Lobular neoplasia: Core needle breast biopsy underestimation of malignancy in relation to radiologic and pathologic features

Upgrade Rates of Variant Lobular Carcinoma In Situ Compared to Classic Lobular Carcinoma In Situ Diagnosed in Core Needle Biopsies: A 10-Year Single Institution Retrospective Study

The primary aim of this study was to determine the upgrade rates of variant lobular carcinoma in situ (V-LCIS, ie, combined florid [F-LCIS] and pleomorphic [P-LCIS]) compared with classic LCIS (C-LCIS) when diagnosed on core needle biopsy (CNB). The secondary goal was to determine the rate of progression/development of invasive carcinoma on long-term follow-up after primary excision. After institutional review board approval, our institutional pathology database was searched for patients with "pure" LCIS diagnosed on CNB who underwent subsequent excision. Radiologic findings were reviewed, radiologic-pathologic (rad-path) correlation was performed, and follow-up patient outcome data were obtained. One hundred twenty cases of LCIS were identified on CNB (C-LCIS = 97, F-LCIS = 18, and P-LCIS = 5). Overall upgrade rates after excision for C-LCIS, F-LCIS, and P-LCIS were 14% (14/97), 44% (8/18), and 40% (2/5), respectively. Of the total cases, 79 (66%) were deemed rad-path concordant. Of these, the upgrade rate after excision for C-LCIS, F-LCIS, and P-LCIS was 7.5% (5 of 66), 40% (4 of 10), and 0% (0 of 3), respectively. The overall upgrade rate for V-LCIS was higher than for C-LCIS (P = .004), even for the cases deemed rad-path concordant (P value: .036). Most upgraded cases (23 of 24) showed pT1a disease or lower. With an average follow-up of 83 months, invasive carcinoma in the ipsilateral breast was identified in 8/120 (7%) cases. Six patients had died: 2 of (contralateral) breast cancer and 4 of other causes. Because of a high upgrade rate, V-LCIS diagnosed on CNB should always be excised. The upgrade rate for C-LCIS (even when rad-path concordant) is higher than reported in many other studies. Rad-path concordance read, surgical consultation, and individualized decision making are recommended for C-LCIS cases. The risk of developing invasive carcinoma after LCIS diagnosis is small (7% with ∼7-year follow-up), but active surveillance is required to diagnose early-stage disease.

Comparison of Outcomes for Classic-Type Lobular Carcinoma In Situ Managed with Surgical Excision After Core Biopsy Versus Observation

BACKGROUND

Studies report low upgrade rates following excision for classic-type lobular carcinoma in situ (LCIS) with radiologic-pathologic concordance. Thus, in the absence of other high-risk lesions, observation has become standard. We report long-term outcomes of excision versus observation following a core biopsy diagnosis of classic-type LCIS.

METHODS

Women with LCIS treated from 2013-2020 and managed with excision or observation were identified from a prospective database. Women with cancer upgrade at excision or history of cancer were excluded. We compared rates and characteristics of subsequent breast cancers by clinical management strategy.

RESULTS

Of 312 women, 170 (54%) underwent excision and 142 (46%) were managed with observation. Among the excision group, 36 of 170 (21%) had radiologic-pathologic concordant LCIS without other high-risk lesions, mass, or symptoms (concordant LCIS excision group). Overall, at 3.1 years median follow-up, 11 (6.5%) women managed with excision and 11 (7.7%) women managed with observation developed cancer. Cancer development was not associated with management choice (overall excision cohort vs. observation group [p = 0.8]) and did not differ between the concordant LCIS excision and observation groups (p > 0.9). The 5-year cancer development rate was 8.9% (95% confidence interval [CI]: 2.3-31.6%) in the concordant LCIS excision group and 10.3% (95% CI 5.5-18.6%) in the observation group.

CONCLUSIONS

No difference in breast cancer rates existed among women with a core-biopsy diagnosis of classic-type LCIS managed with excision or observation. These data support management of LCIS as a risk factor, with consideration of chemoprophylaxis, rather than as an indication for surgical excision.

Intra-radiological pathology-calibrated Electrical Impedance Spectroscopy in the evaluation of excision-required breast lesions

PURPOSE

Evaluating a real-time complementary bioelectrical diagnostic device based on Electrical Impedance Spectroscopy(EIS) for improving breast imaging-reporting and data system (BIRADS) scoring accuracy, especially in high-risk or borderline breast diseases. The primary purpose is to characterize breast tumors based on their dielectric properties. Early detection of high-risk lesions and increasing the accuracy of tumor sampling and pathological diagnosis are secondary objectives of the study.

METHODS

The tumor detection probe (TDP) was first applied to the mouse model for electrical safety evaluations by electrical current measurement, then to 138 human palpable breast lesions undergo CNB, VAB, or FNA with the surgeon's requests. Impedance phase slope(IPS) in frequency ranges of 100 kHz to 500 kHz and impedance magnitude in f = 1kHz were extracted as the classification parameters. Consistency of radiological and pathological declarations for the excisional recommendation was then compared with the IPS values.

