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Freeman K, Mansbridge A, Stobart H, Clements K, Wallis MG, Pinder SE, Kearins O, Shaaban AM, Kirwan CC, Wilkinson LS, Webb S, O'Sullivan E, Jenkins J, Wright S, Taylor K, Bailey C, Holcombe C, Wyld L, Edwards K, Jenkinson DJ, Sharma N, Provenzano E, Hilton B, Stallard N, Thompson AM, Taylor-Phillips S. Evidence-informed recommendations on managing breast screening atypia: perspectives from an expert panel consensus meeting reviewing results from the Sloane atypia project. Br J Radiol 2024; 97:324-330. [PMID: 38265306 DOI: 10.1093/bjr/tqad053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 11/27/2023] [Accepted: 12/13/2023] [Indexed: 01/25/2024] Open
Abstract
Evidence-based clinical guidelines are essential to maximize patient benefit and to reduce clinical uncertainty and inconsistency in clinical practice. Gaps in the evidence base can be addressed by data acquired in routine practice. At present, there is no international consensus on management of women diagnosed with atypical lesions in breast screening programmes. Here, we describe how routine NHS breast screening data collected by the Sloane atypia project was used to inform a management pathway that maximizes early detection of cancer and minimizes over-investigation of lesions with uncertain malignant potential. A half-day consensus meeting with 11 clinical experts, 1 representative from Independent Cancer Patients' Voice, 6 representatives from NHS England (NHSE) including from Commissioning, and 2 researchers was held to facilitate discussions of findings from an analysis of the Sloane atypia project. Key considerations of the expert group in terms of the management of women with screen detected atypia were: (1) frequency and purpose of follow-up; (2) communication to patients; (3) generalizability of study results; and (4) workforce challenges. The group concurred that the new evidence does not support annual surveillance mammography for women with atypia, irrespective of type of lesion, or woman's age. Continued data collection is paramount to monitor and audit the change in recommendations.
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Affiliation(s)
- Karoline Freeman
- Warwick Screening, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry CV4 7AL, United Kingdom
| | - Alice Mansbridge
- Warwick Screening, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry CV4 7AL, United Kingdom
| | - Hilary Stobart
- Independent Cancer Patients' Voice, London, EC1R 0LL, United Kingdom
| | - Karen Clements
- Screening Quality Assurance Service, NHS England, Birmingham, B2 4BH, United Kingdom
| | - Matthew G Wallis
- Cambridge Breast Unit and NIHR Cambridge Biomedical Research Centre, Cambridge University Hospitals NHS Trust, Cambridge CB2 0QQ, United Kingdom
| | - Sarah E Pinder
- School of Cancer & Pharmaceutical Sciences, King's College London, Comprehensive Cancer Centre at Guy's Hospital, King's College London, London SE1 9RT, United Kingdom
| | - Olive Kearins
- Screening Quality Assurance Service, NHS England, Birmingham, B2 4BH, United Kingdom
| | - Abeer M Shaaban
- Breast Unit, Queen Elizabeth Hospital Birmingham and University of Birmingham, Edgbaston, Birmingham B15 2GW, United Kingdom
| | - Cliona C Kirwan
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, M20 4BX, United Kingdom
| | - Louise S Wilkinson
- Oxford Breast Imaging Service, Churchill Hospital, Oxford OX3 7LE, United Kingdom
| | - Sharon Webb
- Public Health Commissioning and Operations, Directorate of the Chief Operating Officer, NHS England, London, SE1 8UG, United Kingdom
| | - Emma O'Sullivan
- Public Health Commissioning and Operations, Directorate of the Chief Operating Officer, NHS England, London, SE1 8UG, United Kingdom
| | - Jacquie Jenkins
- Public Health Commissioning and Operations, Directorate of the Chief Operating Officer, NHS England, London, SE1 8UG, United Kingdom
| | - Suzanne Wright
- Public Health Commissioning and Operations, Directorate of the Chief Operating Officer, NHS England, London, SE1 8UG, United Kingdom
| | - Kathryn Taylor
- Cambridge Breast Unit and NIHR Cambridge Biomedical Research Centre, Cambridge University Hospitals NHS Trust, Cambridge CB2 0QQ, United Kingdom
| | - Claire Bailey
- SW London Breast Screening Service, St George's University Hospitals NHS Foundation Trust, London, SW17 0QT, United Kingdom
| | - Chris Holcombe
- Association of Breast Surgery, Royal College of Surgeons of England, London WC2A 3PE, United Kingdom
| | - Lynda Wyld
- Department of Oncology and Metabolism, University of Sheffield, Sheffield S10 2RX, United Kingdom
| | - Kim Edwards
- Breast Test Wales, Public Health Wales, Llandudno LL30 1QY, United Kingdom
| | - David J Jenkinson
- Warwick Screening, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry CV4 7AL, United Kingdom
| | - Nisha Sharma
- Breast Screening Unit, Seacroft Hospital, Leeds LS14 6UH, United Kingdom
| | - Elena Provenzano
- Histopathology and NIHR Cambridge Biomedical Research Centre, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, United Kingdom
| | - Bridget Hilton
- Screening Quality Assurance Service, NHS England, Birmingham, B2 4BH, United Kingdom
| | - Nigel Stallard
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry CV4 7AL, United Kingdom
| | - Alastair M Thompson
- Department of Surgical Oncology, Dan L Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, TX 77005, United States
| | - Sian Taylor-Phillips
- Warwick Screening, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry CV4 7AL, United Kingdom
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Freeman K, Jenkinson D, Clements K, Wallis MG, Pinder SE, Provenzano E, Stobart H, Stallard N, Kearins O, Sharma N, Shaaban A, Kirwan CC, Hilton B, Thompson AM, Taylor-Phillips S. Atypia detected during breast screening and subsequent development of cancer: observational analysis of the Sloane atypia prospective cohort in England. BMJ 2024; 384:e077039. [PMID: 38302129 PMCID: PMC10831586 DOI: 10.1136/bmj-2023-077039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/22/2023] [Indexed: 02/03/2024]
Abstract
OBJECTIVE To explore how the number and type of breast cancers developed after screen detected atypia compare with the anticipated 11.3 cancers detected per 1000 women screened within one three year screening round in the United Kingdom. DESIGN Observational analysis of the Sloane atypia prospective cohort in England. SETTING Atypia diagnoses through the English NHS breast screening programme reported to the Sloane cohort study. This cohort is linked to the English Cancer Registry and the Mortality and Birth Information System for information on subsequent breast cancer and mortality. PARTICIPANTS 3238 women diagnosed as having epithelial atypia between 1 April 2003 and 30 June 2018. MAIN OUTCOME MEASURES Number and type of invasive breast cancers detected at one, three, and six years after atypia diagnosis by atypia type, age, and year of diagnosis. RESULTS There was a fourfold increase in detection of atypia after the introduction of digital mammography between 2010 (n=119) and 2015 (n=502). During 19 088 person years of follow-up after atypia diagnosis (until December 2018), 141 women developed breast cancer. Cumulative incidence of cancer per 1000 women with atypia was 0.95 (95% confidence interval 0.28 to 2.69), 14.2 (10.3 to 19.1), and 45.0 (36.3 to 55.1) at one, three, and six years after atypia diagnosis, respectively. Women with atypia detected more recently have lower rates of subsequent cancers detected within three years (6.0 invasive cancers per 1000 women (95% confidence interval 3.1 to 10.9) in 2013-18 v 24.3 (13.7 to 40.1) in 2003-07, and 24.6 (14.9 to 38.3) in 2008-12). Grade, size, and nodal involvement of subsequent invasive cancers were similar to those of cancers detected in the general screening population, with equal numbers of ipsilateral and contralateral cancers. CONCLUSIONS Many atypia could represent risk factors rather than precursors of invasive cancer requiring surgery in the short term. Women with atypia detected more recently have lower rates of subsequent cancers detected, which might be associated with changes to mammography and biopsy techniques identifying forms of atypia that are more likely to represent overdiagnosis. Annual mammography in the short term after atypia diagnosis might not be beneficial. More evidence is needed about longer term risks.
