North Carolina
| | - E Shelley Hwang
- Department of Surgery, Duke University Medical Center, Durham, North Carolina; Duke Cancer Institute, Durham, North Carolina
| | - Jennifer K Plichta
- Department of Surgery, Duke University Medical Center, Durham, North Carolina; Duke Cancer Institute, Durham, North Carolina.
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Chen LY, Hu J, Tsang JYS, Lee MA, Ni YB, Chan SK, Tse GMK. Diagnostic upgrade of atypical ductal hyperplasia of the breast based on evaluation of histopathological features and calcification on core needle biopsy. Histopathology 2019; 75:320-328. [PMID: 31013355 DOI: 10.1111/his.13881] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Revised: 03/27/2019] [Accepted: 04/19/2019] [Indexed: 02/06/2023]
Abstract
AIMS Atypical ductal hyperplasia (ADH) of breast is increasingly diagnosed in core needle biopsy (CNB). As higher-grade lesions were found in the excision in a substantial proportion of ADH on CNB, factors predicting risk of subsequent upgrade are clinically significant. This study aims to investigate relevant histopathological factors in CNB that could predict diagnostic upgrade at excision. METHODS AND RESULTS One hundred and forty-three cases of CNB with paired subsequent excision were evaluated for multiple clinicopathological parameters related to CNB sampling, ADH morphology, calcification and other co-existing histological features, and which of these parameters were associated with diagnostic upgrade at subsequent excisions were determined. Forty-eight cases (34.3%) were upgraded to malignancy, including 15 invasive cancers and 33 ductal carcinomas in situ (DCIS). An increased tissue area occupied by ADH (P = 0.026), a higher number of ADH foci (P = 0.004), the presence of solid pattern (P = 0.037) and older age (P = 0.012) were positively associated with upgrade, while negative associations were found with the presence of micropapillary pattern (P = 0.025), co-existing columnar cell lesions (CCL) (P = 0.001) and the presence of calcifications (P = 0.009). Multivariate logistic regression analysis showed that the number of ADH foci (HR = 2.810, P = 0.013) was an independent positive predictor, while co-existing CCL (HR = 0.391, P = 0.013) was an independent negative predictor for upgrade. CONCLUSIONS Patients with ADH in CNB showing the presence of co-existing CCL and a lower number of ADH foci have a lower risk of disease upgrade at excision, and are potential candidates for observation-only management.
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Affiliation(s)
- Lin-Ying Chen
- Department of Pathology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Jintao Hu
- Department of Pathology, Shenzhen People's Hospital, Shenzhen, China
| | - Julia Y S Tsang
- Department of Anatomical and Cellular Pathology, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong, China
| | - Michelle A Lee
- Department of Anatomical and Cellular Pathology, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong, China
| | - Yun-Bi Ni
- Department of Anatomical and Cellular Pathology, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong, China
| | - Siu-Ki Chan
- Department of Pathology, Kwong Wah Hospital, Hong Kong, China
| | - Gary M K Tse
- Department of Anatomical and Cellular Pathology, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong, China
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Radiologic and Pathologic Features Associated With Upgrade of Atypical Ductal Hyperplasia at Surgical Excision. Acad Radiol 2019; 26:893-899. [PMID: 30318287 DOI: 10.1016/j.acra.2018.09.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 09/07/2018] [Accepted: 09/12/2018] [Indexed: 11/24/2022]
Abstract
RATIONALE AND OBJECTIVES To evaluate radiologic and pathologic features associated with upgrade of atypical ductal hyperplasia (ADH) to ductal carcinoma in situ or invasive breast cancer at surgical excision, in order to identify patients who may consider alternatives to excision. MATERIALS AND METHODS This retrospective analysis examined patients who underwent surgical excision of biopsy-proven ADH at our institution. Imaging and pathology from biopsy were reviewed to determine radiologic (lesion size, radiologic abnormality, biopsy type, needle gauge, number of cores, percent of lesion removed) and pathologic features (histologic calcifications, presence of necrosis, micropapillary features, extent of ADH) associated with ADH upgrade. RESULTS One hundred twenty four cases of percutaneous biopsy-proven ADH with subsequent excision were included. The overall upgrade rate was 17.7% (n = 22), with 17 cases to ductal carcinoma in situ and five to invasive cancer. Radiologic features associated with a lower upgrade rate were smaller lesion size (p = 0.032) and larger percent of lesion removed at biopsy (p = 0.047). Larger needle gauge at biopsy (p = 0.070), absence of necrosis (p = 0.051) and focal ADH (<3 foci, p = 0.12) were nearly associated with a lower rate of upgrade and were included for the purpose of multi parameter analyses. CONCLUSION For women with ADH identified on percutaneous biopsy, the risk of upgrade may in part be determined by lesion size, percent of lesion removed at biopsy, presence of necrosis, and extent of ADH. Using a combination of these radiographic and pathologic features to stratify patients with biopsy-proven ADH may help identify women who could be considered for alternative treatment options.