RESULTS

Considering pathological results as the gold standard, meaningful correlations between IPS and pathophysiological status of lesions recommended for excision (such as atypical ductal hyperplasia, papillary lesions, complex sclerosing adenosis, and fibroadenoma, etc.) were observed (p<0.0001). These pathophysiological properties may include cells size, membrane permeability, packing density, adenosis, cytoplasm structure, etc. Benign breast lesions showed IPS values greater than zero, while high-risk proliferative, precancerous, or cancerous lesions had negative IPS values. Statistical analysis showed 95% sensitivity with Area Under the Curve(AUC) equal to 0.92.

CONCLUSION

Borderline breast diseases and high-risk lesions that should be excised according to standard guidelines can be diagnosed with TDP before any sampling process. It is a precious outcome for high-risk lesions that are radiologically underestimated to BI-RADS3, specifically in younger patients with dense breast masses, challenging in mammographic and sonographic evaluations. Also, the lowest IPS value detects the most pathologic portions of the tumor for increasing sampling accuracy in large tumors.

SIGNIFICANCE

Precise detection of high-risk breast masses, which may be declared BI-RADS3 instead of BI-RADS4a. This article is protected by copyright. All rights reserved.

Trends in incidence, treatment, survival and subsequent breast cancer in lobular carcinoma in situ in the Netherlands: A population-based analysis

Purpose

We analysed incidence, treatment, survival, occurrence of ductal carcinoma in situ (DCIS) and invasive breast cancer (IBC) after lobular carcinoma in situ (LCIS) in the Netherlands.

Methods

All women diagnosed with classic LCIS between 1989 and 2017 were identified from the Netherlands Cancer Registry. We calculated overall (OS), relative survival (RS) and cumulative incidence functions (CIF, accounting for competing risks) of mortality, DCIS and IBC. For IBC, standardised incidence ratios (SIR) of IBC were calculated. Analyses were stratified for surgical treatment.

Results

We included 1890 patients. Median age was 51 years. Median follow-up was 8.5 years. In 1989–2017, LCIS incidence increased from 41 to 124, surgical treatment decreased from 100% to 41.1 % – mostly BCS. 10-year OS and 20-year RS exceeded 90 % in all subgroups. Overall, 48 (2.5 %) and 270 (14.3 %) patients were diagnosed with DCIS and IBC. IBCs were mostly early-stage. After mastectomy, 13 of 14 IBCs presented contralaterally. In the other groups, 64.8–70.9 % of IBCs presented ipsilaterally, 34.5–53.9 % of these were lobular. The SIR of ipsilateral IBC was highest after no surgery (6.9, 95%CI:4.9–9.4), lowest after mastectomy (0.2, 95%CI:0.4–0.8).

Conclusion

LCIS incidence increased, surgical treatment decreased. The low mortality risks support consideration of active surveillance. However, the increased IBC incidence suggests careful monitoring.

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The incidence of LCIS increased, while surgical treatment decreased over time.

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10- and 20-year relative survival rates exceeded 90 %, irrespective of surgery.

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The risk of breast cancer was highest after no surgery, lowest after mastectomy.

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Subsequent breast cancers were generally of low stage.

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Active surveillance for LCIS is advised, with the current follow-up five years.

Lobular intraepithelial neoplasia: Outcomes and optimal management

INTRODUCTION

Lobular neoplasia is a term encompassing both atypical lobular hyperplasia and lobular carcinoma in situ. These pathological findings are of uncertain malignant potential and predispose to a higher lifetime risk of breast cancer. Debate surrounds the management of such lesions, with the rationale for diagnostic excision based on the possibility of upgrading to malignancy. In this study, we report the upgrade rate of these lesions and risk of subsequent development of breast cancer.

METHODS

This is a retrospective review of a prospectively maintained data base of all biopsies of breast screening-detected abnormalities in a single Irish breast-screening unit. We included all patients with lobular neoplasia on core needle biopsy who underwent diagnostic excision from 2005 to 2012. We excluded those who had concurrent high-risk lesions on biopsy. End points included upgrade rate and subsequent diagnosis of malignancy on follow-up.

RESULTS

During the study period, 66 patients met criteria for inclusion, with a mean age of 53.74 years. Upgrade rate following excision was 13.64% (n = 9/66). Of those not upgraded, 7.02% (n = 4/57) were subsequently diagnosed with malignancy. Median time to diagnosis was 59.61 months (range = 10.5-124.4).

CONCLUSION

There is a significant rate of upgrade following diagnostic excision of lobular neoplasia, supporting the practice of diagnostic excision. There is an increased lifetime risk of breast cancer for women with a diagnosis of lobular neoplasia, with many of these cancers occurring outside the standard five-year monitoring period, suggesting a potential benefit in extending surveillance.

Risk for Upgrade to Malignancy After Breast Core Needle Biopsy Diagnosis of Lobular Neoplasia: A Systematic Review and Meta-Analysis

PURPOSE

Lobular neoplasia (LN) detected on breast core needle biopsy is frequently managed with surgical excision because of concern for undersampled malignancy. The authors performed a systematic review and meta-analysis to estimate the risk for upgrade to malignancy in the setting of imaging-concordant classic LN diagnosed on core biopsy.

