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

Upgrade rate to malignancy of uncertain malignant potential breast lesions (B3 lesions) diagnosed on vacuum-assisted biopsy (VAB) in screen detected microcalcifications: Analysis of 366 cases from a single institution

PURPOSE

We retrospectively investigated clinical, radiological, and pathological features of B3 lesions associated with the risk of subsequent upgrade to malignancy.

METHODS

We included consecutive vacuum-assisted biopsies (VABs) performed during 2011-2020 on suspicious microcalcifications not associated with other radiological signs diagnosed as B3 lesions and followed by surgical excision (SE) with definitive histological examination. Multiple logistic regression models were fitted to identify independent predictors of malignancy.

RESULTS

Out of the 366 B3 lesions included, 56 (15.3 %, 95 % CI 11.8-19.4 %) had upgraded to malignancy at SE: of these, 42/366 (11.5 %, 95 % CI 8.4-15.2 %) and 14/366 (3.8 %, 95 % CI 2.1-6.3 %) were in situ and invasive carcinoma, respectively. At univariate analysis, variables positively associated with upgrade to malignancy were age ≥ 60 years (p = 0.008), mixed morphology (p = 0.018), scattered distribution (p = 0,001), extension of microcalcifications > 10 mm (p = 0.001), and mixed B3 lesion (p = 0.017). Among B3 subtypes, the highest rates of upgrade were observed for AIDEP, LCIS/LIN2, FEA + AIDEP, FEA + LCIS/LIN2, and FEA + AIDEP + LCIS/LIN2 (24.6 %, 21.4 %, 25.3 %, 20.0 % and 40.0 % respectively), while FEA and ALH/LIN1 had a lower rates of upgrade (7.5 % and 3.7 %, respectively). Multiple logistic regression analysis confirmed as risk factors older age (p = 0.029), larger extension (p = 0.001) and mixed morphology (p = 0.007) of microcalcifications, AIDEP (p = 0.011) among pure B3 lesions, and FEA + AIDEP (p = 0.001) and FEA + AIDEP + LCIS/LIN2 (p = 0.037) among mixed B3 lesions.

CONCLUSIONS

Based on our findings, vacuum-assisted excision is reasonable as definitive management for FEA and ALH/LIN1, while SE should remain the mainstay of treatment for AIDEP and LCIS/LIN2, whose upgrade rates are too high to safely recommend VAE.

European guidelines for the diagnosis, treatment and follow-up of breast lesions with uncertain malignant potential (B3 lesions) developed jointly by EUSOMA, EUSOBI, ESP (BWG) and ESSO

INTRODUCTION

Breast lesions of uncertain malignant potential (B3) include atypical ductal and lobular hyperplasias, lobular carcinoma in situ, flat epithelial atypia, papillary lesions, radial scars and fibroepithelial lesions as well as other rare miscellaneous lesions. They are challenging to categorise histologically, requiring specialist training and multidisciplinary input. They may coexist with in situ or invasive breast cancer (BC) and increase the risk of subsequent BC development. Management should focus on adequate classification and management whilst avoiding overtreatment. The aim of these guidelines is to provide updated information regarding the diagnosis and management of B3 lesions, according to updated literature review evidence.

METHODS

These guidelines provide practical recommendations which can be applied in clinical practice which include recommendation grade and level of evidence. All sections were written according to an updated literature review and discussed at a consensus meeting. Critical appraisal by the expert writing committee adhered to the 23 items in the international Appraisal of Guidelines, Research and Evaluation (AGREE) tool.

RESULTS

Recommendations for further management after core-needle biopsy (CNB) or vacuum-assisted biopsy (VAB) diagnosis of a B3 lesion reported in this guideline, vary depending on the presence of atypia, size of lesion, sampling size, and patient preferences. After CNB or VAB, the option of vacuum-assisted excision or surgical excision should be evaluated by a multidisciplinary team and shared decision-making with the patient is crucial for personalizing further treatment. De-escalation of surgical intervention for B3 breast lesions is ongoing, and the inclusion of vacuum-assisted excision (VAE) will decrease the need for surgical intervention in further approaches. Communication with patients may be different according to histological diagnosis, presence or absence of atypia, or risk of upgrade due to discordant imaging. Written information resources to help patients understand these issues alongside with verbal communication is recommended. Lifestyle interventions have a significant impact on BC incidence so lifestyle interventions need to be suggested to women at increased BC risk as a result of a diagnosis of a B3 lesion.

CONCLUSIONS

These guidelines provide a state-of-the-art overview of the diagnosis, management and prognosis of B3 lesions in modern multidisciplinary breast practice.

