Long term clinical follow-up of atypical ductal hyperplasia and lobular carcinoma in situ in breast core needle biopsies

Atypical ductal or lobular hyperplasia, lobular carcinoma in-situ, flat epithelial atypia, and future risk of developing breast cancer: Systematic review and meta-analysis

BACKGROUND

Biopsy-proven breast lesions such as atypical ductal hyperplasia (ADH) or atypical lobular hyperplasia (ALH), lobular carcinoma in situ (LCIS) and flat epithelial atypia (FEA) increase subsequent risk of breast cancer (BC), but long-term risk has not been synthesized. A systematic review was conducted to quantify future risk of breast cancer accounting for time since diagnosis of these high-risk lesions.

METHODS

A systematic search of literature from 2000 was performed to identify studies reporting BC as an outcome following core-needle or excision biopsy histology diagnosis of ADH, ALH, LCIS, lobular neoplasia (LN) or FEA. Meta-analyses were conducted to estimate cumulative BC incidence at five-yearly intervals following initial diagnosis for each histology type.

RESULTS

Seventy studies reporting on 47,671 subjects met eligibility criteria. BC incidence at five years post-diagnosis with a high-risk lesion was estimated to be 9.3 % (95 % CI 6.9-12.5 %) for LCIS, 6.6 % (95 % CI 4.4-9.7 %) for ADH, 9.7 % (95 % CI 5.3-17.2 %) for ALH, 8.6 % (95 % CI 6.5-11.4 %) for LN, and 3.8 % (95 % CI 1.2-11.7 %) for FEA. At ten years post-diagnosis, BC incidence was estimated to be 11.8 % (95 % CI 9.0-15.3 %) for LCIS, 13.9 % (95 % CI 7.8-23.6 %) for ADH, 15.4 % (95 % CI 7.2-29.3 %) for ALH, 17.0 % (95 % CI 7.2-35.3 %) for LN and 7.2 % (95 % CI 2.2-21.2 %) for FEA.

CONCLUSION

Our findings demonstrate increased BC risk sustained over time since initial diagnosis of high-risk breast lesions, varying by lesion type, with relatively less evidence for FEA.

Atypia detected during breast screening and subsequent development of cancer: observational analysis of the Sloane atypia prospective cohort in England

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.

Long-Term Follow-Up of High-Risk Breast Lesions at Vacuum-Assisted Biopsy without Subsequent Surgical Resection

Introduction

B3-lesions of the breast are a heterogeneous group of neoplasms, associated with a higher risk of breast cancer. Recent studies show a low upgrade rate into malignancy after subsequent open surgical excision (OE) of most B3-lesions when proven by vacuum-assisted biopsy (VAB). However, there is a lack of long-term follow-up data after VAB of high-risk lesions. The primary aim of this study was to demonstrate whether follow-up of B3 lesions is a beneficial and reliable alternative to OE in terms of long-term outcome. The secondary aim was to identify patient and lesion characteristics of B3 lesions for which OE is still necessary.

Methods

This retrospective multicenter study was conducted at 8 Swiss breast centers between 2010 and 2019. A total of 278 women (mean age: 53.5 ± 10.7 years) with 286 B3-lesions who had observation only and who had at least 24 months of follow-up were included. Any event during follow-up (ductal carcinoma in situ [DCIS], invasive cancer, new B3-lesion) was systematically recorded. Data from women who had an event during follow-up were compared with those who did not. The results for the different B3 lesions were analyzed using the t test and Fisher's exact test. A p value of <0.05 was considered statistically significant.

Results

The median follow-up interval was 59 months (range: 24-143 months) with 52% (148/286) having a follow-up of more than 5 years. During follow-up, in 42 women, 44 suspicious lesions occurred, with 36.4% (16/44) being invasive cancer and 6.8% (3/44) being DCIS. Thus, 6.6% (19/286) of all women developed malignancy during follow-up after a median follow-up interval of 6.5 years (range: 31-119 months). The initial histology of the B3 lesion influenced the subsequent occurrence of a malignant lesion during follow-up (p < 0.038). The highest malignancy-developing rate was observed in atypical ductal hyperplasia (ADH) (24%, 19/79), while all other B3-lesions had malignant findings ipsi- and contralateral between 0% and 6%. The results were not influenced by the VAB method (Mx-, US-, magnetic resonance imaging-guided), the radiological characteristics of the lesion, or the age or menopausal status of the patient (p > 0.12).

Conclusion

With a low risk of <6% of developing malignancy, VAB followed by long-term follow-up is a safe alternative to OE for most B3-lesions. A higher malignancy rate only occurred in ADH (24%). Based on our results, radiological follow-up should be bilateral, preferable using the technique of initial diagnosis. As we observed a late peak (6-7 years) of breast malignancies after B3-lesions, follow-up should be continued for a longer period (>10 years). Knowledge of these long-term outcome results will be helpful in making treatment decisions and determining the optimal radiological follow-up interval.