METHODS

PubMed and Embase were searched for original articles published from 1998 to 2020 that reported rates of upgrade to malignancy for classic LN, including atypical lobular hyperplasia (ALH) and classic lobular carcinoma in situ (LCIS). Two reviewers extracted study data and assessed the following quality criteria: exclusion of variant LCIS, exclusion of imaging-discordant lesions, and outcome reporting for ≥70% of lesions. For studies meeting all criteria, pooled risks for upgrade to any malignancy (invasive carcinoma or ductal carcinoma in situ) and invasive malignancy for all LN, ALH, and LCIS were estimated using random-effects models.

RESULTS

For 65 full-text articles included in the review, the risk for upgrade to any malignancy ranged from 0% to 45%. Among the 16 studies that met all quality criteria for the meta-analysis, pooled risks for upgrade to any malignancy were 3.1% (95% confidence interval [CI], 1.8%-5.2%) for all LN, 2.5% (95% CI, 1.6%-3.9%) for ALH, and 5.8% (95% CI, 2.9%-11.3%) for LCIS. Risks for upgrade to invasive malignancy were 1.3% (95% CI, 0.7%-2.4%) for all LN, 0.4% (95% CI, 0.0%-4.2%) for ALH, and 3.5% (95% CI, 2.0%-5.9%) for LCIS.

CONCLUSIONS

The risk for upgrade to malignancy for LN found on breast biopsy is low. Imaging surveillance can likely be offered as an alternative to surgical management for LN, particularly for ALH.

Atypical Ductal Hyperplasia and Lobular Neoplasia: Update and Easing of Guidelines

OBJECTIVE. Atypical ductal hyperplasia (ADH), atypical lobular hyperplasia (ALH), and lobular carcinoma in situ (LCIS) are among high-risk lesions that have been previously recommended for surgical excision when diagnosed on core needle biopsy. Recent studies have examined whether imaging surveillance is a reasonable alternative to surgical management for these lesions. This article synthesizes the evidence regarding management of atypical hyperplasia and LCIS diagnosed on core needle biopsy and clinical implications of these diagnoses on future breast cancer risk as well as highlights areas of further research needed to improve practice guidelines for these high-risk lesions. CONCLUSION. Although surgical excision is still recommended after diagnosis of ADH on core needle biopsy, in specific circumstances ALH and LCIS can safely be managed by imaging surveillance.

Outcomes of classic lobular neoplasia diagnosed on breast core needle biopsy: a retrospective multi-center study

Management of classic lobular neoplasia (cLN) diagnosed on core needle biopsy (CNB) is controversial. Our aim in this study was to review cases of cLN diagnosed on CNB to determine the rate and risk factors of an upgrade to ductal carcinoma in situ (DCIS) or invasive carcinoma on excision. All breast CNBs with a diagnosis of atypical lobular hyperplasia (ALH) or classic lobular carcinoma in situ (cLCIS) from three different institutions within a single health care system between 2013 and 2018 were retrieved. Cases with any additional high-risk lesions in the same CNB or discordant radiological-pathological correlation were excluded. Information about age, personal history of prior or concurrent breast cancer (P/CBC), and radiological and histological findings were recorded. A total of 287 cLN cases underwent surgical excision. Analysis of these 287 cLN cases showed 11 (3.8%) upgrade lesions on excision. Among the 172 ALH cases, there were 3 (1.7%) upgrades, which were all invasive lobular carcinomas (ILCs). On the other hand, 8 of 115 (7%) cLCIS cases revealed upgrade on excision (2 ILC, 5 DCIS. and 1 ILC + DCIS). Statistical analysis revealed that cLN cases with P/CBC, radiological asymmetry, or architectural distortion had a statistically significant higher upgrade rate on excision. Our findings revealed a low upgrade rate (3.8%) on the excision of classic lobular neoplasia diagnosed on breast core needle biopsy. Clinicoradiological surveillance can be appropriate when lobular neoplasia is identified on core biopsy with pathological radiological concordance in patients without a history of breast cancer, with the caveat that radiological asymmetry and architectural distortion are associated with a significant increase in an upgrade on excision.

Observation versus excision of lobular neoplasia on core needle biopsy of the breast

PURPOSE

Controversy surrounds management of lobular neoplasia (LN), [atypical lobular hyperplasia (ALH) or lobular carcinoma in situ (LCIS)], diagnosed on core needle biopsy (CNB). Retrospective series of pure ALH and LCIS reported "upgrade" rate to DCIS or invasive cancer in 0-40%. Few reports document radiologic/pathologic correlation to exclude cases of discordance that are the likely source of most upgrades, and there is minimal data on outcomes with follow-up imaging and clinical surveillance.

METHODS

Cases of LN alone on CNB (2001-2014) were reviewed. CNB yielding LN with other pathologic findings for which surgery was indicated were excluded. All patients had either surgical excision or clinical follow-up with breast imaging. All cases included were subject to radiologic-pathologic correlation after biopsy.

