Current management practice of breast borderline lesions—need for further research and guidelines

Impact of Atypical Hyperplasia at Surgical Margins on breast cancer outcomes in patients treated with neoadjuvant chemotherapy

Background

Women with atypical hyperplasia (AH) is associated with a higher risk of future breast cancer. However, whether AH found at margins in patients with breast-conserving surgery (BCS) after neoadjuvant chemotherapy (NAC) needs re-excision is not well-defined. The aim of the present study was to evaluate the impact of AH at the surgical margins on the local recurrence and survival outcomes in breast cancer patients treated with NAC and BCS.

Methods

A retrospective analysis comparing patients who treated with NAC and BCS with AH at the margins to those without AH was performed.

Results

598 patients were included in this study. The 5-year rates of ipsilateral breast tumor recurrence (IBTR) were 4.6% and 6.2% in patients with and without AH, respectively. No significant differences were observed among the two groups in terms of IBTR, DMFS, or OS. HER2 overexpressing breast cancer patients with severe AH at margins have a significantly higher risk of IBTR compared to those without severe AH.

Conclusion

Our study suggests that the presence of AH at the surgical margins of BCS in patients who received NAC does not appear to increase the risk of ipsilateral breast cancer. Therefore, there is no need for surgeons to routinely perform additional re-excision of AH found at the margins of BCS in these patients. However, selective re-excision should be considered in certain cases, particularly in patients with HER2 overexpression.

High-risk and selected benign breast lesions diagnosed on core needle biopsy: Evidence for and against immediate surgical excision

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.

Risk-Associated Lesions of the Breast in Core Needle Biopsies: Current Approaches to Radiological-Pathological Correlation

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.

Pure Radial Scars Do Not Require Surgical Excision When Concordant and Benign at Image-guided Breast Biopsy

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.

A survey of Canadian breast health professionals’ recommendations for high-risk benign breast disease

Summary

The management of high-risk benign breast disease (BBD) is changing because of improvements in radiological and pathological analysis. We sought to determine the current practice recommendations of breast health professionals in managing patients with high-risk BBD. We surveyed members of the Canadian Society of Surgical Oncology, Canadian Association of General Surgeons and Canadian Association of Radiologists. The survey contained demographic and case-based questions concerning management of high-risk benign breast lesions. Participants were asked for their recommendations and opinions regarding future risk of breast cancer as well as the role of chemoprevention. There was no consistency among the 41 respondents in the treatment recommendations for any of the high-risk benign conditions, and the lifetime risk associated with classic lobular carcinoma in situ was vastly underestimated. Education and evidenced-based guidelines are urgently needed to ensure more uniform practice nationally.

Core needle biopsy of benign, borderline and in-situ problematic lesions of the breast: Diagnosis, differential diagnosis and immunohistochemistry

Core needle biopsy (CNB) is the most common sampling technique for the histologic evaluation of breast abnormalities. Diagnosing benign proliferative, borderline and some in-situ lesions in CNB is challenging and subject to a significant degree of interobserver variability. In addition, due to the inherent limitations of CNB, "upgrading" to a more significant pathology at excision is an important consideration for some lesions. Pathologists carry a major responsibility in patient diagnosis, risk stratification and management. Familiarity with the histologic features and the clinical significance of these common and problematic lesions encountered in CNB is necessary for adequate treatment and patient follow-up. This review will focus on benign, atypical and in-situ epithelial proliferations, papillary lesions, radial sclerosing lesions, adenosis and cellular fibroepithelial lesions. Highlights of histologic features, useful strategies for accurate diagnosis, basic immunohistochemistry and management will be presented.

CXCL1 Derived from Mammary Fibroblasts Promotes Progression of Mammary Lesions to Invasive Carcinoma through CXCR2 Dependent Mechanisms