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Moseley TW, Shah SS, Nguyen CV, Rosenblat J, Resetkova E, Sneige N, Brandt KR, Huo L. Clinical Management of Mucocele-Like Lesions of the Breast with Limited or no Epithelial Atypia on Core Biopsy: Experience from Two Institutions. Ann Surg Oncol 2019; 26:3478-3488. [PMID: 31187364 DOI: 10.1245/s10434-019-07377-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Indexed: 11/18/2022]
Abstract
PURPOSE Mucocele-like lesions of the breast identified on core biopsy are rare high-risk lesions associated with variable upgrade rates to carcinoma on excision. We aimed to identify the clinicoradiopathological features that can help optimize management of this lesion. METHODS We evaluated 50 mucocele-like lesions identified on core biopsies from two institutions, including 36 with no atypia and 14 with limited atypia. Outcome data from excision or clinicoradiological follow-up were reviewed with core biopsy results. RESULTS Radiological targets were calcifications in 74% of cases, calcifications with associated mass or density in 16%, and mass in 10%. One of the 16 excised lesions without atypia on core biopsy, which was a mass lesion, was upgraded to mucinous carcinoma on excision. Of the 12 excised lesions with limited atypia, none were upgraded on excision. Among the lesions not excised, 20 without atypia had a median follow-up of 61 months, and 2 with limited atypia had follow-up of 97 and 109 months. None of these 22 patients had new development of their lesions on follow-up. The upgrade rate was 2% in our entire cohort, 3% for lesions without atypia, and 0% for lesions with limited atypia. CONCLUSIONS Clinicoradiological surveillance can be appropriate when a mucocele-like lesion without atypia is identified on core biopsy for a non-mass lesion with pathological-radiological concordance. For mucocele-like lesions with limited atypia, a nonsurgical approach could be considered if the atypia by itself does not warrant excision. The latter recommendation requires careful clinicopathological correlation and support from additional studies.
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Affiliation(s)
- Tanya W Moseley
- Department of Diagnostic Radiology, Breast Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sejal S Shah
- Department of Anatomic Pathology, Mayo Clinic, Rochester, MN, USA
| | - Christopher V Nguyen
- Department of Pathology, Unit 85, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX, 77030, USA
| | - Juliana Rosenblat
- Department of Diagnostic Radiology, Breast Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Erika Resetkova
- Department of Pathology, Unit 85, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX, 77030, USA
| | - Nour Sneige
- Department of Pathology, Unit 85, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX, 77030, USA
| | - Kathy R Brandt
- Department of Radiology, College of Medicine, Mayo Clinic, Rochester, MN, 55905, USA.
| | - Lei Huo
- Department of Pathology, Unit 85, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX, 77030, USA.
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Is bigger better? Twenty-year institutional experience of atypical ductal hyperplasia discovered by core needle biopsy. Am J Surg 2019; 217:906-909. [PMID: 30771862 DOI: 10.1016/j.amjsurg.2019.01.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 01/27/2019] [Accepted: 01/28/2019] [Indexed: 11/22/2022]
Abstract
OBJECTIVES The increasing accuracy of large-bore (11- or 8-gauge) vacuum-assisted core needle biopsies (VACNB) has challenged the commonly-accepted practice that surgery is needed for definitive diagnosis when atypical ductal hyperplasia (ADH) is found on VACNB. This study seeks to demonstrate the impact of increased VACNB caliber on the pathologic upgrade rate of ADH. METHODS Patients diagnosed with isolated ADH by VACNB who subsequently underwent surgical excision at our tertiary medical center were retrospectively studied. Demographics, needle gauge, number of needle passes, and pathology results were analyzed. RESULTS From June 1996 to June 2016, approximately 3740 VACNBs were performed. 139 patients were diagnosed with isolated ADH on VACNB and underwent surgical excision. 30 patients (22%) were upgraded to ductal carcinoma in-situ or invasive cancer; 17 upgrades (21%) from 11-gauge CNB vs. 13 upgrades (23%) from 8-gauge CNB (p = 0.67). CONCLUSION Increasing core needle biopsy size from 11 g to 8 g does not decrease the rate of pathologic upstaging at the time of surgical excision. Surgical excision of ADH is still required for complete diagnosis.