Breast Lesions of Uncertain Malignant Potential (B3) and the Risk of Breast Cancer Development: A Long-Term Follow-Up Study

Breast lesions of uncertain malignant potential (B3) are frequently diagnosed in the era of breast cancer (BC) screening and their management is controversial. They are generally removed surgically, but some international organizations and guidelines for breast research suggest follow-up care alone or, more recently, propose vacuum-assisted excision (VAE). The risk of upgrade to BC is known, but very little data exist on its role as risk factor for future BC development. We analyzed 966 B3 lesions diagnosed at our institution, 731 of which had long-term follow-up available. Surgical removal was performed in 91%, VAE in 3.8%, and follow-up in 5.2% of cases. The B3 lesions included flat epithelial atypia (FEA), atypical ductal hyperplasia (ADH), lobular intraepithelial neoplasia (LIN), atypical papillary lesions (PLs), radial scars (RSs), and others. Overall, immediate upgrade to BC (invasive or in situ) was 22.7%. After long-term follow-up, 9.2% of the patients were diagnosed with BC in the same or contralateral breast. The highest risk was associated with ADH diagnosis, with 39.8% of patients upgraded and 13.6% with a future BC diagnosis (p < 0.0001). These data support the idea that B3 lesions should be removed and provide evidence to suggest annual screening mammography for women after a B3 diagnosis because their BC risk is considerably increased.

Third International Consensus Conference on lesions of uncertain malignant potential in the breast (B3 lesions)

The heterogeneous group of B3 lesions in the breast harbors lesions with different malignant potential and progression risk. As several studies about B3 lesions have been published since the last Consensus in 2018, the 3rd International Consensus Conference discussed the six most relevant B3 lesions (atypical ductal hyperplasia (ADH), flat epithelial atypia (FEA), classical lobular neoplasia (LN), radial scar (RS), papillary lesions (PL) without atypia, and phyllodes tumors (PT)) and made recommendations for diagnostic and therapeutic approaches. Following a presentation of current data of each B3 lesion, the international and interdisciplinary panel of 33 specialists and key opinion leaders voted on the recommendations for further management after core-needle biopsy (CNB) and vacuum-assisted biopsy (VAB). In case of B3 lesion diagnosis on CNB, OE was recommended in ADH and PT, whereas in the other B3 lesions, vacuum-assisted excision was considered an equivalent alternative to OE. In ADH, most panelists (76%) recommended an open excision (OE) after diagnosis on VAB, whereas observation after a complete VAB-removal on imaging was accepted by 34%. In LN, the majority of the panel (90%) preferred observation following complete VAB-removal. Results were similar in RS (82%), PL (100%), and FEA (100%). In benign PT, a slim majority (55%) also recommended an observation after a complete VAB-removal. VAB with subsequent active surveillance can replace an open surgical intervention for most B3 lesions (RS, FEA, PL, PT, and LN). Compared to previous recommendations, there is an increasing trend to a de-escalating strategy in classical LN. Due to the higher risk of upgrade into malignancy, OE remains the preferred approach after the diagnosis of ADH.

High-Risk Lesion Management

High-risk lesions or lesions of uncertain malignant potential are frequent findings on image-guided needle biopsy of the breast and comprise a number of distinct entities. These lesions are known for having risk of underlying malignancy and are usually associated with an increased lifetime risk for breast cancer. Surgical excision was traditionally recommended for all high-risk lesions but recent studies have demonstrated that vacuum-assisted excision or surveillance may be adequate for some lesions. While management of high-risk lesion varies among institutions, this chapter describes the management recommendations based on recent literature of the most frequent types of lesions.

Mammography in Breast Disease Screening and Diagnosis

Female breasts can suffer from a wide spectrum of pathologies, ranging from inflammatory diseases to benign and malignant tumors [...].

[B3 lesions of the breast: histological, clinical, and epidemiological aspects : Update]

B3 lesions of the breast are a heterogeneous group of lesions with uncertain malignant potential encompassing a broad spectrum of histologically distinct alterations that often pose challenging decisions if diagnosed on the preoperative core or vacuum biopsies. B3 lesions are mostly detected due to mammographic calcifications or mass lesions and, in most cases, encompass a spectrum of atypical lesions such as atypical ductal hyperplasia, classic lobular neoplasia, flat epithelial atypia, papillomas, fibroepithelial tumors, and rarely other lesions such as mucocele-like lesions, atypical apocrine lesions, and rare stromal proliferations. The use of immunohistochemical stains (estrogen receptors, basal cytokeratin, myoepithelial markers, and stromal marker panel) is useful in the differentiation of these lesions and allowing proper classification. Regarding clinical management of B3 lesions, the radiological-pathological correlation of the given entity plays the most important key element for the proper next diagnostic and therapeutic step.