With improved screening methods, the numbers of abnormal breast lesions diagnosed in women have been increasing over time. However, it remains unclear whether these breast lesions will develop into invasive cancers. To more effectively predict the outcome of breast lesions and determine a more appropriate course of treatment, it is important to understand the underlying mechanisms that regulate progression of non-invasive lesions to invasive breast cancers. A hallmark of invasive breast cancers is the accumulation of fibroblasts. Fibroblast proliferation and activation in the mammary gland is in part regulated by the Transforming Growth Factor beta1 pathway (TGF-β). In animal models, TGF-β suppression of CCL2 and CXCL1 chemokine expression is associated with metastatic progression of mammary carcinomas. Here, we show that transgenic overexpression of the Polyoma middle T viral antigen in the mouse mammary gland of C57BL/6 mice results in slow growing non-invasive lesions that progress to invasive carcinomas in a stage dependent manner. Invasive carcinomas are associated with accumulation of fibroblasts that show decreased TGF-β expression and high levels of CXCL1, but not CCL2. Using co-transplant models, we show that decreased TGF-β signaling in fibroblasts contribute to mammary carcinoma progression through enhancement of CXCL1/CXCR2 dependent mechanisms. Using cell culture models, we show that CXCL1 mediated mammary carcinoma cell invasion through NF-κB, AKT, Stat3 and p42/44MAPK dependent mechanisms. These studies provide novel mechanistic insight into the progression of pre-invasive lesions and identify new stromal biomarkers, with important prognostic implications.

Malignancy rates of B3-lesions in breast magnetic resonance imaging - do all lesions have to be excised?

BACKGROUND

Approximately 10% of all MRI-guided vacuum-assisted breast biopsies (MR-VAB) are histologically classified as B3 lesions. In most of these cases surgical excision is recommended. The aim of our study was to evaluate the malignancy rates of different B3 lesions which are visible on MRI to allow a lesion-adapted recommendation of further procedure.

METHODS

Retrospective analysis of 572 consecutive MR-VAB was performed. Inclusion criteria were a representative (=successful) MR-VAB, histologic diagnosis of a B3 lesion and either the existence of a definite histology after surgical excision or proof of stability or regression of the lesion on follow-up MRI. Malignancy rates were evaluated for different histologies of B3 lesions. Lesion size and lesion morphology (mass/non-mass enhancement) on MRI were correlated with malignancy.

RESULTS

Of all MR-VAB 43 lesions fulfilled the inclusion criteria. The malignancy rate of those B3 lesions was 23.3% (10/43). The highest malignancy rate was found in atypical ductal hyperplasia (ADH) lesions (50.0%; 4/8), 33.3% (2/6) in flat epithelial atypia (FEA), 28.6% (2/7) in lobular intraepithelial neoplasia (LIN) and 12.5% (2/16) in papillary lesions (PL). All 6 complex sclerosing lesions were benign. Mass findings were significantly more frequently malignant (31.3%, 10/32; p < 0.05) than non-mass findings (0/11). Small lesions measuring 5-10 mm were most often malignant (35.0%; 7/20). All large lesions (> 20 mm) were not malignant (0/10). Intermediate sized lesions (11-20 mm) turned out to be malignant in 23.1% (3/13).

CONCLUSIONS

The malignancy rate of B3 lesions which were diagnosed after MR-VAB was 23.3%. ADH, FEA and LIN showed considerable malignancy rates (50%, 33% and 29%) and should therefore undergo surgical excision. None of the cases, which were diagnosed as radial scars, non-mass enhancement or larger lesions (> 20 mm) were malignant. Here, a follow-up MRI seems to be advisable to avoid unnecessary operations.

TRIAL REGISTRATION

Retrospective study design, waived by the IRB.

Use of Breast Magnetic Resonance Imaging in Women Diagnosed With Atypical Ductal Hyperplasia at Core Needle Biopsy Helps Select Women for Surgical Excision

PURPOSE

The study sought to investigate the role of breast magnetic resonance imaging (MRI) in patients diagnosed with atypical ductal hyperplasia (ADH) at core needle biopsy (CNB).

METHODS

The breast MRI database at our centre was queried for studies performed between January 2010 and December 2016 for the clinical indication of ADH diagnosed at CNB. Medical files were reviewed for demographic data, clinical information, and radiology and pathology reports. Pathological results of the surgical specimens were considered the gold standard for comparison with breast MRI findings. In women not undergoing excision, at least 2 years of follow-up was used to ascertain the benign nature of the finding.