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Affiliation(s)
- Karoline Freeman
- Warwick Screening, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - David Jenkinson
- Warwick Screening, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Karen Clements
- Screening Quality Assurance Service, NHS England, Birmingham, UK
| | - Matthew G Wallis
- Cambridge Breast Unit and NIHR Cambridge Biomedical Research Centre, Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - Sarah E Pinder
- School of Cancer & Pharmaceutical Sciences, King's College London, London, UK
- Comprehensive Cancer Centre at Guy's Hospital, King's College London, London, UK
| | - Elena Provenzano
- Histopathology and NIHR Cambridge Biomedical Research Centre, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Hilary Stobart
- Patient representative, Independent Cancer Patients' Voice, UK
| | - Nigel Stallard
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Olive Kearins
- Screening Quality Assurance Service, NHS England, Birmingham, UK
| | - Nisha Sharma
- Breast Screening Unit, Seacroft Hospital, York Road, Leeds, UK
| | - Abeer Shaaban
- University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, Edgbaston, Birmingham, UK
| | - Cliona Clare Kirwan
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Bridget Hilton
- Screening Quality Assurance Service, NHS England, Birmingham, UK
| | - Alastair M Thompson
- Department of Surgical Oncology, Dan L Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, TX, USA
| | - Sian Taylor-Phillips
- Warwick Screening, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
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Willers N, Neven P, Floris G, Colpaert C, Oldenburger E, Han S, Van Ongeval C, Smeets A, Duhoux FP, Wildiers H, Denolf P, Laudus N, Dequeker E, De Brabander I, Van Damme N, De Schutter H. The Upgrade Risk of B3 Lesions to (Pre)Invasive Breast Cancer After Diagnosis on Core Needle or Vacuum Assisted Biopsy. A Belgian National Cohort Study. Clin Breast Cancer 2023; 23:e273-e280. [PMID: 37085379 DOI: 10.1016/j.clbc.2023.03.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 03/15/2023] [Accepted: 03/16/2023] [Indexed: 04/23/2023]
Abstract
INTRODUCTION Flat epithelial atypia (FEA), lobular neoplasia (LN), papillary lesions (PL), radial scar (RS) and atypical ductal hyperplasia (ADH) are lesions of uncertain malignant potential and classified as B3 lesions by the European guidelines for quality assurance in breast cancer screening and diagnosis. Current management is usually wide local excision (WE), surveillance may be sufficient for some. We investigated the upgrade rate of B3 lesions to breast malignancy in a subsequent resection specimen after diagnosis on core needle-or vacuum assisted biopsy (CNB-VAB) in a national population-based series. METHODS Using data from the Belgian Cancer Registry (BCR) between January 1, 2013 and December 31, 2016, inclusion criteria were new diagnosis of a B3 lesion on CNB or VAB with subsequent histological assessment on a wider excision specimen. Histological agreement between first- and follow-up investigation was analyzed to determine the upgrade risk to ductal adenocarcinoma in situ (DCIS) or invasive breast cancer (IC) according to the type of B3 lesion. RESULTS Of 1855 diagnosed B3 lesions, 812 were included in this study: 551 after CNB-261 after VAB. After diagnosis on CNB and VAB, we found 19.0% and 14.9% upgrade to malignancy respectively. Upgrade risks after CNB and VAB were: FEA 39.5% and 17.6%; LN 40.5% and 4.3%; PL 10.4% and 12.5%; RS 25.7%and 0.0%; ADH 29.5% and 20.0%. CONCLUSION Based on the observed upgrade rate we propose three recommendations: first, resection of ADH, and FEA with WE; second, resection of RS and classical LN with therapeutic VAB and further surveillance when radio-pathological correlation is concordant; third, surveillance of PL.
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Affiliation(s)
- Nynke Willers
- Department of Oncology, KU Leuven - University of Leuven, Leuven, Belgium; Department of Senology, AZ Sint Blasius, Dendermonde, Belgium.
| | - Patrick Neven
- Department of Oncology, KU Leuven - University of Leuven, Leuven, Belgium; Department of Gynecological Oncology, University Hospitals Leuven, Leuven, Belgium
| | - Giuseppe Floris
- Department of Imaging and Pathology, Laboratory of Translational Cell & Tissue Research, KU Leuven - University of Leuven, Leuven, Belgium; Department of Pathology, University Hospitals Leuven, Leuven, Belgium
| | - Cecile Colpaert
- Department of Pathology, University Hospitals Leuven, Leuven, Belgium; Research Department, Belgian Cancer Registry, Brussels, Belgium
| | - Eva Oldenburger
- Department of Oncology, KU Leuven - University of Leuven, Leuven, Belgium; Department of Radiation Oncology, University Hospitals Leuven, Leuven, Belgium
| | - Sileny Han
- Department of Oncology, KU Leuven - University of Leuven, Leuven, Belgium; Department of Gynecological Oncology, University Hospitals Leuven, Leuven, Belgium
| | - Chantal Van Ongeval
- Department of Oncology, KU Leuven - University of Leuven, Leuven, Belgium; Department of Radiology, University Hospitals Leuven, Leuven, Belgium
| | - Ann Smeets
- Department of Oncology, KU Leuven - University of Leuven, Leuven, Belgium; Department of Surgical Oncology, University Hospitals Leuven, Leuven, Belgium
| | - Francois P Duhoux
- Institut de Recherche Expérimentale et Clinique, Université catholique de Louvain, and Breast Clinic, King Albert II Cancer Institute, Cliniques universitaires Saint-Luc, Brussels, Belgium
| | - Hans Wildiers
- Department of Oncology, KU Leuven - University of Leuven, Leuven, Belgium; Department of Oncology, University Hospitals Leuven, Leuven, Belgium
| | - Petra Denolf
- Research Department, Belgian Cancer Registry, Brussels, Belgium
| | - Nele Laudus
- Department of Biomedical Quality Assurance, KU Leuven-University of Leuven, Belgium
| | - Els Dequeker
- Department of Biomedical Quality Assurance, KU Leuven-University of Leuven, Belgium
| | | | - Nancy Van Damme
- Research Department, Belgian Cancer Registry, Brussels, Belgium
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Cullinane C, Byrne J, Kelly L, O Sullivan M, Antony Corrigan M, Paul Redmond H. The positive predictive value of vacuum assisted biopsy (VAB) in predicting final histological diagnosis for breast lesions of uncertain malignancy (B3 lesions): A systematic review & meta-analysis. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2022; 48:1464-1474. [PMID: 35491362 DOI: 10.1016/j.ejso.2022.04.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 03/22/2022] [Accepted: 04/08/2022] [Indexed: 10/18/2022]
Abstract
INTRODUCTION High-risk or B3 breast lesions are considered lesions of uncertain malignant potential and comprise between 5 and 12% of initial biopsy results. We sought to perform a systematic review and meta-analysis of studies published within the last twenty years to determine the pooled Positive Predictive Value (PPV) of VAB in selected B3 lesions. METHODS The study report is based on the guidelines of PRISMA and Meta-Analysis of Observational Studies in Epidemiology. OUTCOMES The primary outcome of this study was to determine the PPV of VAB in determining final histological diagnosis in B3 breast lesions using pooled estimates. The secondary outcomes were to determine if needle gauge or the re-classification of Lobular Carcinoma in Situ(LCIS) introduced in 2012 influenced pooled estimates. RESULTS 78 studies incorporating 6,377 B3 lesions were included in this review, 1214 of which were upgraded to DCIS or invasive malignancy following surgical excision(19%). The pooled PPV of VAB in Atypical Ductal Hyperplasia(ADH) and Lobular Neoplasia(LN) were 0.79(CI 0.76-0.83) and 0.84(CI 0.8-0.88). VAB of Flat Epithelial Atypia(FEA), radial scar and papillary lesions with/without atypia all had a pooled PPV >90% (underestimation rates 7%, 1%, 5% and 3% respectively). Needle gauge size and the change in LCIS classification did not appear to influence underestimation rates on subgroup analysis. CONCLUSION Results from this meta-analysis suggests it is reasonable to perform VAB as definitive treatment for certain B3 lesions, specifically LN, FEA, radial scar, and papillary lesions when specific criteria are fulfilled. Surgical excision should continue as the mainstay of treatment for ADH.
