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Turashvili G. Nonneoplastic and neoplastic sclerosing lesions of the breast. Histopathology 2024. [PMID: 38923027 DOI: 10.1111/his.15252] [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: 06/28/2024]
Abstract
Sclerosing lesions of the breast encompass a spectrum of benign and malignant entities and often pose a diagnostic challenge. Awareness of key morphologic features and pitfalls in the assessment of morphology and immunophenotype is essential to avoid over- or underdiagnosis and ensure optimal clinical management. This review summarizes nonneoplastic sclerosing lesions such as radial scar/complex sclerosing lesion, sclerosing adenosis, sclerosing intraductal papilloma, sclerosing variants of ductal adenoma and nipple adenoma, and fibroadenoma with extensive sclerosis, including their clinical presentation, characteristic morphology, differential diagnostic considerations, appropriate immunohistochemical work-up, when needed, and the clinical significance. In addition, atypical or neoplastic entities (such as atypical ductal hyperplasia, ductal carcinoma in situ, low-grade adenosquamous carcinoma, and fibromatosis-like metaplastic carcinoma) that can involve these sclerosing lesions are also briefly discussed.
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Affiliation(s)
- Gulisa Turashvili
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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2
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Whitman GJ. Editorial Comment: Upstaging Rates and Management of Radial Scars. AJR Am J Roentgenol 2024; 222:e2431239. [PMID: 38630090 DOI: 10.2214/ajr.24.31239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2024]
Affiliation(s)
- Gary J Whitman
- The University of Texas MD Anderson Cancer Center, Houston, TX
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3
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Crowley C, Bahl M. Radial Scars on Screening Digital Breast Tomosynthesis: Upstaging Rates and Management Strategies. AJR Am J Roentgenol 2024; 222:e2430845. [PMID: 38477526 DOI: 10.2214/ajr.24.30845] [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: 03/14/2024]
Abstract
BACKGROUND. Radial scars are more commonly identified on digital breast tomosynthesis (DBT) than on digital mammography (DM). Nonetheless, universal guidelines for radial scar management in the current era of DBT are lacking. OBJECTIVE. The purpose of this study was to determine the upstaging rates of screening DBT-detected radial scars with and without atypia and to identify features related to upstaging risk. METHODS. This retrospective study included patients who underwent core needle biopsy (CNB) showing a radial scar after screening DBT and DM from January 1, 2013, to December 31, 2020. Patients without surgical excision or at least 2 years of imaging follow-up after CNB were excluded. Rates of upstaging to breast cancer (ductal carcinoma in situ [DCIS] or invasive disease) were compared between radial scars with and without atypia at CNB. Associations of upstaging with patient, imaging, and pathologic variables were explored using standard statistical tests. RESULTS. Of 165 women with 171 radial scars, the final study sample included 153 women (mean age, 56 years; range, 33-83 years) with 159 radial scars that underwent surgical excision (80.5%, 128/159) or at least 2 years of imaging follow-up (19.5%, 31/159). Seven radial scars were upstaged to DCIS and one to invasive disease. Therefore, the up-staging rate of radial scars to cancer was 5.0% (8/159). The upstaging rate of radial scars without atypia at CNB was 1.6% (2/129) and that of radial scars with atypia was 20.0% (6/30) (p < .001). On multivariable analysis, features associated with higher upstaging risk included a prior breast cancer diagnosis (62.5% vs 4.8%; p = .01) and the presence of atypia at CNB (75.0% vs 15.9%; p = .02). The upstaging rate according to mammographic finding type was 7.1% (1/14) for asymmetries, 12.5% (2/16) for masses, 5.3% (5/95) for architectural distortion, and 0.0% (0/34) for calcifications. CONCLUSION. Screening-detected radial scars without atypia at CNB have a low upstaging rate to breast cancer of 1.6%. CLINICAL IMPACT. Imaging surveillance rather than surgery is a reasonable approach for radial scars without atypia, particularly for those presenting as calcifications.
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Affiliation(s)
- Claire Crowley
- Department of Radiology, Massachusetts General Hospital, 55 Fruit St, WAC 240, Boston, MA 02114
| | - Manisha Bahl
- Department of Radiology, Massachusetts General Hospital, 55 Fruit St, WAC 240, Boston, MA 02114
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4
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Ferre R, Covington MF, Kuzmiak CM. Meta-analysis: Radial Scar and Breast MRI. Acad Radiol 2024:S1076-6332(24)00214-9. [PMID: 38714429 DOI: 10.1016/j.acra.2024.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Revised: 04/03/2024] [Accepted: 04/06/2024] [Indexed: 05/09/2024]
Abstract
BACKGROUND The implementation of digital breast tomosynthesis has increased the detection of radial scar (RS). Managing this finding may be experienced as a clinical dilemma in daily practice. Breast Contrast-Enhanced MRI (CE-BMR) is a known modality in case of problem-solving tool for mammographic abnormalities. However, the data about AD and CE-BMR are scant. OBJECTIVE The purpose was to estimate the benefit of CE-BMR in the setting of RS detected mammographically through a systematic review and meta-analysis of the literature. METHODS A search of MEDLINE and EMBASE databases were conducted in 2022. Based on the PRISMA guidelines, an analysis was performed. The primary endpoint was the correlation between CE-BMR findings and definite outcome for RS (pure RS versus RS associated with atypia or malignancy). RESULTS Three studies were available. The negative predictive value (NPV) was 100% for each. CONCLUSION The high NPV could allow for deferral of a biopsy in favor of a short-interval imaging follow-up in the setting of a negative CE-BMR.
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Affiliation(s)
| | - Matthew F Covington
- Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, Utah 84112, USA
| | - Cherie M Kuzmiak
- Professor of Radiology Faculty, Division of Breast Imaging, Department of Radiology, CB #7510, UNC School of Medicine, Physicians' Office Building, Rm #118, 170 Manning Drive, Chapel Hill, North Carolina 27599, USA
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Cohen EO, Perry RE, Legha RS, Tso HH, Shin K, Speer ME, Phalak KA, Sun J, Leung JWT. Suspicious Ultrasound-Occult Non-Calcified Mammographic Masses, Asymmetries, and Architectural Distortions Are Moderate Probability for Malignancy. Cancers (Basel) 2024; 16:655. [PMID: 38339406 PMCID: PMC10854793 DOI: 10.3390/cancers16030655] [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: 01/03/2024] [Revised: 01/26/2024] [Accepted: 02/01/2024] [Indexed: 02/12/2024] Open
Abstract
Suspicious non-calcified mammographic findings have not been evaluated with modern mammographic technique, and the purpose of this work is to compare the likelihood of malignancy for those findings. To do this, 5018 consecutive mammographically guided biopsies performed during 2016-2019 at a large metropolitan, community-based hospital system were retrospectively reviewed. In total, 4396 were excluded for targeting calcifications, insufficient follow-up, or missing data. Thirty-seven of 126 masses (29.4%) were malignant, 44 of 194 asymmetries (22.7%) were malignant, and 77 of 302 architectural distortions (AD, 25.5%) were malignant. The combined likelihood of malignancy was 25.4%. Older age was associated with a higher likelihood of malignancy for each imaging finding type (all p ≤ 0.006), and a possible ultrasound correlation was associated with a higher likelihood of malignancy when all findings were considered together (p = 0.012). Two-view asymmetries were more frequently malignant than one-view asymmetries (p = 0.03). There were two false-negative biopsies (98.7% sensitivity and 100% specificity). In conclusion, the 25.4% likelihood of malignancy confirms the recommendation for biopsy of suspicious, ultrasound-occult, mammographic findings. Mammographically guided biopsies were highly sensitive and specific in this study. Older patient age and a possible ultrasound correlation should raise concern given the increased likelihood of malignancy in those scenarios.