RESULTS

178 cases were identified out of 62213 (0.3%). 115 (65%) patients underwent surgery, and 54 (30%) patients had surveillance for > 12 months (mean = 55 months). Of the patients who underwent surgical excision, 13/115 (11%) were malignant. Eight of these 13 found malignancy at excision when CNB results were considered discordant (5 DCIS, and 3 invasive lobular carcinoma), with the remainder, 5/115 (4%), having a true pathologic upgrade: 3 DCIS, and 2 microinvasive lobular carcinoma. Among 54 patients not having excision, 12/54 (22%) underwent subsequent CNB with only 1 carcinoma found at the initial biopsy site.

CONCLUSIONS

Surgical excision of LN yields a low upgrade rate when careful consideration is given to radiologic/pathologic correlation to exclude cases of discordance. Observation with interval breast imaging is a reasonable alternative for most cases.

Lobular Carcinoma In Situ

Lobular carcinoma in situ (LCIS) is a risk factor and a nonobligate precursor of breast carcinoma. The relative risk of invasive carcinoma after classic LCIS diagnosis is approximately 9 to 10 times that of the general population. Classic LCIS diagnosed on core biopsy with concordant imaging and pathologic findings does not mandate surgical excision, and margin status is not reported. The identification of variant LCIS in a needle core biopsy specimen mandates surgical excision, regardless of radiologic-pathologic concordance. The presence of variant LCIS close to the surgical margin of a resection specimen is reported, and reexcision should be considered.

Upgrade rates of high-risk breast lesions diagnosed on core needle biopsy: a single-institution experience and literature review

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.

Core Breast Biopsies Showing Lobular Carcinoma In Situ Should Be Excised and Surveillance Is Reasonable for Atypical Lobular Hyperplasia

OBJECTIVE

The purpose of this article is to determine the upgrade rate to ductal carcinoma in situ (DCIS) or invasive carcinoma at excision at the same site after percutaneous breast biopsy findings of atypical lobular hyperplasia (ALH) or lobular carcinoma in situ (LCIS) using current imaging and strict pathologic criteria.

MATERIALS AND METHODS

From January 2006 through September 2013, 32,960 breast core biopsies were performed; 1084 (3.3%) core biopsies found ALH or classic LCIS. For 447 lesions in 433 women, this was the only high-risk lesion at that site, with no ipsilateral malignancy, and results of excision were available.

RESULTS

Among the 447 lesions, 22 (4.9%) were malignant at excision, including 10 invasive carcinomas (two grade 2 and eight grade 1; all node negative) and 12 DCIS. The upgrade rate of LCIS was 9.3% (10/108; 95% CI, 5.1-16.2%) and that of ALH was 3.5% (12/339; 95% CI, 2.0-6.1%; p = 0.02). After excluding five cases with radiologic-pathologic discordance and reclassifying one core from ALH to LCIS at review, the upgrade rate for LCIS remained higher (8.4%; 9/107; 95% CI, 4.5-15.2%) than that for ALH (2.4%; 8/335; 95% CI, 1.2-4.6%; p = 0.01).

CONCLUSION

Excision is recommended for LCIS on core biopsy because of its 8.4-9.3% upgrade rate. Excluding discordant cases, patients with other high-risk lesions or concurrent malignancy, the risk of upgrade of ALH was 2.4%. Surveillance at 6, 12, and 24 months can be performed in lieu of excision because a short delay in diagnosis of the few malignancies is not expected to cause harm.

Atypical epithelial hyperplasia of the breast: state of the art

INTRODUCTION

Atypical epithelial hyperplasia (AEH) of the breast is considered benign histological lesions with breast cancer risk. This review focuses on clinical signification and management of AEH that remains controversial.

AREAS COVERED

A review of published studies was performed using medline database. In this review, we fully describe the current evidence available. In particular, we describe 1) data from immunohistochemistry and molecular studies that suggest AEH is a precursor of breast cancer; 2) epidemiological studies demonstrate low rate of breast cancer in women with AEH; 3) surgical excision is necessary after diagnosis of AEH, such as lobular carcinoma in situ or atypical ductal hyperplasia, on core needle biopsy; 4) although current recommendations are evolving to fewer (if not no) excisions for flat epithelial with atypia and classic lobular neoplasia found on percutaneous biopsy (without radiologic indications for excision). Expert commentary: HEA management steel need prospective evidences, but recent retrospective data give some clue for less invasive management for some of HEA.

[Shall all lobular intraepithelial neoplasia diagnosed on image-guided biopsy require a surgical management?]

OBJECTIVE

Lobular intraepithelial neoplasia (LIN) diagnosed on image-guided biopsy may be associated with an undiagnosed cancer. This is called under-diagnosis. The consequence is that management of these lesions is often surgical. But many surgeries finally are unnecessary. The aim of our study was to define criteria to avoid unnecessary surgery.

MATERIALS AND METHODS

This is a single-center, retrospective after a database collected prospectively study. Fourteen thousand biopsies were analyzed, including 456 diagnosed NLI. Under-diagnosis rates were analyzed according to many criteria. The average duration of following was 45 months.