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A Machine Learning Ensemble Based on Radiomics to Predict BI-RADS Category and Reduce the Biopsy Rate of Ultrasound-Detected Suspicious Breast Masses. Diagnostics (Basel) 2022; 12:diagnostics12010187. [PMID: 35054354 PMCID: PMC8774734 DOI: 10.3390/diagnostics12010187] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 01/07/2022] [Accepted: 01/10/2022] [Indexed: 01/01/2023] Open
Abstract
We developed a machine learning model based on radiomics to predict the BI-RADS category of ultrasound-detected suspicious breast lesions and support medical decision-making towards short-interval follow-up versus tissue sampling. From a retrospective 2015–2019 series of ultrasound-guided core needle biopsies performed by four board-certified breast radiologists using six ultrasound systems from three vendors, we collected 821 images of 834 suspicious breast masses from 819 patients, 404 malignant and 430 benign according to histopathology. A balanced image set of biopsy-proven benign (n = 299) and malignant (n = 299) lesions was used for training and cross-validation of ensembles of machine learning algorithms supervised during learning by histopathological diagnosis as a reference standard. Based on a majority vote (over 80% of the votes to have a valid prediction of benign lesion), an ensemble of support vector machines showed an ability to reduce the biopsy rate of benign lesions by 15% to 18%, always keeping a sensitivity over 94%, when externally tested on 236 images from two image sets: (1) 123 lesions (51 malignant and 72 benign) obtained from two ultrasound systems used for training and from a different one, resulting in a positive predictive value (PPV) of 45.9% (95% confidence interval 36.3–55.7%) versus a radiologists’ PPV of 41.5% (p < 0.005), combined with a 98.0% sensitivity (89.6–99.9%); (2) 113 lesions (54 malignant and 59 benign) obtained from two ultrasound systems from vendors different from those used for training, resulting into a 50.5% PPV (40.4–60.6%) versus a radiologists’ PPV of 47.8% (p < 0.005), combined with a 94.4% sensitivity (84.6–98.8%). Errors in BI-RADS 3 category (i.e., assigned by the model as BI-RADS 4) were 0.8% and 2.7% in the Testing set I and II, respectively. The board-certified breast radiologist accepted the BI-RADS classes assigned by the model in 114 masses (92.7%) and modified the BI-RADS classes of 9 breast masses (7.3%). In six of nine cases, the model performed better than the radiologist did, since it assigned a BI-RADS 3 classification to histopathology-confirmed benign masses that were classified as BI-RADS 4 by the radiologist.
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Jenkinson D, Freeman K, Clements K, Hilton B, Dulson-Cox J, Kearins O, Stallard N, Wallis MG, Sharma N, Kirwan C, Pinder S, Provenzano E, Shaaban AM, Stobart H, McDonnell S, Thompson AM, Taylor-Phillips S. Breast screening atypia and subsequent development of cancer: protocol for an observational analysis of the Sloane database in England (Sloane atypia cohort study). BMJ Open 2022; 12:e058050. [PMID: 34996804 PMCID: PMC8744119 DOI: 10.1136/bmjopen-2021-058050] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION The National Health Service (NHS) Breast Screening Programme aims to detect cancer earlier when treatment is more effective but can harm women by over diagnosing and overtreating cancers which would never have become symptomatic. As well as breast cancer, a spectrum of atypical epithelial proliferations (atypia) can also be detected as part of screening. This spectrum of changes, while not cancer, may mean that a woman is more likely to develop breast cancer in the future. Follow-up of atypia is not evidence based. We currently do not know which atypia should be detected to avoid future cancer. This study will explore how atypia develops into breast cancer in terms of number of women, time of cancer development, cancer type and severity, and whether this varies for different types of atypia. METHODS AND ANALYSIS The Sloane cohort study began in April 2003 with ongoing data collection including atypia diagnosed through screening at screening units in the UK. The database for England has 3645 cases (24 September 2020) of epithelial atypia, with follow-up from 1 to 15 years. The outcomes include subsequent invasive breast cancer and the nature of subsequent cancer. Descriptive statistics will be produced. The observed rates of breast cancer at 1, 3 and 6 years for types of atypia will be reported with CIs, to enable comparison to women in the general population. Time to event methods will be used to describe the time to breast cancer diagnosis for the types of atypia, including flexible parametric modelling if appropriate. Patient representatives from Independent Cancer Patients' Voice are included at every stage of the research. ETHICS AND DISSEMINATION The study has received research ethics approval from the University of Warwick Biomedical and Scientific Research Ethics Committee (BSREC 10/20-21, 8 October 2020), Public Health England office for data release approvals (ODR1718_313) and approval from the English Breast Research Advisory Committee (BSPRAC_031). The findings will be disseminated to breast screening clinicians (via journal publication and conference presentation), to the NHS Breast Screening Programme to update their guidelines on how women with atypia should be followed up, and to the general public.