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Affiliation(s)
- Ethan O. Cohen
- Department of Breast Imaging, Division of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (R.E.P.); (R.S.L.); (H.H.T.); (K.S.); (M.E.S.); (K.A.P.); (J.W.T.L.)
| | - Rachel E. Perry
- Department of Breast Imaging, Division of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (R.E.P.); (R.S.L.); (H.H.T.); (K.S.); (M.E.S.); (K.A.P.); (J.W.T.L.)
| | - Ravinder S. Legha
- Department of Breast Imaging, Division of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (R.E.P.); (R.S.L.); (H.H.T.); (K.S.); (M.E.S.); (K.A.P.); (J.W.T.L.)
| | - Hilda H. Tso
- Department of Breast Imaging, Division of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (R.E.P.); (R.S.L.); (H.H.T.); (K.S.); (M.E.S.); (K.A.P.); (J.W.T.L.)
| | - Kyungmin Shin
- Department of Breast Imaging, Division of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (R.E.P.); (R.S.L.); (H.H.T.); (K.S.); (M.E.S.); (K.A.P.); (J.W.T.L.)
| | - Megan E. Speer
- Department of Breast Imaging, Division of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (R.E.P.); (R.S.L.); (H.H.T.); (K.S.); (M.E.S.); (K.A.P.); (J.W.T.L.)
| | - Kanchan A. Phalak
- Department of Breast Imaging, Division of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (R.E.P.); (R.S.L.); (H.H.T.); (K.S.); (M.E.S.); (K.A.P.); (J.W.T.L.)
| | - Jia Sun
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA;
| | - Jessica W. T. Leung
- Department of Breast Imaging, Division of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (R.E.P.); (R.S.L.); (H.H.T.); (K.S.); (M.E.S.); (K.A.P.); (J.W.T.L.)
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Rubio IT, Wyld L, Marotti L, Athanasiou A, Regitnig P, Catanuto G, Schoones JW, Zambon M, Camps J, Santini D, Dietz J, Sardanelli F, Varga Z, Smidt M, Sharma N, Shaaban AM, Gilbert F. European guidelines for the diagnosis, treatment and follow-up of breast lesions with uncertain malignant potential (B3 lesions) developed jointly by EUSOMA, EUSOBI, ESP (BWG) and ESSO. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:107292. [PMID: 38061151 DOI: 10.1016/j.ejso.2023.107292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 11/17/2023] [Indexed: 01/16/2024]
Abstract
INTRODUCTION Breast lesions of uncertain malignant potential (B3) include atypical ductal and lobular hyperplasias, lobular carcinoma in situ, flat epithelial atypia, papillary lesions, radial scars and fibroepithelial lesions as well as other rare miscellaneous lesions. They are challenging to categorise histologically, requiring specialist training and multidisciplinary input. They may coexist with in situ or invasive breast cancer (BC) and increase the risk of subsequent BC development. Management should focus on adequate classification and management whilst avoiding overtreatment. The aim of these guidelines is to provide updated information regarding the diagnosis and management of B3 lesions, according to updated literature review evidence. METHODS These guidelines provide practical recommendations which can be applied in clinical practice which include recommendation grade and level of evidence. All sections were written according to an updated literature review and discussed at a consensus meeting. Critical appraisal by the expert writing committee adhered to the 23 items in the international Appraisal of Guidelines, Research and Evaluation (AGREE) tool. RESULTS Recommendations for further management after core-needle biopsy (CNB) or vacuum-assisted biopsy (VAB) diagnosis of a B3 lesion reported in this guideline, vary depending on the presence of atypia, size of lesion, sampling size, and patient preferences. After CNB or VAB, the option of vacuum-assisted excision or surgical excision should be evaluated by a multidisciplinary team and shared decision-making with the patient is crucial for personalizing further treatment. De-escalation of surgical intervention for B3 breast lesions is ongoing, and the inclusion of vacuum-assisted excision (VAE) will decrease the need for surgical intervention in further approaches. Communication with patients may be different according to histological diagnosis, presence or absence of atypia, or risk of upgrade due to discordant imaging. Written information resources to help patients understand these issues alongside with verbal communication is recommended. Lifestyle interventions have a significant impact on BC incidence so lifestyle interventions need to be suggested to women at increased BC risk as a result of a diagnosis of a B3 lesion. CONCLUSIONS These guidelines provide a state-of-the-art overview of the diagnosis, management and prognosis of B3 lesions in modern multidisciplinary breast practice.
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Affiliation(s)
- Isabel T Rubio
- Breast Surgical Oncology, Clinica Universidad de Navarra, Madrid, Spain; European Society of Breast Cancer Specialists (EUSOMA), Florence, Italy; European Society of Surgical Oncology (ESSO), Brussels, Belgium.
| | - Lynda Wyld
- Department of Oncology and Metabolism, University of Sheffield Medical School, Beech Hill Road, Sheffield, S10 2RX, UK; Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust, Doncaster, UK
| | - Lorenza Marotti
- European Society of Breast Cancer Specialists (EUSOMA), Florence, Italy
| | | | - Peter Regitnig
- Diagnostic and Research Institute of Pathology, Medical University of Graz, Graz, Austria
| | - Giuseppe Catanuto
- Humanitas-Istituto Clinico Catanese Misterbianco, Italy; Fondazione G.Re.T.A., ETS, Napoli, Italy
| | - Jan W Schoones
- Research Policy & Graduate School Advisor, Leiden University Medical Center Leiden, the Netherlands
| | - Marzia Zambon
- Europa Donna - The European Breast Cancer Coalition, Milan, Italy
| | - Julia Camps
- Breast Health Units in Ribera Salud Hospitals.Valencia, Spain
| | - Donatella Santini
- Department of Pathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy
| | - Jill Dietz
- The American Society of Breast Surgeons, Columbia, MD, USA
| | - Francesco Sardanelli
- Department of Biomedical Sciences for Health, Università Degli Studi di Milano, Milan, Italy; Unit of Radiology, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Zsuzsanna Varga
- Department of Pathology and Molecular Pathology, University Hospital Zurich, Zurich, Switzerland
| | - Marjolein Smidt
- GROW-School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, the Netherlands; Department of Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Nisha Sharma
- Breast Unit, Level 1 Chancellor Wing, St James Hospital, Beckett Street Leeds, West Yorkshire, LS9 7TF, UK
| | - Abeer M Shaaban
- Cellular Pathology, Queen Elizabeth Hospital Birmingham, Birmingham, UK; Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Fiona Gilbert
- Department of Radiology, University of Cambridge, Cambridge Biomedical Campus, UK.