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Sutton T, Farinola M, Johnson N, Garreau JR. Atypical ductal hyperplasia: Clinicopathologic factors are not predictive of upgrade after excisional biopsy. Am J Surg 2019; 217:848-850. [PMID: 30611396 DOI: 10.1016/j.amjsurg.2018.12.020] [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: 11/06/2018] [Revised: 12/04/2018] [Accepted: 12/14/2018] [Indexed: 10/27/2022]
Abstract
INTRODUCTION National Comprehensive Cancer Network (NCCN) guidelines currently recommend excisional biopsy for atypical ductal hyperplasia (ADH) diagnosed on core needle biopsy (CNB) due to the possibility of pathologic upgrade to breast cancer upon excisional biopsy. We aimed to quantify the current rate of upgrade and identify risk factors. METHODS A retrospective review of women in the Legacy Health Care System with a diagnosis of ADH was performed for 2014 through 2015. Initial pathology and patient factors were reviewed for potential predictors of upgrade. RESULTS 91 women with ADH were identified. 84 (92%) underwent excisional biopsy; 16 (19%) were upgraded to breast cancer. Those upgraded were significantly older than non-upgraded patients (64.6 versus 56.7 years, p < 0.01), and 15 (94%) had greater than one duct involved by ADH. CONCLUSION The principal clinicopathologic factor associated with upgrade is increasing patient age, however this is not sufficiently predictive. Excisional biopsy in patients diagnosed with ADH on CNB should continue. Further study may provide an avenue for selective excisional biopsy in patients with ADH.
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Affiliation(s)
- Thomas Sutton
- Oregon Health & Science University, Department of Surgery, 3181 SW Sam Jackson Park Rd, Portland, OR, 97239, USA.
| | - Maryam Farinola
- Legacy Cancer Institute, Legacy Medical Group Surgical Oncology, 1040 NW 22nd Ave, Suite 560, Portland, OR, 97227, USA.
| | - Nathalie Johnson
- Legacy Cancer Institute, Legacy Medical Group Surgical Oncology, 1040 NW 22nd Ave, Suite 560, Portland, OR, 97227, USA.
| | - Jennifer R Garreau
- Legacy Cancer Institute, Legacy Medical Group Surgical Oncology, 1040 NW 22nd Ave, Suite 560, Portland, OR, 97227, USA.
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Rageth CJ, Rubenov R, Bronz C, Dietrich D, Tausch C, Rodewald AK, Varga Z. Atypical ductal hyperplasia and the risk of underestimation: tissue sampling method, multifocality, and associated calcification significantly influence the diagnostic upgrade rate based on subsequent surgical specimens. Breast Cancer 2018; 26:452-458. [PMID: 30591993 PMCID: PMC6570781 DOI: 10.1007/s12282-018-00943-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 12/18/2018] [Indexed: 12/15/2022]
Abstract
Background Risk assessment and therapeutic options are challenges when counselling patients with an atypical ductal hyperplasia (ADH) to undergo either open surgery or follow-up only. Methods We retrospectively analyzed a series of ADH lesions and assessed whether the morphological parameters of the biopsy materials indicated whether the patient should undergo surgery. A total of 207 breast biopsies [56 core needle biopsies (CNBs) and 151 vacuum-assisted biopsies (VABs)] histologically diagnosed as ADH were analyzed retrospectively, together with subsequently obtained surgical specimens. All histological slides were re-analyzed with regard to the presence/absence of ADH-associated calcification, other B3 lesions (lesion of uncertain malignant potential), extent of the lesion, and the presence of multifocality. Results The overall underestimation rate for the whole cohort was 39% (57% for CNB, 33% for VAB). In the univariate analysis, the method of biopsy (CNB vs VAB, p = 0.002) and presence of multifocality in VAB specimens (p = 0.0176) were significant risk factors for the underestimation of the disease (ductal carcinoma in situ or invasive cancer detected on subsequent open biopsy). In the multivariate logistic regression model, the absence of calcification (p = 0.0252) and the presence of multifocality (unifocal vs multifocal ADH, p = 0.0147) in VAB specimens were significant risk factors for underestimation. Conclusions Multifocal ADH without associated calcification diagnosed by CNB tends to have a higher upgrade rate. Because the upgrade rate was 16.5% even in the group with the lowest risk (VAB-diagnosed unifocal ADH with calcification), we could not identify a subgroup that would not require an open biopsy.
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Affiliation(s)
- Christoph J Rageth
- Centre du sein, Département de Gynécologie et d'Obstétrique, Hôpitaux Universitaires de Genève, Bd de la Cluse 30, 1211, Geneva 14, Switzerland. .,Brust-Zentrum Zürich, Seefeldstr. 214, 8008, Zurich, Switzerland. .,, Ringlikerstrasse 53, 8142, Uitikon Waldegg, Switzerland.
| | - Ravit Rubenov
- Brust-Zentrum Zürich, Seefeldstr. 214, 8008, Zurich, Switzerland
| | - Cristian Bronz
- Clinic for Gynecology, University Hospital Zurich, 8091, Zurich, Switzerland
| | | | - Christoph Tausch
- Brust-Zentrum Zürich, Seefeldstr. 214, 8008, Zurich, Switzerland
| | - Ann-Katrin Rodewald
- Institute of Pathology and Molecular Pathology, University Hospital Zurich, Schmelzbergstrasse 12, 8091, Zurich, Switzerland
| | - Zsuzsanna Varga
- Institute of Pathology and Molecular Pathology, University Hospital Zurich, Schmelzbergstrasse 12, 8091, Zurich, Switzerland
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