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Affiliation(s)
| | | | - Karen Clements
- Screening Quality Assurance Services, NHS England and NHS Improvement, Birmingham, UK
| | - Bridget Hilton
- Screening Quality Assurance Services, NHS England and NHS Improvement, Birmingham, UK
| | - Joanne Dulson-Cox
- Screening Quality Assurance Services, NHS England and NHS Improvement, Birmingham, UK
| | - Olive Kearins
- Screening Quality Assurance Services, NHS England and NHS Improvement, Birmingham, UK
| | - Nigel Stallard
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Matthew G Wallis
- Cambridge Breast Unit and NIHR Cambridge Biomedical Research Centre, Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - Nisha Sharma
- Breast Screening Unit, Seacroft Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Cliona Kirwan
- Department of Surgery, The University of Manchester, Manchester, UK
| | - Sarah Pinder
- School of Cancer & Pharmaceutical Sciences, King's College London, London, UK
- Comprehensive Cancer Centre at Guy's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Elena Provenzano
- Histopathology and NIHR Cambridge Biomedical Research Centre, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Abeer M Shaaban
- University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | | | | | - Alastair M Thompson
- Department of Surgical Oncology, Dan L Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, Texas, USA
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Cozzi A, Schiaffino S, Fanizza M, Magni V, Menicagli L, Monaco CG, Benedek A, Spinelli D, Di Leo G, Di Giulio G, Sardanelli F. Contrast-enhanced mammography for the assessment of screening recalls: a two-centre study. Eur Radiol 2022; 32:7388-7399. [PMID: 35648209 PMCID: PMC9668944 DOI: 10.1007/s00330-022-08868-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Revised: 04/19/2022] [Accepted: 05/08/2022] [Indexed: 01/03/2023]
Abstract
OBJECTIVES To evaluate the potential of contrast-enhanced mammography (CEM) for reducing the biopsy rate of screening recalls. METHODS Recalled women were prospectively enrolled to undergo CEM alongside standard assessment (SA) through additional views, tomosynthesis, and/or ultrasound. Exclusion criteria were symptoms, implants, allergy to contrast agents, renal failure, and pregnancy. SA and CEM were independently evaluated by one of six radiologists, who recommended biopsy or 2-year follow-up. Biopsy rates according to SA or recombined CEM (rCEM) were compared with the McNemar's test. Diagnostic performance was calculated considering lesions with available final histopathology. RESULTS Between January 2019 and July 2021, 220 women were enrolled, 207 of them (median age 56.6 years) with 225 suspicious findings analysed. Three of 207 patients (1.4%) developed mild self-limiting adverse reactions to iodinated contrast agent. Overall, 135/225 findings were referred for biopsy, 90/225 by both SA and rCEM, 41/225 by SA alone and 4/225 by rCEM alone (2/4 being one DCIS and one invasive carcinoma). The rCEM biopsy rate (94/225, 41.8%, 95% CI 35.5-48.3%) was 16.4% lower (p < 0.001) than the SA biopsy rate (131/225, 58.2%, 95% CI 51.7-64.5%). Considering the 124/135 biopsies with final histopathology (44 benign, 80 malignant), rCEM showed a 93.8% sensitivity (95% CI 86.2-97.3%) and a 65.9% specificity (95% CI 51.1-78.1%), all 5 false negatives being ductal carcinoma in situ detectable as suspicious calcifications on low-energy images. CONCLUSIONS Compared to SA, the rCEM-based work-up would have avoided biopsy for 37/225 (16.4%) suspicious findings. Including low-energy images in interpretation provided optimal overall CEM sensitivity. KEY POINTS • The work-up of suspicious findings detected at mammographic breast cancer screening still leads to a high rate of unnecessary biopsies, involving between 2 and 6% of screened women. • In 207 recalled women with 225 suspicious findings, recombined images of contrast-enhanced mammography (CEM) showed a 93.8% sensitivity and a 65.9% specificity, all 5 false negatives being ductal carcinoma in situ detectable on low-energy images as suspicious calcifications. • CEM could represent an easily available one-stop shop option for the morphofunctional assessment of screening recalls, potentially reducing the biopsy rate by 16.4%.
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Affiliation(s)
- Andrea Cozzi
- grid.4708.b0000 0004 1757 2822Department of Biomedical Sciences for Health, Università degli Studi di Milano, Via Luigi Mangiagalli 31, 20133 Milano, Italy
| | - Simone Schiaffino
- grid.419557.b0000 0004 1766 7370Unit of Radiology, IRCCS Policlinico San Donato, Via Rodolfo Morandi 30, 20097 San Donato Milanese, Italy
| | - Marianna Fanizza
- grid.419425.f0000 0004 1760 3027Department of Breast Radiology, Fondazione IRCCS Policlinico San Matteo, Viale Camillo Golgi 19, 27100 Pavia, Italy
| | - Veronica Magni
- grid.4708.b0000 0004 1757 2822Department of Biomedical Sciences for Health, Università degli Studi di Milano, Via Luigi Mangiagalli 31, 20133 Milano, Italy
| | - Laura Menicagli
- grid.419557.b0000 0004 1766 7370Unit of Radiology, IRCCS Policlinico San Donato, Via Rodolfo Morandi 30, 20097 San Donato Milanese, Italy
| | - Cristian Giuseppe Monaco
- grid.419557.b0000 0004 1766 7370Unit of Radiology, IRCCS Policlinico San Donato, Via Rodolfo Morandi 30, 20097 San Donato Milanese, Italy
| | - Adrienn Benedek
- grid.419557.b0000 0004 1766 7370Unit of Radiology, IRCCS Policlinico San Donato, Via Rodolfo Morandi 30, 20097 San Donato Milanese, Italy
| | - Diana Spinelli
- grid.419557.b0000 0004 1766 7370Unit of Radiology, IRCCS Policlinico San Donato, Via Rodolfo Morandi 30, 20097 San Donato Milanese, Italy
| | - Giovanni Di Leo
- grid.419557.b0000 0004 1766 7370Unit of Radiology, IRCCS Policlinico San Donato, Via Rodolfo Morandi 30, 20097 San Donato Milanese, Italy
| | - Giuseppe Di Giulio
- grid.419425.f0000 0004 1760 3027Department of Breast Radiology, Fondazione IRCCS Policlinico San Matteo, Viale Camillo Golgi 19, 27100 Pavia, Italy
| | - Francesco Sardanelli
- grid.4708.b0000 0004 1757 2822Department of Biomedical Sciences for Health, Università degli Studi di Milano, Via Luigi Mangiagalli 31, 20133 Milano, Italy ,grid.419557.b0000 0004 1766 7370Unit of Radiology, IRCCS Policlinico San Donato, Via Rodolfo Morandi 30, 20097 San Donato Milanese, Italy
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Rakha EA, Brogi E, Castellano I, Quinn C. Spindle cell lesions of the breast: a diagnostic approach. Virchows Arch 2021; 480:127-145. [PMID: 34322734 PMCID: PMC8983634 DOI: 10.1007/s00428-021-03162-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 06/27/2021] [Accepted: 07/12/2021] [Indexed: 12/13/2022]
Abstract
Spindle cell lesions of the breast comprise a heterogeneous group of lesions, ranging from reactive and benign processes to aggressive malignant tumours. Despite their rarity, they attract the attention of breast pathologists due to their overlapping morphological features and diagnostic challenges, particularly on core needle biopsy (CNB) specimens. Pathologists should recognise the wide range of differential diagnoses and be familiar with the diverse morphological appearances of these lesions to make an accurate diagnosis and to suggest proper management of the patients. Clinical history, immunohistochemistry, and molecular assays are helpful in making a correct diagnosis in morphologically challenging cases. In this review, we present our approach for the diagnosis of breast spindle cell lesions, highlighting the main features of each entity and the potential pitfalls, particularly on CNB. Breast spindle cell lesions are generally classified into two main categories: bland-appearing and malignant-appearing lesions. Each category includes a distinct list of differential diagnoses and a panel of immunohistochemical markers. In bland-appearing lesions, it is important to distinguish fibromatosis-like spindle cell metaplastic breast carcinoma from other benign entities and to distinguish fibromatosis from scar tissue. The malignant-appearing category includes spindle cell metaplastic carcinoma, stroma rich malignant phyllodes tumour, other primary and metastatic malignant spindle cell tumours of the breast, including angiosarcoma and melanoma, and benign mimics such as florid granulation tissue and nodular fasciitis.