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Darras C, Uchida M. Upgrade risk of image-targeted radial scar and complex sclerosing lesions diagnosed at needle-guided biopsy: a retrospective study. Eur Radiol 2023; 33:8399-8406. [PMID: 37386299 DOI: 10.1007/s00330-023-09877-6] [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: 10/18/2022] [Revised: 04/29/2023] [Accepted: 06/04/2023] [Indexed: 07/01/2023]
Abstract
OBJECTIVES To determine the upgrade rate of radial scar (RS) and complex sclerosing lesions (CSL) diagnosed with percutaneous biopsy. The secondary objectives were to determine the new atypia rate after surgery and to assess the diagnosis of subsequent malignancy on follow-up. METHODS This single-institution retrospective study had IRB approval. All image-targeted RS and CSL diagnosed with percutaneous biopsy between 2007 and 2020 were reviewed. Patient demographics, imaging presentation, biopsy characteristics, histological report, and follow-up data were collected. RESULTS During the study period, 120 RS/CSL were diagnosed in 106 women (median age, 43.5 years; range, 23-74), and 101 lesions were analyzed. At biopsy, 91 (90.1%) lesions were not associated with another atypia or malignancy and 10 (9.9%) were associated with another atypia. Out of the 91 lesions that were not associated with malignancy or atypia, 75 (82.4%) underwent surgical excision, and one upgrade to low-grade CDIS was detected (1.3%). Among the 10 lesions initially associated with another atypia, 9 were surgically excised and no malignancy was detected. After a median follow-up of 47 months (range: 12-143 months), two (1.98%) developed malignancy in a different quadrant; in both cases, another atypia was present at biopsy. CONCLUSION We found a low upgrade rate on image-detected RS/CSL, with or without another atypia associated. Associated atypia was underdiagnosed at biopsy in almost one-third of cases. Subsequent cancer risk could not be established because the only two cases were associated with another high-risk lesion (HRL), which might have increased the patient's risk of developing malignancy. CLINICAL RELEVANCE STATEMENT Our upgrade rates of RS/CSL with or without atypia diagnosed with core needle biopsy are almost as low as the ones reported with larger sampling methods. This result has particular importance in places with limited accessibility to US-guided vacuum-assisted biopsy. KEY POINTS •New evidence is showing lower upgrade rates of RS and CSL after surgery, leading to a more conservative management with extensive sampling using VAB or VAE. •Our study showed only one upgrade to a low-grade DCIS after surgery, yielding an upgrade rate of 1.33%. •During follow-up, no new malignancy was detected in the same quadrant where RS/CSL was diagnosed, including patients without surgery.
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Affiliation(s)
- Carla Darras
- Radiology Department, Clínica Alemana de Santiago, Vitacura 5951, 7630000, Santiago, RM, Chile.
| | - Marcela Uchida
- Radiology Department, Clínica Alemana de Santiago, Vitacura 5951, 7630000, Santiago, RM, Chile
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Manzar BZ, Phillips J, Dibble EH, Quintana LM, Lourenco AP. Imaging and Management of Radial Scars and Complex Sclerosing Lesions. Radiographics 2023; 43:e230022. [PMID: 37733620 DOI: 10.1148/rg.230022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/23/2023]
Abstract
Radial scars and complex sclerosing lesions, often collectively referred to as radial sclerosing lesions (RSLs), are breast lesions characterized by sclerotic stroma with entrapped epithelial elements. RSLs have imaging features that overlap with those of breast malignancy and often become the target of imaging-guided biopsy given their suspicious imaging appearance. These can be identified in isolation or can also be associated with atypia or other high-risk lesions that have intrinsic malignant potential, increasing the risk of carcinoma and affecting prognosis and management of RSLs. Because of this, management of these lesions remains controversial. Traditional management has been surgical excisional biopsy. However, as more RSLs are identified (because digital breast tomosynthesis allows identification of more architectural distortions), optimal management is evolving. Physicians in some practices are using a multidisciplinary approach to the management of RSLs when deciding on surgical excision of these lesions versus imaging follow-up. These discussions also incorporate individual patient risk factors and greater patient informed medical decision making. Reported upgrade rates of RSLs at core needle biopsy vary and can depend on the sampling method, number of samples, gauge of the needle, target being sampled, and radiologic-pathologic concordance or discordance. A precise sampling technique also allows greater accuracy of diagnosis and lower upgrade rates for these lesions, with radiologic-pathologic correlation as an integral component for further management decisions. The authors review the overall histopathologic, clinical, and imaging features of RSLs and discuss appropriate management based on currently available data regarding upgrade rates. ©RSNA, 2023 Quiz questions for this article are available through the Online Learning Center.
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Affiliation(s)
- Bushra Z Manzar
- From the Department of Radiology, Boston Medical Center, Boston, Mass (B.Z.M., J.P.); Department of Diagnostic Imaging, Warren Alpert Medical School of Brown University and Rhode Island Hospital, 593 Eddy St, 3rd Floor, Providence, RI 02903 (E.H.D., A.P.L.); and Department of Pathology, Beth Israel Deaconess Medical Center, Boston, Mass (L.M.Q.)
| | - Jordana Phillips
- From the Department of Radiology, Boston Medical Center, Boston, Mass (B.Z.M., J.P.); Department of Diagnostic Imaging, Warren Alpert Medical School of Brown University and Rhode Island Hospital, 593 Eddy St, 3rd Floor, Providence, RI 02903 (E.H.D., A.P.L.); and Department of Pathology, Beth Israel Deaconess Medical Center, Boston, Mass (L.M.Q.)
| | - Elizabeth H Dibble
- From the Department of Radiology, Boston Medical Center, Boston, Mass (B.Z.M., J.P.); Department of Diagnostic Imaging, Warren Alpert Medical School of Brown University and Rhode Island Hospital, 593 Eddy St, 3rd Floor, Providence, RI 02903 (E.H.D., A.P.L.); and Department of Pathology, Beth Israel Deaconess Medical Center, Boston, Mass (L.M.Q.)
| | - Liza M Quintana
- From the Department of Radiology, Boston Medical Center, Boston, Mass (B.Z.M., J.P.); Department of Diagnostic Imaging, Warren Alpert Medical School of Brown University and Rhode Island Hospital, 593 Eddy St, 3rd Floor, Providence, RI 02903 (E.H.D., A.P.L.); and Department of Pathology, Beth Israel Deaconess Medical Center, Boston, Mass (L.M.Q.)
| | - Ana P Lourenco
- From the Department of Radiology, Boston Medical Center, Boston, Mass (B.Z.M., J.P.); Department of Diagnostic Imaging, Warren Alpert Medical School of Brown University and Rhode Island Hospital, 593 Eddy St, 3rd Floor, Providence, RI 02903 (E.H.D., A.P.L.); and Department of Pathology, Beth Israel Deaconess Medical Center, Boston, Mass (L.M.Q.)
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9
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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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10
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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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11
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Warwar S, Kulkarni S. Selective surgical excision of high-risk lesions. Surgery 2023:S0039-6060(23)00117-4. [PMID: 37059651 DOI: 10.1016/j.surg.2023.02.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 02/17/2023] [Accepted: 02/23/2023] [Indexed: 04/16/2023]
Abstract
Intraductal papilloma, flat epithelial atypia, radial scar, atypical lobular hyperplasia, and lobular carcinoma in situ have historically been referred to as high-risk lesions and managed with routine surgical excision after diagnosis on core needle biopsy. The misnomer high-risk stems from high rates of upgrade to malignancy reported in historic literature. However, recent studies have found much lower upgrade rates, <2%, than previously thought. These findings are explained by advances in imaging technology, larger-bore biopsy needles, and emphasis on radiology-pathology concordance. Concordant lesions have a low upgrade risk and can be managed with radiographic and clinical surveillance instead of surgical excision. Surgical de-escalation is feasible for many of these lesions with careful multidisciplinary review and a detailed risk-benefit discussion with patients.
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Affiliation(s)
- Samantha Warwar
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Swati Kulkarni
- Division of Breast Surgery, Department of Surgery, Robert H. Lurie Comprehensive Cancer Center, Feinberg School of Medicine, Northwestern University, Chicago, IL.