Vacuum-assisted excision biopsy for definitive diagnosis of breast lesions of uncertain malignant potential (B3 lesions) on core biopsy - A single centre Western Australian experience

INTRODUCTION

In Australia, the usual approach to breast lesions where core biopsy returns an uncertain result ("B3" breast lesion) is to perform surgical diagnostic open biopsy (DOB). This is associated with patient time off work, costs of hospital admission, risks of general anaesthesia and surgical complications. The majority of B3 lesions return benign results following surgery. Vacuum assisted excision biopsy (VAEB) is a less invasive, lower cost alternative, and is standard of care for selected B3 lesions in the United Kingdom. Similar use of VAEB in Australia, could save many women unnecessary surgery. The aim of this study was to document our experience during the introduction of VAEB as an alternative to DOB for diagnosis of selected B3 lesions.

METHODS

The multidisciplinary team developed an agreed VAEB pathway for selected B3 lesions. Technically accessible papillary lesions, mucocele-like lesions and radial scars without atypia measuring ≤ 15mm were selected.

RESULTS

Over a 7 month period, 18 women with 20 B3 lesions were offered VAEB. 16 women (18 lesions) chose VAEB over DOB. Papillomas were the commonest lesion type. All lesions were successfully sampled: 17/18 were benign. One lesion (6%) was upgraded to malignancy (ductal carcinoma in situ on VAEB, invasive ductal carcinoma at surgery). No major complications occurred. Patient satisfaction was high: 15/16 respondents would again choose VAEB over surgery.

CONCLUSION

VAEB is a patient-preferred, safe, well-tolerated, lower-cost alternative to DOB for definitive diagnosis of selected B3 breast lesions.

Factors Indicating Surgical Excision in Classical Type of Lobular Neoplasia of the Breast

PURPOSE

Classical type of lobular neoplasia (LN) encompassing both atypical lobular hyperplasia and classical lobular carcinoma in situ of the breast is a lesion with uncertain malignant potential and has been the topic of several studies with conflicting outcome results. The aim of our study was to clarify outcome-relevant factors and treatment options of classical LN.

METHODS

We performed a pathological re-evaluation of the preoperative biopsy specimens and a retrospective clinical and radiological data analysis of 160 patients with LN from the Breast Center Zurich. Open surgery was performed in 65 patients, vacuum-assisted biopsy (VAB) in 79 patients, and surveillance after breast core needle biopsy (CNB) in 16 patients.

RESULTS

The upgrade rate into ductal carcinoma in situ/invasive cancer was the highest in case of imaging/histology discordance (40%). If the number of foci in the biopsy specimen was ≥3, the upgrade rate in the consecutive surgical specimens was increased (p = 0.01). The association of classical LN with histological microcalcification correlated with shortened disease-free survival (p < 0.01), whereas other factors showed no impact on follow-up.

CONCLUSIONS

Surveillance or subsequent VAB after CNB of LN is sufficient in most cases. Careful consideration of individual radiological and histological factors is required to identify patients with a high risk of upgrade into malignancy. In those cases, surgical excision is indicated.

Atypical Ductal Hyperplasia after Vacuum-Assisted Breast Biopsy: Can We Reduce the Upgrade to Breast Cancer to an Acceptable Rate?

(1) Background: to evaluate which factors can reduce the upgrade rate of atypical ductal hyperplasia (ADH) to in situ or invasive carcinoma in patients who underwent vacuum-assisted breast biopsy (VABB) and subsequent surgical excision. (2) Methods: 2955 VABBs were reviewed; 141 patients with a diagnosis of ADH were selected for subsequent surgical excision. The association between patients’ characteristics and the upgrade rate to breast cancer was evaluated in both univariate and multivariate analyses. (3) Results: the upgrade rates to ductal carcinoma in situ (DCIS) and invasive carcinoma (IC) were, respectively, 29.1% and 7.8%. The pooled upgrade rate to DCIS or IC was statistically lower at univariate analysis, considering the following parameters: complete removal of the lesion (p-value < 0.001); BIRADS ≤ 4a (p-value < 0.001); size of the lesion ≤15 mm (p-value: 0.002); age of the patients <50 years (p-value: 0.035). (4) Conclusions: the overall upgrade rate of ADH to DCIS or IC is high and, as already known, surgery should be recommended. However, ADH cases should always be discussed in multidisciplinary meetings: some parameters appear to be related to a lower upgrade rate. Patients presenting these parameters could be strictly followed up to avoid overtreatment.

Breast lesions excised via vacuum-assisted system: could we get any clues for B3 lesions before excision biopsy?