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Affiliation(s)
- Emad A Rakha
- Division of Cancer and Stem Cells, School of Medicine, The University of Nottingham and Nottingham University Hospitals NHS Trust, Nottingham City Hospital, Nottingham, NG5 1PB, UK.
| | - Edi Brogi
- Department of Pathology At Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Cecily Quinn
- Histopathology, BreastCheck, Irish National Breast Screening Programme and St. Vincent's University Hospital, Dublin, Ireland.,University College Dublin, Dublin, Ireland
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Apparent diffusion coefficient values in borderline breast lesions upgraded and not upgraded at definitive histopathological examination after surgical excision. Pol J Radiol 2021; 86:e255-e261. [PMID: 34093923 PMCID: PMC8147718 DOI: 10.5114/pjr.2021.105857] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Accepted: 05/13/2020] [Indexed: 01/04/2023] Open
Abstract
Purpose The study aims were to evaluate if the apparent diffusion coefficient (ADC) value could distinguish between breast lesions classified as B3 at core needle biopsy (CNB) that show or do not show atypia or malignancy at definitive histopathological examination (DHE) after surgical excision. Material and methods From January 2013 to December 2017, 141 patients with a B3 breast lesion underwent magnetic resonance imaging and were included in the study. The ADC value was assessed drawing a ROI outlining the entire lesion, evaluating the mean (ADCmean) and minimum ADC values (ADCmin). Results Both ADCmean and ADCmin values showed a statistically significant difference between B3 lesions without and with malignancy or, for B3a lesions, atypia at DHE. They both showed a statistically significant difference also between B3a lesions without or with atypia or malignancy at DHE, but only ADCmin (not ADCmean) showed statistically significant difference between B3b lesions without or with malignancy at DHE. Conclusions The ADC value could help distinguish between B3a lesions without or with atypia/malignancy at DHE after surgical excision and between B3b lesions without or with malignancy at DHE. Therefore, it could be used to help guide the diagnostic-therapeutic pathway of these lesions, particularly of B3a lesions.
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Elsharkawy M, Vestring T, Raatschen HJ. A ten-year, single-center experience: Concordance between breast core needle biopsy/vacuum-assisted biopsy and postoperative histopathology in B3 and B5a cases. PLoS One 2020; 15:e0233574. [PMID: 32437426 PMCID: PMC7241768 DOI: 10.1371/journal.pone.0233574] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 05/07/2020] [Indexed: 12/29/2022] Open
Abstract
Purpose To determine the concordance rate between core needle biopsy/vacuum-assisted biopsy (CNB/VAB) and postoperative histopathology in B3 (lesions of uncertain malignant potential) and B5a (in situ) lesions found on mammograms or ultrasound. Material and methods 2,029 consecutive biopsies performed over 10 years for patients who underwent mammograms or ultrasounds. For CNB 14G needle and for VAB 8G/10G needles were used. In all biopsies, we identified the age, BI-RADS®, histopathological biopsy results, B-category, nuclear grade for DCIS and postoperative histopathology results in B3 and B5a cases from the biopsy. Results The B-categories from CNB/VAB were as follows: B2 42.2 percent (n = 856), B3 4.5 percent (n = 91), B5a 5.7 percent (n = 115), and B5b 47.6 percent (n = 967). In the B3-category, 72/91 patients underwent surgical excision, with a concordance rate of 83.3 percent (n = 60/72) and a discordance rate of 16.7 percent (n = 12/72) to postoperative histopathology. From the discordant cases, 67.7 percent (n = 8/12) showed DCIS and 32.3 percent (n = 4/12) showed invasive breast cancer. The BIRADS of the discordant cases was 4b in 41.7 percent (n = 5/12) and 5 in 58.3 percent (n = 7/12). The PPVs for malignancy of B3 lesions were 0.21, with no statistical significance between subgroups. In the B5a-category, 101 of 115 patients underwent surgery in our hospital, with a concordance rate of 80.2 percent (n = 81/101) and a discordance rate of 19.8 percent (n = 20/101) to postoperative histopathology. From the discordant cases, 55 percent (n = 11/20) showed invasive breast carcinoma of no special type (NST). Conclusion Our concordance rate for B3 (83.3 percent) and B5a (80.2 percent) lesions in the biopsies to postoperative histopathology is matching to previously published literature. Surgical excision is our recommendation for lesions biopsied with a B3 category in the histopathology and a BIRADS category of (4b, 4c and 5). The PPVs for malignancy of B3 lesions showed no statistical significance between subgroups. Also, the nuclear grade of DCIS was not statistically significant in terms of upgrade into invasive breast cancer.
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Affiliation(s)
- Mohamed Elsharkawy
- Diagnostic and Interventional Radiology/Neuroradiology Department, Agaplesion Diakonieklinikum, Rotenburg Wuemme, Germany
- * E-mail:
| | - Thomas Vestring
- Diagnostic and Interventional Radiology/Neuroradiology Department, Agaplesion Diakonieklinikum, Rotenburg Wuemme, Germany
| | - Hans-Juergen Raatschen
- Diagnostic and Interventional Radiology Department, Hannover Medical School, Hanover, Germany
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Forester ND, Lowes S, Mitchell E, Twiddy M. High risk (B3) breast lesions: What is the incidence of malignancy for individual lesion subtypes? A systematic review and meta-analysis. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2018; 45:519-527. [PMID: 30579653 DOI: 10.1016/j.ejso.2018.12.008] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Revised: 11/30/2018] [Accepted: 12/10/2018] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Provide evidence to support evolving management strategies for high-risk (B3) breast lesions by assessing risk of carcinoma in subgroups of B3 lesions using systematic review and meta-analysis. METHODS Databases identified observational studies between 1980 and 2015 that reported on underestimation of malignancy following B3 lesion diagnosis at core needle biopsy. Critical appraisal, quality assessment, data extraction and meta-analysis was undertaken to calculate rate of malignancy of the whole B3 group and individual lesions. Study heterogeneity and association between variables and underestimation rate was investigated using random effects logistic modelling. RESULTS Meta-analysis, using data from 129 studies, assessed 11 423 lesions of which 2160 were upgraded to malignancy after surgical excision biopsy (17% malignancy rate, 95% CI 15-19%). Malignancy rates varied from 6% in radial scars with no atypia (95% CI 2-13%, I2 72.8%), to 32% in papillomas with atypia (95% CI 23-41%, I2 57.4%). Differences in upgrade rates between atypical and non-atypical lesions were statistically significant (p < 0.05). Study heterogeneity could not be explained by differences in core biopsy size or year of publication. CONCLUSIONS This comprehensive, inclusive assessment of all published literature, provides an accurate estimate of malignancy risk in subgroups of B3 lesions, to guide tailored management strategies. Some lesions have a high risk of malignancy, while others have a much lower risk, and could be safely managed with surveillance strategies rather than surgery.