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12
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Pathologic Outcomes in Single Versus Multiple Areas of Architectural Distortion on Digital Breast Tomosynthesis. AJR Am J Roentgenol 2023; 220:50-62. [PMID: 35895298 DOI: 10.2214/ajr.22.27625] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND. Digital breast tomosynthesis (DBT) has led to increased detection of architectural distortion (AD). Management of patients with multiple areas of AD is not established. OBJECTIVE. The purpose of this article is to compare pathologic outcomes between single and multiple areas of AD identified on DBT. METHODS. This retrospective study included 402 patients (mean age, 56 years) who underwent image-guided core needle biopsy of AD visualized on DBT between April 7, 2017, and April 16, 2019. Patients were classified as having a single or multiple areas of AD according to the presence of distinct areas of AD described in the clinical radiology reports. The pathologic diagnosis for each AD was on the basis of the most aggressive pathology identified on either biopsy or surgical excision, if performed. Patients with single and multiple areas of AD were compared. RESULTS. The sample included 372 patients with a single AD (145 benign, 121 high risk, 105 malignant, one other) and 30 patients with multiple visualized ADs, including 66 biopsied ADs (10 benign, 35 high risk, 21 malignant). At pathologic assessment on a per-lesion basis, multiple compared with single ADs showed higher frequency of high-risk pathology (53.0% vs 32.5%, p = .002) but no difference in frequency of malignancy (31.8% vs 28.2%, p = .56). In multivariable analysis of a range of patient-related characteristics, the presence of single versus multiple areas of AD was not independently associated with malignancy (p = .51). In patients with multiple areas of AD, the most aggressive pathology (benign, high risk, or malignant) across all ADs was not associated with the number of ADs (p = .73). In 8 of 24 patients with at least two ipsilateral biopsied ADs, the ipsilateral areas varied in terms of most aggressive pathology; in 5 of 10 patients with contralateral biopsied ADs, the contralateral areas varied in most aggressive pathology. CONCLUSION. The presence of multiple areas of AD, compared with a single AD, was significantly more likely to yield high-risk pathology but was not significantly different in yield of malignancy. In patients with multiple ADs, multiple ipsilateral or contralateral ADs commonly varied in pathologic classification (benign, high risk, or malignant). CLINICAL IMPACT. These findings may help guide management of AD visualized by DBT, including multiple ADs. For patients with multiple areas of AD, biopsy of all areas may be warranted given variation in pathologic diagnoses.
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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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14
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Rethinking Routine Surgical Excision for all Radial Sclerosing Lesions of the Breast. J Surg Res 2022; 279:611-618. [PMID: 35926311 DOI: 10.1016/j.jss.2022.06.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 06/10/2022] [Accepted: 06/28/2022] [Indexed: 11/22/2022]
Abstract
INTRODUCTION The need for routine surgical excision of a radial sclerosing lesions (RSL) of the breast identified on percutaneous biopsy remains controversial, as contemporary upgrade rates are lower than historically cited. MATERIALS AND METHODS A prospectively-maintained database of high-risk breast biopsies undergoing multidisciplinary review at a single institution was queried to identify cases of RSL from 2/2015 to 11/2020. Demographic, radiologic, and pathologic variables were summarized using frequencies and analyzed in association with RSL excision status using mixed-effects logistic regression or Fisher's exact tests. RESULTS 217 RSL were identified, diagnosed at a mean age of 57 y. The median imaging size was 1.3 cm and the majority had estimated >50% of the target removed by core needle biopsy. 32.3% underwent surgical excision of the RSL biopsy site and 2/70 (2.9%) upgraded to ductal carcinoma in situ (DCIS) on final surgical pathology. Upgrade was significantly higher for atypical RSL (P = 0.02). None of the RSL (n = 60) without atypia who had undergone excision were upgraded. For those omitting surgical excision, there was no subsequent breast cancer diagnosis at the RSL site over a mean follow-up of 23 mo. CONCLUSIONS Surgical excision may be omitted for RSL without atypia as this group has 0% risk of upgrade after multidisciplinary review.
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Ambinder EB, Calhoun BC. Risk-Associated Lesions of the Breast in Core Needle Biopsies: Current Approaches to Radiological-Pathological Correlation. Surg Pathol Clin 2022; 15:147-157. [PMID: 35236630 DOI: 10.1016/j.path.2021.11.010] [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
Image-guided core needle biopsies (CNBs) of the breast frequently result in a diagnosis of a benign or atypical lesion associated with breast cancer risk. The subsequent clinical management of these patients is variable, reflecting a lack of consensus on criteria for selecting patients for clinical and radiological follow-up versus immediate surgical excision. In this review, the evidence from prospective studies of breast CNB with radiological-pathological correlation is evaluated and summarized. The data support an emerging consensus on the importance of radiologic-pathologic correlation in standardizing the selection of patients for active surveillance versus surgery.
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Affiliation(s)
- Emily B Ambinder
- Breast Imaging Division, The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Medicine
| | - Benjamin C Calhoun
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, 160 N. Medical Drive, Campus Box 7525, Chapel Hill, NC 27599, USA.
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16
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Ultrasound-guided interventional procedures in breast imaging. RADIOLOGIA 2022; 64:76-88. [DOI: 10.1016/j.rxeng.2021.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 11/30/2021] [Indexed: 11/23/2022]
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17
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Bargallo X, Ubeda B, Ganau S, Gonzalez B, Macedo M, Alonso I, Oses G, Vidal M, Santamaria G. Magnetic Resonance Imaging Assessment of Radial Scars/complex Sclerosing Lesions of the Breast. Curr Med Imaging 2022; 18:242-248. [PMID: 33390120 DOI: 10.2174/1573405616666201231095918] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 10/02/2020] [Accepted: 10/14/2020] [Indexed: 11/22/2022]
Abstract
PURPOSE To describe the magnetic resonance characteristics of radial scars/complex sclerosing lesions (RS/CSL) of the breast using the current BI-RADS lexicon. To investigate the value of diffusion weighted imaging to predict malignancy. PATIENTS AND METHODS From 2010 to 2017, we have found 25 women with architectural distortion at mammography who underwent surgical resection with a final hystopathologic report of RS/CSL. For the description of MRI findings, we adhered to BI-RADS classification (5th edition). RESULTS The final pathological diagnosis was: "pure" RS/CSL in 7 cases (28%), RS/CSL with associated high risk lesions in 12 (48%) and 6 cases (24%) were associated with malignancy. Magnetic resonance findings: four of 25 negative or focus. Five of 25 mass enhancement: irregular, non circumscribed spiculated mass with heterogeneous or rim enhancement and most with type II curves. Sixteen of 25 non mass enhancement: focal or linear distribution and heterogeneous internal enhancement most with type I curves. Six of 25 had cancer associated with the complex sclerosing lesion. All six showed non-mass enhancement. Two cases with invasive breast carcinoma had ADC values under 1.15 x10-3 mm/s while most of the rest had the values above. CONCLUSION Most RS/CSL showed enhancement at MR. The predominant pattern was a non-mass, focal, heterogeneous internal enhancement with type 1 curves. All cases with associated cancer showed non mass enhancement. Invasive breast cancers had ADC values < 1.15 10-3 s/mm2.