RESULTS

For atypical lobular hyperplasia (ALH), we obtained 7.6% under-diagnosis and combining several criteria, we got a low risk of cancer (2%). For LCIS, this rate was 23% and any low-risk group could be identified.

CONCLUSION

ALH with calcifications≤20 mm, without any atypical lesion associated, histologically focal and whose removal is representative may be safely observed. For other LIN, surgery remains indicated.

Atypical lobular hyperplasia and lobular carcinoma in situ at core needle biopsy of the breast: An incidental finding or are there characteristic imaging findings?

BACKGROUND

Atypical lobular hyperplasia and classic-type lobular carcinoma in situ, collectively known as lobular neoplasia, are classically described as incidental findings found on breast core-needle biopsy without distinguishing imaging characteristics.

OBJECTIVE

The purpose of this study was to investigate concordant imaging findings of lobular neoplasia identified at core-needle biopsy after careful radiologic-pathologic correlation.

METHODS

The pathology database was searched from October 1, 2006 to October 1, 2013 for breast biopsies yielding lobular neoplasia not associated with a coexistent malignancy or other high risk lesion in the biopsy specimen.

RESULTS

Of the 482 biopsies performed containing lobular neoplasia, 65 cases had lobular neoplasia as the highest risk lesion at core-needle biopsy. Of the 65 total cases in which lobular neoplasia was the highest risk lesion, 18 (28%) cases had concordant imaging correlates. 13 of 18 (72%) cases presented as calcifications on mammography and 5 of 18 (28%) presented on magnetic resonance imaging as a focus (n = 2) or non-mass enhancement (n = 3).

CONCLUSION

With careful radiologic-pathologic correlation, mammographically detected calcifications and foci or non-mass enhancement on magnetic resonance imaging can be considered concordant imaging findings of lobular neoplasia after breast core-needle biopsy.

Incidence of Adjacent Synchronous Invasive Carcinoma and/or Ductal Carcinoma In-situ in Patients with Lobular Neoplasia on Core Biopsy: Results from a Prospective Multi-Institutional Registry (TBCRC 020)

BACKGROUND

Lobular neoplasia (LN) represents a spectrum of atypical proliferative lesions, including atypical lobular hyperplasia and lobular carcinoma-in-situ. The need for excision for LN found on core biopsy (CB) is controversial. We conducted a prospective multi-institutional trial (TBCRC 20) to determine the rate of upgrade to cancer after excision for pure LN on CB.

METHODS

Patients with a CB diagnosis of pure LN were prospectively identified and consented to excision. Cases with discordant imaging and those with additional lesions requiring excision were excluded. Upgrade rates to cancer were quantified on the basis of local and central pathology review. Confidence intervals and sample size were based on exact binomial calculations.

RESULTS

A total of 77 of 79 registered patients underwent excision (median age 51 years, range 27-82 years). Two cases (3%; 95% confidence interval 0.3-9) were upgraded to cancer (one tubular carcinoma, one ductal carcinoma-in-situ) at excision per local pathology. Central pathology review of 76 cases confirmed pure LN in the CB in all but two cases. In one case, the tubular carcinoma identified at excision was also found in the CB specimen, and in the other, LN was not identified, yielding an upgrade rate of one case (1%; 95% CI 0.01-7) by central pathology review.

CONCLUSIONS

In this prospective study of 77 patients with pure LN on CB, the upgrade rate was 3% by local pathology and 1% by central pathology review, demonstrating that routine excision is not indicated for patients with pure LN on CB and concordant imaging findings.

Lesion stiffness measured by shear-wave elastography: Preoperative predictor of the histologic underestimation of US-guided core needle breast biopsy

OBJECTIVES

To determine whether lesion stiffness measured by shear-wave elastography (SWE) can be used to predict the histologic underestimation of ultrasound (US)-guided 14-gauge core needle biopsy (CNB) for breast masses.

METHODS

This retrospective study enrolled 99 breast masses from 93 patients, including 40 high-risk lesions and 59 ductal carcinoma in situ (DCIS), which were diagnosed by US-guided 14-gauge CNB. SWE was performed for all breast masses to measure quantitative elasticity values before US-guided CNB. To identify the preoperative factors associated with histologic underestimation, patients' age, symptoms, lesion size, B-mode US findings, and quantitative SWE parameters were compared according to the histologic upgrade after surgery using the chi-square test, Fisher's exact test, or independent t-test. The independent factors for predicting histologic upgrade were evaluated using multivariate logistic regression analysis.

RESULTS

The underestimation rate was 28.3% (28/99) in total, 25.0% (10/40) in high-risk lesions, and 30.5% (18/59) in DCIS. All elasticity values of the upgrade group were significantly higher than those of the non-upgrade group (P<0.001). On multivariate analysis, the mean (Odds ratio [OR]=1.021, P=0.001), maximum (OR=1.015, P=0.008), and minimum (OR=1.028, P=0.001) elasticity values were independently associated with histologic underestimation. The patients' age, lesion size, and final assessment category on US of the upgrade group were higher than those of the non-upgrade group (P=0.046 for age; P=0.021 for lesion size; P=0.030 for US category), but these were not independent predictors of histologic underestimation on multivariate analysis.