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Affiliation(s)
- Nerys Dawn Forester
- Breast Screening and Assessment Unit, Royal Victoria Infirmary, Queen Victoria Road, Newcastle, NE1 4LP, UK.
| | - Simon Lowes
- Breast Screening and Assessment Unit, Queen Elizabeth Hospital, Gateshead, NE9 6SX, UK
| | - Elizabeth Mitchell
- Hull York Medical School, Institute of Clinical and Applied Health Research, The Allam Medical Building, University of Hull, Hull, HU6 7RX, UK
| | - Maureen Twiddy
- Hull York Medical School, Institute of Clinical and Applied Health Research, The Allam Medical Building, University of Hull, Hull, HU6 7RX, UK
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Gulla S, Lancaster R, De Los Santos J. High-Risk Breast Lesions and Current Management. Semin Roentgenol 2018; 53:252-260. [DOI: 10.1053/j.ro.2018.08.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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13
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Lesions of "uncertain malignant potential" in the breast (B3) identified with mammography screening. BMC Cancer 2018; 18:829. [PMID: 30115017 PMCID: PMC6097423 DOI: 10.1186/s12885-018-4742-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Accepted: 08/10/2018] [Indexed: 11/12/2022] Open
Abstract
Background Core needle biopsy (CNB) is a standard diagnostic procedure in the setting of breast cancer screening. However, CNB may result in the borderline diagnoses of lesion of uncertain malignant potential (B3). The aim of this study was to access the outcome of lesions diagnosed as B3 category in a large series of screen-detected cases to evaluate the rates of malignancy for the different histological subtypes. Methods We identified all CNBs over a six-year period (2009-2015) in a breast cancer screening unit in Germany. A total of 8.388 CNB’s were performed for screen detected breast lesions. B3 diagnosis comprised 4.5% (376/8.388). Of the 376 patients who were diagnosed as B3, 299 underwent subsequent excision biopsy with final excision histology. Results Out of 376 patients diagnosed with B3 lesions, the prevalence of different histopathology showed 161 (42.8%) patients with atypical ductal hyperplasia (ADH), 98 (26.1%) with flat epithelial atypia (FEA), 50 women (13.3%) showed lobular neoplasia (LN), in 40 (10.6%) patients papillary findings and in 27 patients (7.2%) a radial scar complex. Final excision histology was benign in 74% (221/299) and malignant in 26% (78/299) of the patients. Lesion specific positive predictive values (PPV) for a subsequent diagnosis of in situ or invasive carcinoma were as follows: ADH 40%, FEA 20.5%, papillary lesion 13.5%, radial scar 16.6%, LN 0%. Conclusion Our results show that approximately one-third of core needle biopsies of screen detected breast lesions classified as B3 are premalignant or malignant on excision. Lesions of uncertain malignant potential of the breast (B3) are heterogeneous in respect to risk of malignancy.
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Bozzini A, Cassano E, Raciti D, Disalvatore D, Pala O, Vingiani A, Renne G. Analysis of Efficacy and Accuracy of 2 Vacuum-Assisted Breast Biopsy Devices: Mammotome and Elite. Clin Breast Cancer 2018; 18:e1277-e1282. [PMID: 30072194 DOI: 10.1016/j.clbc.2018.06.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 06/25/2018] [Accepted: 06/25/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND Ultrasound-guided vacuum-assisted breast biopsy (US-VABB) has recently replaced surgical biopsy as a result of its high diagnostic accuracy and low patient discomfort, and at present it relies mainly on 2 devices, Mammotome and, more recently, Mammotome Elite (Elite). Our purpose was to compare the efficacy of these 2 bioptical devices. PATIENTS AND METHODS We performed US-VABB on 195 patients with Mammotome 8G or 11G in 130 patients and Elite 13G in 65 patients. Of these 195 patients, 95 were submitted to surgery for lumpectomy or mastectomy in case of malignant lesions or of lesions of uncertain malignant potential (B5 and B3), while the remaining 100 were strictly monitored clinically and radiologically for 12 to 24 months. RESULTS Both the devices showed high absolute sensitivity (96.2% for Mammotome and 83.3% for Elite), complete sensitivity (98.1% for Mammotome and 90.0% for Elite), specificity (92.3% for Mammotome and 94.3% for Elite), and diagnostic accuracy (99.1% for Mammotome and 95% for Elite), thus fulfilling criteria suggested by the European guidelines. Total underestimation rate seemed to be higher in the Elite cohort (14.2%) than in the Mammotome cohort (3.4%) (P = .02). However, none of the patients with a benign diagnosis (B2) presented any event during the follow-up period. CONCLUSION US-VABB is an accurate method for sampling breast lesions. Our study did not show large, statistically significant differences in diagnostic accuracy between the Elite and Mammotome systems, except for a slight increase in diagnostic underestimation of benign pathologies when using the Elite.
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Affiliation(s)
- Anna Bozzini
- Breast Imaging Unit, European Institute of Oncology, Milan, Italy
| | - Enrico Cassano
- Breast Imaging Unit, European Institute of Oncology, Milan, Italy
| | - Dario Raciti
- Breast Imaging Unit, European Institute of Oncology, Milan, Italy
| | - Davide Disalvatore
- IFOM, The FIRC Institute for Molecular Oncology Foundation, Milan, Italy
| | - Oriana Pala
- Division of Pathology, European Institute of Oncology, Milan, Italy
| | - Andrea Vingiani
- Division of Pathology, European Institute of Oncology, Milan, Italy.
| | - Giuseppe Renne
- Division of Uropathology and Intraoperative Consultation, European Institute of Oncology, Milan, Italy
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Lipman M, Chambers A, Umphrey HR. Current Management of High-Risk Breast Lesions. CURRENT RADIOLOGY REPORTS 2018. [DOI: 10.1007/s40134-018-0268-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Upgrade rates of high-risk breast lesions diagnosed on core needle biopsy: a single-institution experience and literature review. Mod Pathol 2016; 29:1471-1484. [PMID: 27538687 DOI: 10.1038/modpathol.2016.127] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2016] [Revised: 05/31/2016] [Accepted: 06/02/2016] [Indexed: 11/08/2022]
Abstract
Optimal management of high-risk breast lesions detected by mammogram yielding atypical ductal hyperplasia, flat epithelial atypia, atypical lobular hyperplasia, lobular carcinoma in situ, and radial scar without atypia on core needle biopsy is controversial. This is a single-institution retrospective review of 5750 core needle biopsy cases seen over 14.5 years, including 249 (4.3%), 72 (1.3%), 50 (0.9%), 37 (0.6%), and 54 (0.9%) cases of atypical ductal hyperplasia, flat epithelial atypia, atypical lobular hyperplasia, lobular carcinoma in situ, and radial scar without atypia, respectively. Patient age, radiologic characteristics, needle gauge, and excision diagnoses were recorded. Of 462 high-risk cases analyzed, 333 (72%) underwent excision. Upgrade rate to ductal carcinoma in situ, pleomorphic carcinoma in situ, or invasive mammary carcinoma was 18% for atypical ductal hyperplasia, 11% for flat epithelial atypia, 9% for atypical lobular hyperplasia, 28% for lobular carcinoma in situ, and 16% for radial scar. Carcinoma diagnosed on excision was more likely to be in situ than invasive, and if invasive, more likely to be low grade than high grade. Overall, cases that were benign (vs high risk or carcinoma) on excision were less likely to have residual calcifications after biopsy (17% vs 27%, P=0.013), and more likely to have a smaller mass size (<1 cm) (82% vs 50%, P=0.001). On subgroup analysis, atypical ductal hyperplasia cases that were benign (vs high risk or carcinoma) on excision were more likely to have smaller mass size (<1 cm) (P=0.025). Lobular neoplasia diagnosed incidentally (vs targeted) on core needle biopsy was less likely to upgrade on excision (5% vs 39%, P=0.002). A comprehensive literature review was performed, identifying 116 studies reporting high-risk lesion upgrade rates, and our upgrade rates were similar to those of more recent larger studies. Careful radiological-pathological correlation is needed to identify high-risk lesion subgroups that may not need excision.