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Affiliation(s)
- Xavier Bargallo
- Department of Radiology (CDIC), Hospital Clinic de Barcelona, Barcelona, Spain | School of Medicine, University of Barcelona, Barcelona, Spain
| | - Belen Ubeda
- Department of Radiology (CDIC), Hospital Clinic de Barcelona, Barcelona, Spain
| | - Sergi Ganau
- Department of Radiology (CDIC), Hospital Clinic de Barcelona, Barcelona, Spain
| | - Blanca Gonzalez
- Department of Pathology (CDIC), Hospital Clinic de Barcelona, Barcelona, Spain | School of Medicine, University of Barcelona, Barcelona, Spain
| | - Miguel Macedo
- Department of Radiology (CDIC), Hospital Clinic de Barcelona, Barcelona, Spain
| | - Inma Alonso
- Department of Gynecology (CDIC), Hospital Clinic de Barcelona, Barcelona, Spain | School of Medicine, University of Barcelona, Barcelona, Spain
| | - Gabriela Oses
- Department of Radiation Oncology (CDIC), Hospital Clinic de Barcelona, Barcelona, Spain
| | - Maria Vidal
- Department of Oncology (CDIC), Hospital Clinic de Barcelona, Barcelona, Spain | School of Medicine, University of Barcelona, Barcelona, Spain
| | - Gorane Santamaria
- Department of Radiology (CDIC), Hospital Clinic de Barcelona, Barcelona, Spain
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18
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Oliver Goldaracena J. Intervencionismo ecográfico en imagen mamaria. RADIOLOGIA 2022. [DOI: 10.1016/j.rx.2021.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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19
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Yan P, DeMello L, Baird GL, Lourenco AP. Malignancy Upgrade Rates of Radial Sclerosing Lesions at Breast Cancer Screening. Radiol Imaging Cancer 2021; 3:e210036. [PMID: 34766844 DOI: 10.1148/rycan.2021210036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Purpose To determine the upgrade rate for biopsy-proven radial scars and radial sclerosing lesions (RS). Materials and Methods In this retrospective study, radiology and pathology databases from two tertiary breast centers were searched to identify patients with biopsy-confirmed RS between March 1, 2012, and December 31, 2017, during which all mammography was performed with digital breast tomosynthesis (DBT). Adjunct modalities such as MRI or US are performed at our centers to better characterize lesions identified at DBT. Patient demographics, imaging, needle and excisional biopsies, and follow-up data were collected at the patient level. Clopper-Pearson interval estimate for upgrade was calculated for 95% confidence using PropCIs package with R version 4.1.0 (R Foundation for Statistical Computing) (1). Results During the study period, a total of 155 885 DBT examinations were performed. From these examinations, 146 biopsy-proven RS were identified in 142 women (median age, 58 years; age range, 26-87 years). A total of 80.1% (117 of 146) of all RS did not have associated atypia or malignancy, and 19.9% (29 of 146) had associated atypia at initial biopsy. A total of 66.7% (78 of 117) of RS without atypia or malignancy were surgically excised, 25.6% (30 of 117) were followed (median, 3 years; range, 1-7 years) with benign findings on imaging, and 7.7% (nine of 117) were lost to follow-up. The rate of malignancy upgrade was 0.9% (one of 117 [95% CI: 0.02, 4.7]); one RS without concurrent atypia or malignancy demonstrated invasive carcinoma at surgical excision. Conclusion RS without atypia had a low upgrade rate. Keywords: Mammography, Breast © RSNA, 2021.
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Affiliation(s)
- Pamela Yan
- From the Department of Diagnostic Imaging, Alpert Medical School of Brown University, Rhode Island Hospital, 593 Eddy St, Providence, RI 02903
| | - Linda DeMello
- From the Department of Diagnostic Imaging, Alpert Medical School of Brown University, Rhode Island Hospital, 593 Eddy St, Providence, RI 02903
| | - Grayson L Baird
- From the Department of Diagnostic Imaging, Alpert Medical School of Brown University, Rhode Island Hospital, 593 Eddy St, Providence, RI 02903
| | - Ana P Lourenco
- From the Department of Diagnostic Imaging, Alpert Medical School of Brown University, Rhode Island Hospital, 593 Eddy St, Providence, RI 02903
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20
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Girardi V, Guaragni M, Ruzzenenti N, Palmieri F, Fogazzi G, Cozzi A, Lucchini D, Buffoli A, Schiaffino S, Sardanelli F. B3 Lesions at Vacuum-Assisted Breast Biopsy under Ultrasound or Mammography Guidance: A Single-Center Experience on 3634 Consecutive Biopsies. Cancers (Basel) 2021; 13:5443. [PMID: 34771606 PMCID: PMC8582448 DOI: 10.3390/cancers13215443] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 10/22/2021] [Accepted: 10/26/2021] [Indexed: 11/30/2022] Open
Abstract
The rate of upgrade to cancer for breast lesions with uncertain malignant potential (B3 lesions) diagnosed at needle biopsy is highly influenced by several factors, but large series are seldom available. We retrospectively assessed the upgrade rates of a consecutive series of B3 lesions diagnosed at ultrasound- or mammography-guided vacuum-assisted biopsy (VAB) at an EUSOMA-certified Breast Unit over a 7-year timeframe. The upgrade rate was defined as the number of ductal carcinoma in situ (DCIS) or invasive cancer at pathology after excision or during follow-up divided by the total number of B3 lesions. All lesions were reviewed by one of four pathologists with a second opinion for discordant assessments of borderline cases. Excision or surveillance were defined by the multidisciplinary tumor board, with 6- and 12-month follow-up. Out of 3634 VABs (63% ultrasound-guided), 604 (17%) yielded a B3 lesion. After excision, 17/604 B3 lesions were finally upgraded to malignancy (2.8%, 95% confidence interval [CI] 1.8-4.5%), 10/17 (59%) being upgraded to DCIS and 7/17 (41%) to invasive carcinoma. No cases were upgraded during follow-up. B3a lesions showed a significantly lower upgrade rate (0.4%, 95% CI 0.1-2.1%) than B3b lesions (4.7%, 95% CI 2.9-7.5%, p = 0.001), that had a 22.0 adjusted odds ratio for upgrade (95% CI 2.1-232.3). No significant difference was found in upgrade rates according to imaging guidance or needle caliper. Surveillance-oriented management can be considered for B3a lesions, while surgical excision should be pursued for B3b lesions.
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Affiliation(s)
- Veronica Girardi
- Breast Radiology, EUSOMA-Certified Breast Unit, Istituto Clinico Sant’Anna, Via del Franzone 31, 25127 Brescia, Italy;
| | - Monica Guaragni
- Breast Pathology, EUSOMA-Certified Breast Unit, Istituto Clinico Sant’Anna, Via del Franzone 31, 25127 Brescia, Italy; (M.G.); (N.R.)
| | - Nella Ruzzenenti
- Breast Pathology, EUSOMA-Certified Breast Unit, Istituto Clinico Sant’Anna, Via del Franzone 31, 25127 Brescia, Italy; (M.G.); (N.R.)