CONCLUSION

Breast lesion stiffness quantitatively measured by SWE could be helpful to predict the underestimation of malignancy in US-guided 14-gauge CNB.

Underestimation of Atypical Lobular Hyperplasia and Lobular Carcinoma in Situ at Stereotaxic 11-Gauge Vacuum-Assisted Breast Biopsy

The aims of this study are to determine the frequency of diagnosis of atypical lobular hyperplasia (ALH) and lobular carcinoma in situ (LCIS) at stereotaxic-guided 11-gauge vacuum-assisted breast biopsy (VABB) and to assess the rate of underestimation of these at subsequent surgical excision and follow-up. Moreover, we aimed to define clinical, radiological and histological features of nonpalpable lesions in core biopsies that predict the lesion upgrade. Retrospective review of 11-gauge VABB was performed to identify the underestimation rate of nonpalpable lesions diagnosed as ALH or LCIS at VABB. Thirteen cases of ALH and 36 cases of LCIS were sent to surgery, 29 cases of ALH and 14 cases of LCIS were sent to follow-up. The clinical, mammographic and histologic features were assessed. The correlation between mammographic BI-RADS score and histological B-classification for both ALH and LCIS lesions were performed by Pearson's test. Of 1,765 patients enrolled, lobular lesions (ALH and/or LCIS) occurred in 82 cases, and underestimation arose in 9 (10.9%). Two cases of underestimated ALH were upgraded to invasive lobular carcinoma and one to invasive ductal carcinoma. One case of underestimated LCIS was upgraded to ductal carcinoma in situ, two to invasive ductal carcinoma and three to invasive lobular carcinoma. The histology of the core and surgical specimens were compared. A significant difference was seen in the BI-RADS score (4–5 in 91% of underestimated lesions), and the size of the lesions (≥ 1.5 cm) for underestimated cases versus accurately diagnosed cases (p<0.001). Further significant parameters predictive for malignancy were the incomplete lesion removal by VABB and the presence of associated different breast lesions in the specimen. In conclusion, as far as ALH is concerned, we propose surgery as first choice when at least one of the following condition is respected: positive history for breast carcinoma, lesion >1.5cm, co-presence of high-risk lesions in the sample, signs of ductal involvement, high histological grading for atypia and follow-up in the other cases. Surgery is recommended in all cases of LCIS:

Pathologic Upgrade Rates on Subsequent Excision When Lobular Carcinoma In Situ Is the Primary Diagnosis in the Needle Core Biopsy With Special Attention to the Radiographic Target

Context.—Lobular carcinoma in situ (LCIS) as the primary pathologic diagnosis in a needle core biopsy is an infrequent finding, and the management of patients in this setting is controversial.

Objective.—To determine the rate of pathologic upgrade (defined as the presence of a clinically more-significant lesion in the subsequent excision) in patients with a primary pathologic diagnosis of LCIS in the needle core biopsy.

Design.—Patients with a primary diagnosis of LCIS in a needle core biopsy who underwent subsequent excision were identified. Core biopsies containing a concurrent high-risk lesion and cases with radiologic-pathologic discordance were excluded. The presence of selected microscopic features in the needle core biopsy was correlated with pathologic upgrade. Microscopic findings were correlated with the radiographic target in the needle core biopsy.

Results.—Sixty-one women with primary LCIS in their needle core biopsy showed a 10% pathologic upgrade rate. The percentage of cores involved by LCIS was significantly associated with pathologic upgrade (P= .04), whereas the remaining measured parameters were not. When LCIS represented the radiographic target, the pathologic upgrade rate was 18%, whereas when it was an incidental finding, the pathologic upgrade rate was 4%.

Conclusions.—It may be reasonable for patients with primary, yet incidental, LCIS on needle core biopsy to be managed in a nonsurgical fashion. Larger studies are needed to confirm our findings.

Long-term follow-up of lobular neoplasia (atypical lobular hyperplasia/lobular carcinoma in situ) diagnosed on core needle biopsy

BACKGROUND

Lobular neoplasia (LN) includes atypical lobular hyperplasia (ALH) and lobular carcinoma in situ (LCIS). LN often is an incidental finding on breast core needle biopsy (CNBx) and management remains controversial. Our objective was to define the incidence of malignancy in women diagnosed with pure LN on CNBx, and identify a subset of patients that may be observed.

METHODS

Patients diagnosed with LN on CNB between January 1993 and December 2010 were identified. Patients with an associated high-risk lesion or ipsilateral malignancy at time of diagnosis were excluded. All cases were reviewed by dedicated breast pathologists and breast imagers for pathologic classification and radiologic concordance, respectively.