RESULTS

Fifty patients were included in the study. Thirty-one (62%) patients had surgical excision of the ADH lesion, and 7 (23%) were upgraded to malignancy. Breast MRI accurately identified 6 of the 7 cases. Six of the 12 women (50%) with positive MRI findings at the biopsy site were upgraded to malignancy on surgical pathology, compared with only 1 of 19 (5%) with negative MRI findings. Forty-nine percent of the women with a negative MRI did not undergo surgical excision of the ADH lesion, compared with 8% of the women with a positive MRI (P = .009), with no cancer diagnosed during follow-up. The sensitivity, specificity, negative predictive value, and positive predictive value of breast MRI for predicting upgrade to malignancy were 86%, 83%, 97%, and 46%, respectively.

CONCLUSIONS

MRI may have a role in the management of women diagnosed with ADH on CNB, to minimize diagnostic excisional biopsies.

Radial scar on image-guided breast biopsy: is surgical excision necessary?

PURPOSE

Radial scar's stellate appearance may mimic carcinoma mammographically and histologically. Management of radial scar (RS) found on breast core needle biopsies (CNB) ranges from excision to clinical observation due to the variation in reported upgrades to malignancy at surgical excision. We examined the upgrade rate in patients with RS detected on CNB at our institution and reviewed the current literature.

METHODS

A retrospective study was conducted of all cases with RS diagnosed on CNB between December 2006 and March 2017 at our institution. Inclusion criteria were patients with "pure" RS and RS associated with high-risk lesions (HRL). Upgrade was defined as invasive or non-invasive cancer in the excisional biopsy.

RESULTS

157 cases were identified with RS on CNB, and 122 cases met inclusion criteria. Of these 122 cases, 91 (75%) had pure RS on CNB while 31 (25%) had associated atypia or HRL. 81 (66%) of patients proceeded to excisional biopsy and 41 (34%) did not. Two patients (1.6% of total) were found to have a low-grade invasive ductal carcinoma (0.6 and 0.8 cm) upon surgical excision. None of the remaining 120 patients developed an ipsilateral breast cancer with a mean of 32.3-month follow-up.

CONCLUSIONS

We found a very low upgrade rate to breast cancer when RS was found on CNB with or without associated HRL. Our results are consistent with other reported series. Our data do not support surgical excision for RS but rather close clinical follow-up for patients with RS on CNB.

Radial scars diagnosed on breast core biopsy: Frequency of atypia and carcinoma on excision and implications for management

AIMS

The risk of finding carcinoma in excisions following a core needle biopsy diagnosis of radial scar is not well defined and clinical management is variable. The aim of this study is to determine the frequency of high-risk lesions, ductal carcinoma in situ, and invasive carcinoma in excisions following a core biopsy diagnosis of radial scar.

METHODS AND RESULTS

Dedicated breast pathologists and radiologists correlated the histologic and radiologic findings and categorized radial scars as the target lesion or an incidental finding. High-risk lesions were defined as atypical hyperplasia or classical lobular carcinoma in situ. Of the 79 radial scars identified over a 14-year period, 22 were associated with atypia or carcinoma in the core biopsy. Thirty-seven (37) of the 57 benign radial scars underwent excision with benign findings in 30 (81%), high-risk lesions in six (16%), and flat epithelial atypia in one (3%). There were no upgrades to carcinoma. One patient with a benign radial scar developed a 3-mm focus of intermediate-grade estrogen receptor-positive ductal carcinoma in situ in the same quadrant of the ipsilateral breast 72 months after excision. One patient with an incidental un-excised benign radial scar was diagnosed with ductal carcinoma in situ at a separate site of suspicious calcifications.

CONCLUSIONS

In this series, none of the benign radial scars was upgraded to carcinoma. Radial scar was the targeted lesion in all cases with high-risk lesions on excision. Surgical excision may not be mandatory for patients with benign incidental radial scars on core biopsy.

Surgical Outcomes of Lobular Neoplasia Diagnosed in Core Biopsy: Prospective Study of 316 Cases

BACKGROUND

Management recommendations for lobular neoplasia (LN) including lobular carcinoma-in-situ (LCIS) and atypical lobular hyperplasia (ALH) diagnosed in core biopsies (CB) are controversial. Our aim was to prospectively identify a subset of patients who do not require subsequent surgical excision (SE).

PATIENTS AND METHODS

All patients diagnosed with LN on CB were enrolled and referred for SE. Cases with coexistent ductal carcinoma-in-situ or invasive carcinoma were excluded. Cases with coexistent ductal atypia (LN-DA) and LCIS variants (LN-V) were separated from pure classic LN (LN-C). Dedicated breast pathologists and radiologists reviewed cases with careful imaging/pathology correlation.