| | - Fabrizio Palmieri
- Breast Surgery, EUSOMA-Certified Breast Unit, Istituto Clinico Sant’Anna, Via del Franzone 31, 25127 Brescia, Italy;
| | - Gianluca Fogazzi
- Breast Medical Oncology, EUSOMA-Certified Breast Unit, Istituto Clinico Sant’Anna, Via del Franzone 31, 25127 Brescia, Italy;
| | - Andrea Cozzi
- Department of Biomedical Sciences for Health, Università degli Studi di Milano, Via Mangiagalli 31, 20133 Milano, Italy;
| | - Diana Lucchini
- Breast Psycho-Oncology, EUSOMA-Certified Breast Unit, Istituto Clinico Sant’Anna, Via del Franzone 31, 25127 Brescia, Italy;
| | - Alberto Buffoli
- Radiation Oncology, EUSOMA-Certified Breast Unit, Istituto Clinico Sant’Anna, Via del Franzone 31, 25127 Brescia, Italy;
| | - Simone Schiaffino
- Unit of Radiology, IRCCS Policlinico San Donato, Via Morandi 30, 20097 San Donato Milanese, Italy;
| | - Francesco Sardanelli
- Department of Biomedical Sciences for Health, Università degli Studi di Milano, Via Mangiagalli 31, 20133 Milano, Italy;
- Unit of Radiology, IRCCS Policlinico San Donato, Via Morandi 30, 20097 San Donato Milanese, Italy;
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21
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Piraner M, D'Amico K, Gilliland LL, Newell MS, Cohen MA. Pure Radial Scars Do Not Require Surgical Excision When Concordant and Benign at Image-guided Breast Biopsy. JOURNAL OF BREAST IMAGING 2021; 3:572-580. [PMID: 38424945 DOI: 10.1093/jbi/wbab048] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Indexed: 03/02/2024]
Abstract
OBJECTIVE To determine the best management option (surgical excision versus imaging surveillance) following the diagnosis of pure radial scars (RSs) and RSs with associated additional high-risk lesions (HRLs) encountered on percutaneous core-needle breast biopsy. METHODS An IRB-approved retrospective review of the breast imaging reporting system database was performed to identify all cases of pure RS alone or RS plus an additional HRL (papilloma, atypia, lobular neoplasia) diagnosed on core-needle biopsy, from 2007 to 2016, at four breast centers in our institution. Cases with associated malignancy, discordant radiologic-pathologic results, or those lost to follow-up were excluded. The remaining cases were evaluated to determine results of either subsequent surgical excision or long-term follow-up imaging (minimum of two years). Additional data recorded included clinical presentation, breast density, personal and family history of breast cancer, lesion imaging characteristics, and biopsy method. RESULTS The study cohort included 111 patients with 111 lesions: 56.8% (63/111) with RS alone (pure) and 43.2% (48/111) with RS plus additional HRL(s). Out of the 63 radiologic-pathologic concordant pure RSs, there were no upgrades to malignancy in 51 subsequent surgical excisions or 12 long-term surveillance cases (0/63, 0%). Out of the 48 RSs plus additional HRL(s), there were 2 upgrades to malignancy (2/48, 4.2%). CONCLUSION Cases of radiologic-pathologic concordant pure RS diagnosed at core-needle biopsy do not require surgical excision. On the other hand, surgical excision should be considered for RS plus additional HRLs diagnosed at core-needle biopsy.
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Affiliation(s)
- Maria Piraner
- Emory University School of Medicine, Department of Radiology and Imaging Sciences, Atlanta, GA, USA
| | - Kelly D'Amico
- Radiology Imaging Associates, PC, Englewood, CO, USA
| | - Lawrence L Gilliland
- Emory University School of Medicine, Department of Radiology and Imaging Sciences, Atlanta, GA, USA
| | - Mary S Newell
- Emory University School of Medicine, Department of Radiology and Imaging Sciences, Atlanta, GA, USA
| | - Michael A Cohen
- Emory University School of Medicine, Department of Radiology and Imaging Sciences, Atlanta, GA, USA
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22
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Tomosynthesis-Guided Vacuum-Assisted Breast Biopsy of Architectural Distortion Without a Sonographic Correlate: A Retrospective Review. AJR Am J Roentgenol 2021; 217:845-854. [PMID: 33147055 DOI: 10.2214/ajr.20.24740] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND. Digital breast tomosynthesis-guided vacuum-assisted breast biopsy (DBT VAB) allows biopsy of findings seen better or exclusively on digital breast tomosynthesis (DBT), including architectural distortion. Although architectural distortion with an associated sonographic mass correlate has a high risk of malignancy, limited data describe the radiologic-pathologic correlation of tomosynthesis-detected architectural distortion without a sonographic correlate. OBJECTIVE. This study evaluates the malignancy rate of architectural distortions without a sonographic correlate that undergo DBT VAB and provides radiologic-pathologic correlation for benign, high-risk, and malignant entities that are associated with architectural distortion. METHODS. We retrospectively reviewed imaging, as well as pathology slides and/or reports, for DBT VABs performed for architectural distortion without a sonographic correlate at a single institution between June 1, 2017, and January 15, 2020. According to the correlative histopathology, cases were categorized as benign, high risk, or malignant, and specific histopathologic diagnoses were summarized. RESULTS. During the study period, 142 patients (mean age, 59 years) underwent DBT VAB for 151 unique architectural distortions without a sonographic correlate. DBT VAB revealed a malignant diagnosis in 27 (18%), a high-risk lesion in 50 (33%), and a benign diagnosis in 74 (49%). Two cases of atypical ductal hyperplasia were upgraded to malignancy, resulting in a final malignancy rate of 19% (n = 29/151). Most malignant lesions were invasive carcinomas (83%, n = 24/29); most invasive carcinomas were of lobular subtype (54%, n = 13/24). Most high-risk lesions were radial scars/complex sclerosing lesions (62%, n = 31/50). Most benign results represented fibrocystic change (66%, n = 49/74). A subset (11%, n = 8/74) of benign results were considered discordant and subsequently excised, with none representing malignancy. CONCLUSION. The final malignancy rate of 19% in architectural distortion without a sonographic correlate justifies a recommendation for biopsy using DBT VAB. CLINICAL IMPACT. Our results highlight the utility of DBT VAB in the era of DBT. The detailed radiologic-pathologic correlations will assist radiologists in assessing concordance when performing DBT VAB for architectural distortions and provide a reference for future patient management.
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Marti JL. ASO Author Reflections: "High-Risk" Lesions of the Breast: Low Risk of Cancer, High Risk of Overtreatment. Ann Surg Oncol 2021; 28:5156-5157. [PMID: 33782798 DOI: 10.1245/s10434-021-09845-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 03/02/2021] [Indexed: 11/18/2022]
Affiliation(s)
- Jennifer L Marti
- Divisions of Breast and Endocrine Surgery, Department of Surgery, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, NY, USA.
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Abstract
Radial scar (RS) or complex sclerosing lesions (CSL) if > 10 mm is a benign lesion with an increasing incidence of diagnosis (ranging from 0.6 to 3.7%) and represents a challenge both for radiologists and for pathologists. The digital mammography and digital breast tomosynthesis appearances of RS are well documented, according to the literature. On ultrasound, variable aspects can be detected. Magnetic resonance imaging contribution to differential diagnosis with carcinoma is growing. As for the management, a vacuum-assisted biopsy (VAB) with large core is recommended after a percutaneous diagnosis of RS due to potential sampling error. According to the recent International Consensus Conference, a RS/CSL lesion, which is visible on imaging, should undergo therapeutic excision with VAB. Thereafter, surveillance is justified. The aim of this review is to provide a practical guide for the recognition of RS on imaging, illustrating radiological findings according to the most recent literature, and to delineate the management strategies that follow.
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25
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Shi J, Shi J, Yang S. Breast tubular carcinoma at parasternal and retro-nipple area: Two case reports. Medicine (Baltimore) 2021; 100:e24977. [PMID: 33725968 PMCID: PMC7982237 DOI: 10.1097/md.0000000000024977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 02/11/2021] [Indexed: 01/05/2023] Open
Abstract
INTRODUCTION Breast tubular carcinoma (TC) is a well-differentiated infiltrating ductal carcinoma, common in postmenopausal women. PATIENT CONCERNS Two patients concerned their abnormality of their breasts, one at deep parasternal higher chest wall in a 74-year-old female and the other behind the nipple in a 39- year-old female. DIAGNOSIS These masses were detected by mammography, ultrasound and magnetic resonance imaging (MRI) examinations. The parasternal mass identified by mammography showed long spicules along the edges of the mass. Ultrasound examination revealed that these masses had solid irregular hypoechoic nodules. The color Doppler ultrasound of the retro-nipple mass presented with increased blood flow resistance index. The dynamic contrast-enhanced MRI examination of the retro-nipple nodule demonstrated an intensely enhancing mass with a plateau-type time-signal intensity curve. INTERVENTIONS Two cases were surgically removed by local resection of foci under ultrasound guidance. OUTCOMES These imaging examinations strongly suggest possible breast tubular carcinoma, which was confirmed by the pathological evaluation of frozen sections from surgically removed masses. CONCLUSION Although uncommon, breast tubular carcinoma may be considered in the differential diagnosis of small solid masses with long spicules at parasternal breast or behind the nipples in adult women.