RESULTS

The study cohort was comprised of 184 (1.3 %) cases of pure LN (147 ALH, 37 LCIS) from 180 patients. Pathologic-radiologic concordance was achieved in 171 (93 %) cases. Excision was performed in 101 (55 %) cases and 83 (45 %) were observed. Mean follow-up was 50.3 (range, 6-212) months. Of cases excised, 1 of 81 (1.2 %) ALH and 1 of 20 (5 %) LCIS cases were upstaged to ductal carcinoma in situ (DCIS) and invasive lobular carcinoma (ILC), respectively. Only 1 of 101 (1 %) concordant lesions was upstaged on excision. Of the cases observed, 4 of 65 (6.2 %) developed ipsilateral cancer during follow-up: 1 of 51 (2 %) case of ALH and 3 of 14 (21.4 %) cases with LCIS (2 ILC, 2 DCIS). During follow-up, 2.9 % (4/138) patients with excised or observed LN developed a contralateral cancer.

CONCLUSIONS

These data support that not all patients with LN diagnosed on CNB require surgical excision. Patients with pure ALH, demonstrating radiologic-pathologic concordance, may be safely observed.

Pathologic findings of follow-up surgical excision for lobular neoplasia on breast core biopsy performed for calcification

This study aimed to ascertain pathologic findings of surgical follow-up excision (FUE) on patients who had radiologic finding of calcifications and lobular neoplasia (LN) on core biopsy. Breast core biopsy specimens from 2006-2011 with a diagnosis of pure classic-type LN (lobular carcinoma in situ [LCIS] and atypical lobular hyperplasia [ALH]) with no history of invasive carcinoma (IC) or ductal carcinoma in situ (DCIS) were studied. Two hundred thirty-seven patients with the diagnosis of calcium on radiologic studies had FUE and were included in the study. Cases were divided into group 1 (pure ALH, n = 163) and group 2 (pure LCIS, n = 74). The interval between the core biopsy and FUE ranged from 0.2 to 7 months (mean, 1.5 ± 1.1 months). The risk of upstaging on FUE (DCIS or IC) is as follows: LCIS, 8.1% (6/74) and ALH, 3.1% (5/163). The data indicate that there is a low risk of upstaging to DCIS/IC from a core biopsy diagnosis of lobular neoplasia.

Low frequency of cancer occurrence in same breast quadrant diagnosed with lobular neoplasia at percutaneous needle biopsy

PURPOSE

To determine the type of mammographic abnormality leading to needle biopsy of lobular neoplasia (LN) and define the clinical evolution of low-risk LN lesions diagnosed at needle biopsy but not surgically removed.

MATERIALS AND METHODS

This study was approved by the institutional review board, and the requirement to obtain informed consent was waived. Among 16 945 needle biopsies performed between April 1998 and August 2008, LN was determined to be the most suspicious lesion in 352 samples (2.1%) (pleomorphic and necrotic forms were excluded). Among 299 pure LN lesions that were not surgically removed, follow-up was available for 276 lesions in 275 women.

RESULTS

Needle biopsy was performed because of mammographic calcifications in 215 of the 276 lesions (77.9%) and because of mammographic masses in 35 (12.7%). The mean follow-up was 5.0 years ± 2.4 (range, 0.6-12.2 years). All 275 women underwent one mammographic follow-up, 205 (74.5%) underwent a second mammographic follow-up, and 147 (53.5%) underwent a third mammographic follow-up. Cancer was diagnosed in 27 of the 275 cases (9.8%) after a mean of 3.9 years ± 2.6 (range, 1.2-10.8 years). Only three cancers (1.1%) occurred in the same breast quadrant as the one originally diagnosed with LN at needle biopsy.

CONCLUSION

Lumpectomy of pure LN lesions may not prevent malignancy in most cases. Consequently, women with pure LN of a low-risk type diagnosed at needle biopsy are strongly encouraged to undergo a yearly breast clinical examination and yearly mammographic follow-up to detect an eventual cancer in its early stages.

Management of lobular carcinoma in-situ and atypical lobular hyperplasia of the breast--a review

OBJECTIVES

To determine the incidence of malignancy (invasive carcinoma or DCIS) in patients diagnosed with lobular neoplasia (B3) on core needle biopsy (CNB) of breast lesions by reviewing the published literature.

METHODS

Medline, Embase, OVID-database and reference lists were searched to identify and review all English-language articles addressing the management of LN diagnosed on CNB. Studies on mixed breast pathologies were excluded.

RESULTS

Of 1229 LN diagnosed on CNB, 789 (64%) underwent surgical excision. 211 (27%) of excisions contained either DCIS or invasive disease. 280 of the excision specimens were classified as ALH, 241 as LCIS, 22 as pleomorphic LCIS and 246 unspecified LN on the original CNB. After surgical excision, 19% of the ALH cases, 32% of the LCIS cases and 41% of the PLCIS cases, contained malignancy. 29% of the unspecified LNs were upgraded to malignancy. The higher incidence of malignancy within excision specimens for LCIS and PLCIS compared to ALH was significant (P < 0.04, <0.003 respectively).

CONCLUSION

There is a significant underestimation of malignancy in patients diagnosed with breast LN on CNB. 27% cases of CNB-diagnosed LN were found to contain malignancy following surgical excision. All patients diagnosed with LN on CNB should be considered for surgical excision biopsy.