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Saladin C, Haueisen H, Kampmann G, Oehlschlegel C, Seifert B, Rageth L, Rageth C, Stadlmann S, Kubik-Huch RA. Lesions with unclear malignant potential (B3) after minimally invasive breast biopsy: evaluation of vacuum biopsies performed in Switzerland and recommended further management. Acta Radiol 2016; 57:815-21. [PMID: 26552694 PMCID: PMC4906532 DOI: 10.1177/0284185115610931] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Accepted: 09/09/2015] [Indexed: 11/15/2022]
Abstract
Background Histopathological B3 lesions after minimal invasive breast biopsy (VABB) are a particular challenge for the clinician, as there are currently no binding recommendations regarding the subsequent procedure. Purpose To analyze all B3 lesions, diagnosed at VABB and captured in the national central Swiss MIBB database and to provide a data basis for further management in this subgroup of patients. Material and Methods All 9,153 stereotactically, sonographically, or magnetic resonance imaging (MRI)-guided vacuum-assisted breast biopsies, performed in Switzerland between 2009 and 2011, captured in a central database, were evaluated. The rate of B3 lesions and the definitive pathological findings in patients who underwent surgical resection were analyzed. Results The B3 rate was 17.0% (1532 of 9000 biopsies with B classification). Among the 521 lesions with a definitive postoperative diagnosis, the malignancy rate (invasive carcinoma or DCIS) was 21.5%. In patients with atypical ductal hyperplasia, papillary lesions, flat epithelial atypia, lobular neoplasia, and radial scar diagnosed by VABB, the malignancy rates were 25.9%, 3.1%, 18.3%, 26.4%, and 11.1%, respectively. Conclusion B3 lesions, comprising 17%, of all analyzed biopsies, were common and the proportion of malignancies in those lesions undergoing subsequent surgical excision was high (21.5%).
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Affiliation(s)
- Camilla Saladin
- Institute of Radiology, Kantonsspital Baden AG, Baden, Switzerland
| | - Harald Haueisen
- Institute of Radiology, Kantonsspital Aarau AG, Aarau, Switzerland
| | | | | | - B Seifert
- Division of Biostatistics, Institute for Social and Preventive Medicine, University of Zurich, Zürich, Switzerland
| | | | | | - S Stadlmann
- Institute of Pathology, Kantonsspital Baden AG, Baden, Switzerland
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Elizalde A, Pina L, Etxano J, Slon P, Zalazar R, Caballeros M. Additional US or DBT after digital mammography: which one is the best combination? Acta Radiol 2016; 57:13-8. [PMID: 25523063 DOI: 10.1177/0284185114563641] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2014] [Accepted: 11/14/2014] [Indexed: 11/17/2022]
Abstract
BACKGROUND Digital mammography (DM) is widespread used for the detection of breast cancer, but its sensitivity drops in dense breasts. It is well known that additional breast ultrasound (US) and digital breast tomosynthesis (DBT) increase the sensitivity of DM. However, to our knowledge, there are no articles comparing the role of both additional techniques. PURPOSE To assess the diagnostic performance of DM and the different combinations of DM + additional DBT and DM + additional US in an enriched sample of patients. MATERIAL AND METHODS Retrospective study in an enriched sample of 1042 patients. Out of them, 84 patients had histologically proven malignant lesions and 258 patients had benign lesions. Finally 700 patients with normal explorations or benign lesions without biopsy confirmation (but stable for at least 12 months) were included. All of them underwent DM, US, and DBT examinations that were retrospectively reviewed by one expert radiologist, blinded to the final diagnoses. The DBT examinations were performed using one single view with wide angle (50°). The reader categorized the cases as benign (BI-RADS 1 or 2) or malignant (BI-RADS 3-5) for DM and the different combination of techniques. The sensitivity (SE) and specificity (SP) were calculated with the PEPI software and the ROC curves of the different techniques and combinations were calculated by using the SPSS 15.0 software. RESULTS The SE and SP of DM were 69.05% and 88.20%, respectively. Additional DBT significantly increased the AUC of DM as well as additional US or the combination DM + DBT + US (P < 0.05). However there were no significant differences between the AUC of DM + US and DM + DBT (P = 0.7). CONCLUSION Additional US, DBT, or both, in combination with DM, significantly increased the AUC of DM. However, there were no significant differences between DM + DBT and DM + US.
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Affiliation(s)
- Arlette Elizalde
- Department of Radiology, Clínica Universidad de Navarra, Pamplona, Spain
| | - Luis Pina
- Department of Radiology, Clínica Universidad de Navarra, Pamplona, Spain
| | - Jon Etxano
- Department of Radiology, Clínica Universidad de Navarra, Pamplona, Spain
| | - Pedro Slon
- Department of Radiology, Clínica Universidad de Navarra, Pamplona, Spain
| | - Romina Zalazar
- Department of Radiology, Clínica Universidad de Navarra, Pamplona, Spain
| | - Meylin Caballeros
- Department of Radiology, Clínica Universidad de Navarra, Pamplona, Spain
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Ikonomi M, Cela B, Tarifa D. Dysplasia in Gastric Mucosa and its Reporting Problems. Open Access Maced J Med Sci 2015; 3:551-7. [PMID: 27275286 PMCID: PMC4877886 DOI: 10.3889/oamjms.2015.102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Revised: 10/29/2015] [Accepted: 10/30/2015] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The recognition, terminology used and histopathologic evaluation of two essential elements in gastric carcinogenesis, atrophy and dysplasia, are characterized by controversy. MATERIALS AND METHODS One hundred fifteen cases, with slides and their histopathologic reports from the archive of the Laboratory of Pathology were studied for the diagnostic value, reporting of dysplasia, interobserver variability, the relation of dysplastic lesions with inflammation, atrophy and metaplasia. After retrospectively studying the histopathologic reports from the archive we distributed the cases according to endoscopic and histopathologic diagnosis, together with the reexamination of the slides. The comparison of the median values of the numeric variables was made with the Mann-Whitney test (non-parametric equivalent of the Student's "t" test). RESULTS The endoscopic clinical diagnosis were: malignancy/suspicious for malignancy 88 cases (76%) and non-neoplastic diagnosis (like ulcer or gastritis) 27 cases (24%). From the reexamination of the cases it resulted that there is no difference in reporting the malignancy, but there is a difference in the cases reported as dysplasia (p = 0.001) and negative for neoplasia (p = 0.063, borderline). CONCLUSION Clinicians and pathologists can feel directly the discrepancy called "interobserver variability" and should be assured that the use of guidelines will cause a lowering of this variability.