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Affiliation(s)
- Junhua Shi
- Department of Radiology, Affiliated Hospital of Zunyi Medical University
| | - Junli Shi
- Department of Radiology, Affiliated Hospital of Zunyi Medical University
| | - Shengbo Yang
- Department of Anatomy, Zunyi Medical University, Zunyi, Guizhou, China
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Liu RQ, Chen L, Padilla-Thornton A, Pao JS, Warburton R, Dingee C, Bazzarelli A, McKevitt E. Upstage rate of radial scar/complex sclerosing lesion identified on core needle biopsy. Am J Surg 2021; 221:1177-1181. [PMID: 33773749 DOI: 10.1016/j.amjsurg.2021.03.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Revised: 02/12/2021] [Accepted: 03/14/2021] [Indexed: 01/12/2023]
Abstract
BACKGROUND We assessed the cancer upstage rate of Radial Scars (RS), and Complex Sclerosing Lesions (CSL), and risk-stratified lesions based on radiological and pathological features. METHODS Characteristics of RS/CSL treated from 2013 to 2018 were examined for features associated with cancer. RESULTS 78 RS/CSL were found on core needle biopsy (CNB) and surgically excised. 9 (11.5%) lesions were upstaged. Upstaged patients were older (66 vs 51, p = 0.033). More upstaged lesions were accompanied by a mass on both mammography (87.5% vs. 30.0%, p = 0.005) and ultrasound (100.0% vs. 62.8%, p = 0.043). 20.5% of lesions biopsied under ultrasound guidance with small needles (14-18G) were upstaged, but no lesions biopsied under stereotactic guidance with large needles (9-12 G) with vacuum assistance were upstaged (p = 0.009). CONCLUSIONS Excision of RS/CSL seen on CNB is warranted, especially if the patient is older, the CNB is performed under ultrasound guidance with small needles, or if a mass is present on imaging.
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Affiliation(s)
- Rachel Q Liu
- Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, ON, N6A 5A5, Canada; Providence Breast Centre, Mount Saint Joseph Hospital, 3080 Prince Edward Street, Vancouver, BC, V5T 3N4, Canada.
| | - Leo Chen
- Providence Breast Centre, Mount Saint Joseph Hospital, 3080 Prince Edward Street, Vancouver, BC, V5T 3N4, Canada.
| | - Amie Padilla-Thornton
- Providence Breast Centre, Mount Saint Joseph Hospital, 3080 Prince Edward Street, Vancouver, BC, V5T 3N4, Canada; Department of Surgery, Faculty of Medicine, University of British Columbia, 2775 Laurel Street, Vancouver, BC, V5Z 1M9, Canada.
| | - Jin-Si Pao
- Providence Breast Centre, Mount Saint Joseph Hospital, 3080 Prince Edward Street, Vancouver, BC, V5T 3N4, Canada; Department of Surgery, Faculty of Medicine, University of British Columbia, 2775 Laurel Street, Vancouver, BC, V5Z 1M9, Canada.
| | - Rebecca Warburton
- Providence Breast Centre, Mount Saint Joseph Hospital, 3080 Prince Edward Street, Vancouver, BC, V5T 3N4, Canada; Department of Surgery, Faculty of Medicine, University of British Columbia, 2775 Laurel Street, Vancouver, BC, V5Z 1M9, Canada.
| | - Carol Dingee
- Providence Breast Centre, Mount Saint Joseph Hospital, 3080 Prince Edward Street, Vancouver, BC, V5T 3N4, Canada; Department of Surgery, Faculty of Medicine, University of British Columbia, 2775 Laurel Street, Vancouver, BC, V5Z 1M9, Canada.
| | - Amy Bazzarelli
- Providence Breast Centre, Mount Saint Joseph Hospital, 3080 Prince Edward Street, Vancouver, BC, V5T 3N4, Canada; Department of Surgery, Faculty of Medicine, University of British Columbia, 2775 Laurel Street, Vancouver, BC, V5Z 1M9, Canada.
| | - Elaine McKevitt
- Providence Breast Centre, Mount Saint Joseph Hospital, 3080 Prince Edward Street, Vancouver, BC, V5T 3N4, Canada; Department of Surgery, Faculty of Medicine, University of British Columbia, 2775 Laurel Street, Vancouver, BC, V5Z 1M9, Canada.
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Kraft E, Limberg JN, Dodelzon K, Newman LA, Simmons R, Swistel A, Ginter PS, Marti JL. Radial Scars and Complex Sclerosing Lesions of the Breast: Prevalence of Malignancy and Natural History Under Active Surveillance. Ann Surg Oncol 2021; 28:5149-5155. [PMID: 33666811 DOI: 10.1245/s10434-021-09713-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 01/27/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND When needle core biopsies (NCBs) of the breast reveal radial scar or complex sclerosing lesions (RSLs), excision is often recommended despite a low risk of malignancy in the modern era. The optimal management of NCBs revealing RSLs is controversial, and understanding of the natural history of unresected RSLs is limited. METHODS We retrospectively analyzed pathology and imaging data from 148 patients with NCB revealing RSL without atypia from 2015 to 2019 to determine the prevalence of malignancy and the behavior of RSLs undergoing active surveillance (AS). RESULTS The mean age of patients was 52 years, and most lesions were screen-detected (91%). The median lesion size was 6.0 mm (range 2-39). Most patients (66%, n = 98) underwent immediate surgery, while 34% (n = 50) of patients underwent AS, with a median follow-up of 16 months (range 6-51). Of the excised RSLs, 99% (n = 97) were benign and 1% (n = 1) revealed ductal carcinoma in situ (DCIS). In 17% (n = 17) of cases, additional high-risk lesions were discovered upon excision. Among the 50 patients undergoing AS, no lesions progressed on interval imaging. CONCLUSIONS In this cohort, 99% of RSLs undergoing excision were benign, 1% revealed DCIS, and there were no invasive cancers. In the first study of patients with RSLs undergoing AS, we found that all lesions either remained stable or resolved. We propose that the vast majority of patients with RSL on NCB can be safely offered AS, and that routine excision is a low-value intervention.
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Affiliation(s)
- Elizabeth Kraft
- Department of Surgery, New York-Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY, USA
| | - Jessica N Limberg
- Division of Breast Surgery, Department of Surgery, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, NY, USA
| | - Katerina Dodelzon
- Department of Radiology, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, NY, USA
| | - Lisa A Newman
- Division of Breast Surgery, Department of Surgery, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, NY, USA
| | - Rache Simmons
- Division of Breast Surgery, Department of Surgery, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, NY, USA
| | - Alexander Swistel
- Division of Breast Surgery, Department of Surgery, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, NY, USA
| | - Paula S Ginter
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, NY, USA
| | - Jennifer L Marti
- Division of Breast Surgery, Department of Surgery, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, NY, USA.