Radiologic findings of lobular carcinoma in situ: mammography and ultrasonography

PURPOSE

The purpose was to evaluate the mammographic and sonographic (US) features of lobular carcinoma in situ (LCIS). Methods. Mammographic and US findings of nine lesions diagnosed pathologically as pure LCIS were analyzed retrospectively according to the American College of Radiology breast imaging reporting and data system (BI-RADS) lexicon.

RESULTS

With regards to mammographic findings of LCIS, there were no lesions demonstrated in six cases and a mass in three cases, two of which contained microcalcifications. The most common US findings of LCIS were irregular shape (five cases), ill-defined margins (eight cases), and hypoechogenicity (seven cases). All cases had an elongated shape parallel to the skin or were round (no lesion had a taller-than-wide shape). Two cases were associated with microcalcifications. The final BI-RADS categories were category 3 (probably benign finding) in one case, category 4A (low suspicion of malignancy) in two cases, and category 4B (intermediate suspicion of malignancy) in six cases.

CONCLUSIONS

LCIS is frequently mammographically occult, and an incidental finding on routine screening mammograms, usually because of microcalcifications. LCIS, a high-risk lesion, can mimic invasive carcinoma on US.

Lobular carcinoma in situ/atypical lobular hyperplasia on breast needle biopsies: does it warrant surgical excisional biopsy? A study of 27 cases

Lobular neoplasia including lobular carcinoma in situ (LCIS) and atypical lobular hyperplasia (ALH) may be identified in breast core needle biopsies as incidental findings or associated with microcalcifications. There are no general consensus guidelines for follow-up management in patients when lobular neoplasia is the only abnormal finding on core needle biopsy. The aim of this study was to evaluate our experience in the follow-up of these patients. A total of 3163 breast core needle biopsies were retrieved from the surgical pathology files between 2003 and 2009; among them, 56 (1.8%) cases were identified with a diagnosis of ALH or LCIS. Eleven cases were excluded because of the presence of a concurrent more severe lesion in the biopsies that mandated excision. The remaining 45 cases contained only ALH or LCIS and otherwise benign breast tissue; 27 had surgical excision follow-up. In the surgical excision specimens, 5 (19%) of 27 cases showed more severe lesions or were "upgraded" (3 invasive ductal carcinomas, 1 invasive lobular carcinoma, and 1 ductal carcinoma in situ). Histologic features of the lobular neoplasia on the cores, including association with microcalcifications, pagetoid involvement of ducts, and extensive lobular involvement, were retrospectively evaluated. These histologic features were found to have no predictive value for a more severe lesion in the subsequent excision. We suggest that patients with LCIS/ALH on core needle biopsy should be considered for surgical excision to rule out a more significant lesion regardless of the histologic features.

B3 Lesions: Radiological Assessment and Multi-Disciplinary Aspects

B3 lesions comprise different histopathological entities that are considered benign but 'of unknown biological potential'. These entities may act as risk indicators (for both breasts) or as non-obligatory precursors of malignancy. Being diagnosed at percutaneous breast biopsy, an additional risk of underestimate exists. Imaging appearances, histopathological appearance and risk of associated malignancy are presented. B3 lesions of high risk, which thus should usually be excised, include atypical ductal hyperplasia (ADH), pleomorphic or necrotic type of lobular neoplasia (LIN 3), and papillary lesions with atypias. Intermediate risk may be associated with classic lobular carcinoma in situ (LIN 2) or flat epithelial atypia (FEA), and low risk with radial sclerosing lesions (RSLs) and papillary lesions without atypias. LIN 1 is mostly an incidental finding acting as risk indicator. Follow-up is adequate if the initial diagnostic problem is solved. According to international guidelines, risk and subsequent recommendations should be discussed for each individual patient, taking into account biological risk, representative sampling, lesion size, lesion extent, percentage of lesion removal, other individual risks, and the possibility of surveillance. With vacuum-assisted breast biopsy (VABB), surgery may be avoided for more of the small lesions at low risk. Further data collection and diligent evaluation may help to better assess the individual risk, to better adapt treatment recommendations and avoid overtreatment.

[Lobular intra-epithelial neoplasia: atypical lobular hyperplasia and lobular carcinoma in situ]

OBJECTIVE

To review main knowledge about lobular intra-epithelial neoplasia with special interest for daily practice management.

MAIN RESULTS

Intra-epithelial lobular neoplasias (ILN) are non invasive proliferations within the terminal ducto-lobular unit of monomorphic loosely cohesive small cells. A lack of expression of the E-cadherin adhesion molecule is often observed as in invasive lobular breast cancer. ILN are infrequent, however, a rise in incidence partly, due to the generalization of mammographic screening, is observed. Actually ILN are usually asymptomatic and diagnosed after breast biopsy for unspecified microcalcifications. ILN are associated with an increased risk of breast cancer that persists over 20 years after the initial diagnosis. The average risk is 4.2 % for the ipsilateral breast and 3,5 % for the controlateral breast. However, a great variability in the risk estimation is observed between the studies. There is no consensus on how to treat ILN. Surgical options have varied from biopsy to bilateral mastectomy. Current tendency is favouring lumpectomy.