RESULTS

Of 13,772 total percutaneous breast CB procedures, 302 of 370 patients diagnosed with LN underwent SE. Upgrade to carcinoma was present in 3.5% (8/228) LN-C, 26.7% LN-V (4/15), and 28.3% LN-DA (15/53). Calcifications were the imaging target for 180 (79%) of 228 LN-C cases; 7 were associated with upgrade (3.9%). Upgrades were rare for mass lesions (1/32) and magnetic resonance imaging-targeted lesions (0/14). Upgrades were similar for ALH and LCIS (3.4% vs. 4.5%). During postsurgical follow-up (mean, 34.5 months), 6.5% LN-C patients developed carcinoma in either breast.

CONCLUSION

Although LN with nonclassic morphology or with associated ductal atypia requires SE, this can be avoided in LN-C diagnosed on CB targeting calcifications when careful imaging/pathology correlation is applied. Until larger numbers are studied, excising LN-C diagnosed as masses or magnetic resonance imaging-detected lesions may be prudent. Regardless of their selection for surgical management, LN patients need close surveillance in view of their long-term risk of breast cancer.

Radial scar/complex sclerosing lesions: a clinicopathologic correlation study from a single institution

Radial scars (RSs) or complex sclerosing lesions (CSLs) of the breast are benign radiologic and histologic entities. With the introduction of population-based screening programs, their incidence has increased to 0.03% to 0.09% of all core needle biopsies (CNBs). They can pose diagnostic difficulty because their radiologic and histologic appearances mimic carcinoma. We retrospectively searched for and reviewed all cases of RS/CSL diagnosed on image-guided CNB from January 1, 1994, to August 31, 2013, at a single institution. We also assessed the pathologic reports from excisional biopsies to identify cases upstaged to atypia or neoplasm. After exclusions, 100 CNBs were identified from 97 women, which showed RS/CSL without concomitant atypia. Mean age of the women was 52.9 years. Thirty-five women (38/100 CNBs, 38%) had follow-up excision. The median size of the excised RS/CSLs was 1.2 cm; 69% were larger than 1.0 cm. Almost all excised cases (92%) showed radiologic and pathologic concordance, and 79% were designated as suspicious for malignancy (Breast Imaging Reporting and Data System level 4). The most common findings of 38 follow-up excisional biopsies were residual RS (22 [58%]), atypical lobular hyperplasia (5 [13%]), and no residual lesion (5 [13%]). Eleven excisional biopsies (29%) were upstaged to invasive or in situ carcinoma or to atypical hyperplasia. Follow-up excisional biopsy is warranted for RS/CSLs, specifically those larger than 1.0 cm with worrisome radiographic findings or with radiologic and pathologic discordance. Approximately 29% of cases were upstaged to in situ or invasive carcinomas or other high-risk lesions in our study.

Surgical excision of radial scars diagnosed by core biopsy may help predict future risk of breast cancer

Radial scars (RS's) are benign breast lesions known to be associated with carcinomas and other high-risk lesions (HRL's). The upgrade rate to carcinoma after core biopsy revealing RS is 0-40 %. We sought to determine the outcomes of RS with and without HRL diagnosed by core biopsy. Patients who underwent core biopsy revealing RS without carcinoma at our institution between 1/1996 and 11/2012 were identified from a surgical pathology database. Retrospective chart review was utilized to classify patients as RS-no HRL or RS-HRL. HRL was defined as ADH, LCIS, and/or ALH. We determined upgrade rate to carcinoma at surgical excision, and upgrade to HRL for RS-no HRL patients. Univariate analysis was performed to identify risk factors for upgrade in RS-no HRL patients. 156 patients underwent core biopsy revealing RS, 131 RS-no HRL (84 %), and 25 RS-HRL (16 %). The overall rate of upgrade to invasive carcinoma was 0.8 % (1/124). 1.0 % (1/102) of RS-no HRL and 13.6 % (3/22) of RS-HRL patients were upgraded to DCIS (P = 0.0023). The upgrade of RS-no HRL to HRL at excision was 21.6 % (22/102). By univariate analysis, RS-no HRL with radiologic appearance of a mass/architectural distortion had a significantly higher rate of upgrade to HRL or carcinoma compared with calcifications (P = 0.03). Excision of RS to rule out associated invasive carcinoma is not warranted, given a <1 % rate of upgrade at excision. However, excision to evaluate for non-invasive cancer or HRL may be considered to help guide clinical decision-making about use of chemoprevention.