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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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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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Samreen N, Moy L, Lee CS. Architectural Distortion on Digital Breast Tomosynthesis: Management Algorithm and Pathological Outcome. JOURNAL OF BREAST IMAGING 2020; 2:424-435. [PMID: 38424901 DOI: 10.1093/jbi/wbaa034] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2020] [Indexed: 03/02/2024]
Abstract
Architectural distortion on digital breast tomosynthesis (DBT) can occur due to benign and malignant causes. With DBT, there is an increase in the detection of architectural distortion compared with 2D digital mammography, and the positive predictive value is high enough to justify tissue sampling when imaging findings are confirmed. Workup involves supplemental DBT views and ultrasound, with subsequent image-guided percutaneous biopsy using the modality on which it is best visualized. If architectural distortion is subtle and/or questionable on diagnostic imaging, MRI may be performed for problem solving, with subsequent biopsy of suspicious findings using MRI or DBT guidance, respectively. If no suspicious findings are noted on MRI, a six-month follow-up DBT may be performed. On pathology, malignant cases are noted in 6.8%-50.7% of the cases, most commonly due to invasive ductal carcinoma, followed by invasive lobular carcinoma. Radial scars are the most common benign cause, with stromal fibrosis and sclerosing adenosis being much less common. As there is an increase in the number of benign pathological outcomes for architectural distortion on DBT compared with 2D digital mammography, concordance should be based on the level of suspicion of imaging findings. As discordant cases have upgrade rates of up to 25%, surgical consultation is recommended for discordant radiologic-pathologic findings.
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Affiliation(s)
- Naziya Samreen
- NYU Langone Medical Center, Department of Radiology, Garden City, NY
| | - Linda Moy
- NYU Grossman School of Medicine, Department of Radiology, New York, NY
| | - Cindy S Lee
- NYU Langone Medical Center, Department of Radiology, Garden City, NY
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Quinn EM, Dunne E, Flanagan F, Mahon S, Stokes M, Barry MJ, Kell M, Walsh SM. Radial scars and complex sclerosing lesions on core needle biopsy of the breast: upgrade rates and long-term outcomes. Breast Cancer Res Treat 2020; 183:677-682. [PMID: 32696314 DOI: 10.1007/s10549-020-05806-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 07/11/2020] [Indexed: 12/30/2022]
Abstract
PURPOSE Radial scars and complex sclerosing lesions of the breast are part of a group of "indeterminate" breast lesions, which are excised due to risk of coexistent carcinoma. The aim of this study was to assess rate of upgrade of these lesions to invasive and in situ carcinoma and to quantify the risk of development of subsequent cancer in women diagnosed with these lesions. METHODS A retrospective review of a prospectively maintained breast screening database was performed. All patients with radial scar identified at either core biopsy or final excision biopsy between January 2006 and July 2012 were identified. Full pathological reports for both core biopsy and final excision biopsy were reviewed. Patient outcomes were followed for a mean of 117.1 months. RESULTS Of 451 B3 biopsies performed at our screening unit, 95 (22%) were found to have a radial scar or complex sclerosing lesion (CSL) on core needle biopsy. Within this group, 77 had no atypia on CNB, with 7 (9%) upgraded to invasive/in situ carcinoma on final excision. Of nine with definite atypia on CNB, 3 (33%) were upgraded. In those patients without atypia or malignancy on final excision, 7.5% developed cancer during 10-year follow-up. CONCLUSION Patients with radial scar with atypia have a higher risk of upgrade to malignancy. Further research is needed to identify which patients may safely avoid excision of radial scar. Patients with a diagnosis of radial scar on CNB are at increased subsequent risk of breast cancer and may benefit from additional screening.
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Affiliation(s)
- E M Quinn
- Department of Surgery, Breastcheck Eccles Unit, Eccles St, Dublin 7, Ireland.
| | - E Dunne
- Department of Surgery, Breastcheck Eccles Unit, Eccles St, Dublin 7, Ireland
| | - F Flanagan
- Department of Radiology, Breastcheck Eccles Unit, Eccles St, Dublin 7, Ireland
| | - S Mahon
- Department of Histopathology, Breastcheck Eccles Unit, Eccles St, Dublin 7, Ireland
| | - M Stokes
- Department of Surgery, Breastcheck Eccles Unit, Eccles St, Dublin 7, Ireland
| | - M J Barry
- Department of Surgery, Breastcheck Eccles Unit, Eccles St, Dublin 7, Ireland
| | - M Kell
- Department of Surgery, Breastcheck Eccles Unit, Eccles St, Dublin 7, Ireland
| | - S M Walsh
- Department of Surgery, Breastcheck Eccles Unit, Eccles St, Dublin 7, Ireland
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Stachs A, Stubert J, Reimer T, Hartmann S. Benign Breast Disease in Women. DEUTSCHES ARZTEBLATT INTERNATIONAL 2020; 116:565-574. [PMID: 31554551 DOI: 10.3238/arztebl.2019.0565] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 07/02/2019] [Accepted: 07/02/2019] [Indexed: 12/23/2022]
Abstract
BACKGROUND Most clinical breast changes in women are benign; in only 3% to 6% of cases are they due to breast cancer. How- ever, there is a lack of up-to-date, evidence-based treatment recommendations for the various benign differential diagnoses. METHODS Selective literature search of PubMed from 1985 to May 2019, including current national (AWMF, Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften [Association of Scientific Medical Societies in Germany]) and inter- national guidelines. RESULTS Mastalgia and fibrocystic changes are common (around 50% of all women over the age of 30). Fibroadenomas occur in 25% of women; they are the most common benign tumors of the breast and do not require treatment. With most benign breast changes the risk of dedifferentiation is very low. However, it is important in the differential diagnosis to distinguish between such benign changes and breast cancer or changes that carry a risk of malignancy. Complex cysts, for example, carry a risk of malig- nancy of 23% to 31%, papillary lesions 16% , and radial scars 7%. Where there is doubt, histological confirmation should be sought by means of percutaneous biopsy. CONCLUSION Benign breast changes can be definitively distinguished from malignant lesions through the selective use of avail- able diagnostic investigations and interdisciplinary collaboration. When lesions of uncertain malignant potential are found (B3 in the biopsy classification), complete excision is indicated. Prospective studies on the early diagnosis of breast cancer in lesions carrying a risk of malignancy are desirable.
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Affiliation(s)
- Angrit Stachs
- Department of Obstetrics and Gynecology, University of Rostock
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Gašljević G, Hertl K, Gazić B, Lamovec J, Žgajnar J. Reducing indications for radial scar surgical excision in Slovenian breast cancer screening program. Ann Diagn Pathol 2019; 45:151438. [PMID: 31927469 DOI: 10.1016/j.anndiagpath.2019.151438] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 12/05/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE Management of the radial scar (RS)/complex sclerosing lesion (CSL) diagnosed by core needle biopsy (CNB) in breast cancer screening population (BCSP) is controversial due to its intrinsic malignant potential. We aimed to determine (i) the rate of upgrade of the RS/CSL to malignant lesions and (ii) radiological characteristics and CNB histopathological findings of the lesions related to the upgrade of the RS/CSL to malignant lesions after surgical excision in our BCSP. PATIENTS AND METHODS Database of Slovenian National Breast Cancer Screening Program was checked for terms RS/CSL in all patients who underwent CNB in the period 2008-2018. The ratios of upgrade from CNB RS/SCL to malignant lesions after surgical excision were calculated with specific interest to the radiological characteristics and the CNB patohistologically findings of the lesions. RESULTS Of 162 patients with diagnosis of RS/CSL on the CNB, 121/156 (78%) cases underwent surgical excision. 6 of 121 (5%) cases were upgraded to a malignant diagnosis in surgical specimen, 3 cases of invasive carcinoma and 3 cases of DCIS, respectively. Five of the upgraded cases (5/6, 83.3%) showed atypical epithelial proliferative lesions (AEPL) on CNB. In one upgraded case without AEPL the lesion presented as 33 mm architectural distortion with microcalcifications on the mammogram. CONCLUSIONS In BCSP setting RS/CSL without AEPL/papilloma and those measuring less than 2 cm in the largest diameter can be followed radiologically. Increasing the number of cores and adequate sampling of the periphery and the centre of the RS/CSL improves the pick-up rate of associated atypia/malignancy.
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