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Affiliation(s)
| | - Blerina Cela
- Histopathology Laboratory, Oncology Service, Tirana, Albania
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20
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Localization of nonpalpable breast lesions with sonographically visible clip: optimizing tailored resection and clear margins. Am J Surg 2015; 209:950-8. [DOI: 10.1016/j.amjsurg.2014.07.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Revised: 07/03/2014] [Accepted: 07/16/2014] [Indexed: 12/14/2022]
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Cancer du sein infra-clinique sur biopsie percutanée sans lésion maligne sur la pièce opératoire : comment gérer ? ACTA ACUST UNITED AC 2015; 43:18-24. [DOI: 10.1016/j.gyobfe.2014.11.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2014] [Accepted: 10/27/2014] [Indexed: 11/21/2022]
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de Beça FF, Rasteiro C, Correia A, Costa S, Amendoeira I. Improved malignancy prediction by B3 breast lesions subclassification. Ann Diagn Pathol 2013; 17:434-6. [DOI: 10.1016/j.anndiagpath.2013.05.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2013] [Revised: 05/08/2013] [Accepted: 05/11/2013] [Indexed: 11/26/2022]
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Pagni F, Bosisio FM, Salvioni D, Colombo P, Leone BE, Di Bella C. Application of the British National Health Service Breast Cancer Screening Programme classification in 226 breast core needle biopsies: correlation with resected specimens. Ann Diagn Pathol 2011; 16:112-8. [PMID: 22056037 DOI: 10.1016/j.anndiagpath.2011.08.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2011] [Revised: 08/08/2011] [Accepted: 08/08/2011] [Indexed: 10/15/2022]
Abstract
A retrospective study correlating the diagnosis made on core needle breast biopsy (CNB) with the diagnosis made on the final surgical specimen was done using the British National Health Service Breast Cancer Screening Programme (NHSBSP) classification for CNB on 226 patients during a period of 15 months. Statistical analysis was used to evaluate sensitivity, specificity, and positive and negative predictive values of the NHSBSP diagnostic categories. Cohen κ was used to evaluate the agreement between the diagnosis on CNB and the final pathologic diagnosis in "clinically positive cases." Finally, a comparative analysis between the CNB method and fine needle aspiration biopsy was made. The distribution of our cases for each diagnostic category reflects the literature guidelines, with minor differences in the B2 and B4 groups. Statistical data about the patients' follow-up revealed a small number of false-negative cases in the B1 and B2 categories and no false-positive cases in the B4 and B5 groups. Uncertain malignant lesions (B3 category) were divided into 3 major areas (papillary lesions, fibroepithelial proliferations with cellular stroma, and intraepithelial atypical lesions such as ductal intraepithelial neoplasia grade 1/lobular intraepithelial neoplasia grade 1). Of the 29 patients in the B3 category, 26 underwent surgery. Cohen κ analysis showed a strong statistical correlation (κ = 0.77; Z = 4.3; significance >1.96; α = .05) between CNB diagnosis and surgical pathology final results in the subgroup of high-risk patients (diagnosis, ≥ductal intraepithelial neoplasia grade 1 on CNB). Global diagnostic power of CNB in all 226 cases revealed high sensitivity (88.3%) and slightly lower specificity (72.8%). In 42 "doubtful" cases, synchronous fine needle aspiration biopsy and CNB were performed, showing a complementary role in the diagnostic phase of breast lesions. Core needle breast biopsy represents the criterion standard method in the diagnostic phase of many breast tumors; the NHSBSP classification is a useful reporting system that provides a good standardization of the pathologic diagnosis and provides a clear guideline for the correct management of the patient.
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Affiliation(s)
- Fabio Pagni
- Department of Pathology, Azienda Ospedaliera Ospedale di Vimercate-Desio, Italy.
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Rakha EA, Ho BC, Naik V, Sen S, Hamilton LJ, Hodi Z, Ellis IO, Lee AHS. Outcome of breast lesions diagnosed as lesion of uncertain malignant potential (B3) or suspicious of malignancy (B4) on needle core biopsy, including detailed review of epithelial atypia. Histopathology 2011; 58:626-32. [PMID: 21371081 DOI: 10.1111/j.1365-2559.2011.03786.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIMS To provide updated evidence of the outcome of breast lesions of uncertain malignant potential (B3) and suspicious of malignancy (B4) diagnosed on needle core biopsy (NCB) and analyse the outcome of the different types of intraductal epithelial atypia. METHODS AND RESULTS One-hundred and forty-nine B3 and 26 B4 NCBs diagnosed over a 2-year period (2007-2008) were compared with those diagnosed over a previous 2-year period (1998-2000). The proportion of B3 diagnoses increased from 3.1% to 4.5%, and the positive predictive value (PPV) of malignancy of a B3 core decreased from 25% to 10%. Increased diagnosis of radial scar and reductions in the PPV of lobular neoplasia and of atypical intraductal proliferation may explain the reduction in the PPV of the B3 group as a whole. There were no significant changes in the proportion of B4 diagnosis (1.1% and 0.8%) or the PPV of B4 (83% and 88%). Review of cores with intraductal atypia showed a wide range of PPVs, from 100% for suspicious of ductal carcinoma in situ, to 40% for atypical ductal hyperplasia categorized as B3, and 14% for isolated flat epithelial atypia. CONCLUSION The study has found a decrease in the PPV for a B3 diagnosis and suggests possible explanations.
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Affiliation(s)
- Emad A Rakha
- Department of Histopathology, Nottingham University Hospitals, City Hospital Campus, Nottingham, UK
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Rakha EA, Lee AH, Jenkins JA, Murphy AE, Hamilton LJ, Ellis IO. Characterization and outcome of breast needle core biopsy diagnoses of lesions of uncertain malignant potential (B3) in abnormalities detected by mammographic screening. Int J Cancer 2011; 129:1417-24. [DOI: 10.1002/ijc.25801] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2010] [Accepted: 11/04/2010] [Indexed: 11/09/2022]
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El-Sayed ME, Rakha EA, Reed J, Lee AHS, Evans AJ, Ellis IO. Predictive value of needle core biopsy diagnoses of lesions of uncertain malignant potential (B3) in abnormalities detected by mammographic screening. Histopathology 2009; 53:650-7. [PMID: 19076681 DOI: 10.1111/j.1365-2559.2008.03158.x] [Citation(s) in RCA: 104] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
AIMS Breast needle core biopsy (NCB) is now a commonplace diagnostic procedure in breast cancer screening, providing accurate diagnoses of both benign and malignant lesions. However, NCB may result in the borderline diagnoses of lesion of uncertain malignant potential (B3) or suspicious of malignancy (B4). The aim was to study a large series of B3 cases from population-based screening subjects in order to evaluate positive predictive values (PPVs) for malignancy. METHODS AND RESULTS The results of 523 NCBs of women screened over a 7-year period (1999-2006) in the East Midlands region, UK, with a B3 diagnosis who underwent surgical excision, were reviewed and compared with the final excision histology. Five percent of NCBs were reported as B3. The most frequent histological subtypes were atypical intraductal epithelial proliferation (AIDEP) and radial scar/complex sclerosing lesion (RS/CSL). Final excision histology was benign in 417 (80%) and malignant in 106 (20%) subjects (60 ductal carcinoma in situ and 46 invasive carcinoma). Lesion-specific PPVs were as follows: AIDEP 32%; lobular neoplasia (LN) 30%; RS/CSL with AIDEP or LN 24%; RS/CSL without atypia 9%; papillary lesion with AIDEP or LN 36%; and papillary lesion without atypia 4%. Five of the 32 fibroepithelial lesions with cellular stroma were phyllodes tumours (four benign and one borderline). None of the five mucinous lesions on NCB was malignant. CONCLUSIONS Our results show that approximately one-fifth of NCB of screen-detected breast lesions classified as B3 are malignant on excision, and the likelihood of malignancy varies substantially between different histological subtypes.
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Affiliation(s)
- M E El-Sayed
- Department of Histopathology, Nottingham University Hospitals NHS Trust, University of Nottingham, Nottingham, UK
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