Impact of atypical hyperplasia at margins of breast-conserving surgery on the recurrence of breast cancer

PURPOSE

Atypical hyperplasia (AH) is associated with a relatively higher risk of subsequent development of cancer. It remains controversial whether it is necessary to re-excise AH found at surgical margins during breast-conserving surgery (BCS). The aim of this study was to determine the impact of atypical ductal/lobular hyperplasia found at the margins during BCS on the prognosis of early-stage breast cancer patients.

METHODS

A retrospective analysis comparing patients with AH and receiving no further surgical treatment (n = 233) to those without AH at the margins during BCS (n = 158) was performed.

RESULTS

At a median follow-up of 76 months, the 5- and 8-year rates of ipsilateral breast tumor recurrence (IBTR) were 3.26 and 8.79% for women with AH and 2.56 and 8.95% for women without AH, respectively. There were no significant differences between the two groups in terms of IBTR (p = 0.803), distant-metastasis-free survival (DMFS) (p = 0.749), or overall survival (OS) (p = 0.165). Moreover, no significant differences were found in IBTR, DMFS, or OS between patients with severe atypical hyperplasia (n = 86) and those without AH (n = 158) (p = 0.81, 0.82, and 0.78, respectively). Additionally, young women or those with ductal carcinoma in situ or triple-negative breast cancer with AH involving margins did not have a higher IBTR rate when compared to similar patients without AH.

CONCLUSIONS

This study suggests that AH found at the margins during BCS does not increase the risk of subsequently developing an IBTR. There is not enough evidence for re-excision of AH found at the margins during BCS in patients with early-stage breast cancer.

Upgrade of high-risk breast lesions detected on mammography in the Breast Cancer Surveillance Consortium

BACKGROUND

Upgrade rates of high-risk breast lesions after screening mammography were examined.

METHODS

The Breast Cancer Surveillance Consortium registry was used to identify all Breast Imaging Reporting and Data System category 4 assessments followed by needle biopsies with high-risk lesions. Follow-up was performed for all women.

RESULTS

High-risk lesions were found in 957 needle biopsies, with excision documented in 53%. Most (n = 685) were atypical ductal hyperplasia (ADH), 173 were lobular neoplasia, and 99 were papillary lesions. Upgrade to cancer varied with type of lesion (18% in ADH, 10% in lobular neoplasia, and 2% in papillary lesions). In premenopausal women with ADH, upgrade was associated with family history. Cancers associated with ADH were mostly (82%) ductal carcinoma in situ, and those associated with lobular neoplasia were mostly (56%) invasive. During a further 2 years of follow-up, cancer was documented in 1% of women with follow-up surgery and in 3% with no surgery.

CONCLUSIONS

Despite low rates of surgery, low rates of cancer were documented during follow-up. Benign papillary lesions diagnosed on Breast Imaging Reporting and Data System category 4 mammograms among asymptomatic women do not justify surgical excision.

Atypical Ductal Hyperplasia at the Margin of Lumpectomy Performed for Early Stage Breast Cancer: Is there Enough Evidence to Formulate Guidelines?

Background. Negative margins are associated with a reduced risk of ipsilateral breast tumor recurrence (IBTR) in women with early stage breast cancer treated with breast conserving surgery (BCS). Not infrequently, atypical ductal hyperplasia (ADH) is reported as involving the margin of a BCS specimen, and there is no consensus among surgeons or pathologists on how to approach this diagnosis resulting in varied reexcision practices among breast surgeons. The purpose of this paper is to establish a reasonable approach to guide the treatment of ADH involving the margin after BCS for early stage breast cancer. Methods. the published literature was reviewed using the PubMed site from the US National Library of Medicine. Conclusions. ADH at the margin of a BCS specimen performed for early stage breast cancer is a controversial pathological diagnosis subject to large interobserver variability. There is not enough data evaluating this diagnosis to change current practice patterns; however, it is reasonable to consider reexcision for ADH involving a surgical margin, especially if it coexists with low grade DCIS. Further studies with longer followup and closer attention to ADH at the margin are needed to formulate treatment guidelines.