Background

The purpose of this study was to determine the validity of the ultrasound features as well as patient characteristics assigned to B3 (uncertain malignant potential) breast lesions before vacuum-assisted excision biopsy (VAEB).

Methods

This study population consisted of 2245 women with breast-nodular abnormalities, which were conducted ultrasound-guided VAEB (US-VAEB). Patient’s clinical and anamnestic data and lesion-related ultrasonic feature variables of B3 captured before US-VAEB were compared with those of benign or malignant cases, using histopathological results as a benchmark.

Results

The proportions of benign, B3 and malignant breast lesions diagnosed post-US-VAEB were 88.5, 8.2 and 3.4% respectively. B3 high frequent occurred in BI-RADS-US grade 3 (7.7%), grade 4a (11.0%) and grade 4b (9.1%). The overall malignancy underestimation rate of B3 was 4.4% (8/183). Malignant lesions were found mostly in the range of BI-RADS grade 4b (27.3%), grade 4c (33.3%) and grade 5 (100%). Multivariate binary logistic regression analyses (B3 vs benign) showed that non-menopausal patients (95% CI 1.628–8.616, P = 0.002), single (95% CI 1.370–2.650, P = 0.000) or vascularity (95% CI 1.745–4.150, P = 0.000) nodules in ultrasonic features were significant risk factors for B3 occurrences. In addition, patients elder than 50 years (95% CI 3.178–19.816, P = 0.000), unclear margin (95% CI 3.571–14.119, P = 0.000) or suspicious calcification (95% CI 4.010–30.733, P = 0.000) lesions were significantly associated with higher risks of malignant potentials for B3 cases (malignant vs B3).

Conclusion

The results of this study indicate that ultrasound findings and patients’ characteristics might provide valuable information for distinguishing B3 lesions from benign breast abnormalities before VAEB, and help to reduce malignancy underestimation of B3.

Value of stereotactic 11-gauge vacuum-assisted breast biopsy in non-palpable suspicious calcifications: an eight-year single institution experience with 587 patients

Background

Vacuum-assisted breast biopsy (VABB) has been routinely recommended for stereotactic intervention in cases of isolate mammographically-detected calcifications. Herein we aimed to evaluate and compare the diagnostic consistency and accuracy of calcified and noncalcified specimens obtained from same sites of sampling on mammography-visible calcifications. In addition, we presented the biopsy procedure and retrospectively evaluated the usefulness of VABB as well as the complications of this technique over an eight-year experience in our centre.

Methods

This single-institution observational cohort study included 587 patients referred for stereotactic 11-gauge VABB of 594 mammographically-detected calcifications between January 2010 and December 2018. The rate of histopathological underestimation, the false negative, the diagnostic consistency and accuracy between calcified and noncalcified specimens of VABB were comprehensively evaluated based on the surveillance data and final histopathological result of the surgical specimens.

Results

In total, 594 biopsy procedures were performed in 587 patients (mean age 46 years, range, 21-80 years). The average number of biopsy specimens was 14.7 (range, 9-21) per lesion. VABB pathological results revealed 471 (79.3%) benign, 39 (6.6%) high-risk, and 84 (14.1%) malignant cases. The diagnostic inconsistency between calcified and noncalcified specimens was 14.6% (105/123) for high-risk and malignant lesions. Furthermore, calcified specimens exhibited higher diagnostic accuracy of malignant lesion as compared with the noncalcified specimens (97.7% versus 82.6%, respectively). Underestimation rate for high-risk lesions and in situ carcinoma was 5.1% and 54.1%, respectively, along with a false negative rate of 6.25%. In addition, mild complications were reported with high patient tolerance.

Conclusions

Stereotactic 11G-VABB might be preferred for the investigation of non-palpable mammographically-detected calcifications in terms of accuracy and safety profile. The high prevalence of diagnostic discordance between the specimens with and without calcifications revealed a higher value of calcified specimens in diagnosing high-risk and malignant calcifications.

Canine mammary tumours: Size matters-a progression from low to highly malignant subtypes

The purpose of this study was to evaluate a possible association between mammary tumour size and increasing degree of malignancy. Data of 625 dogs with a total of 1459 mammary tumours were analysed retrospectively. 80.3% dogs were intact, mean age at diagnosis was 9.7 ± 2.5 years, 75.8% were pure breed dogs. Median body weight was 20.0 kg. Malignant tumours (n = 580) were significantly larger than their benign counterparts (1.94 cm vs 0.90 cm in mean, respectively; P ≤ .0001), resulting in a positive correlation between increasing tumour size and a change from benign to malignant (P ≤ .0001; r_s  = 0.214). When malignant tumours were grouped into four degrees of increasing malignancy (complex/simple/solid/anaplastic carcinomas) a significant positive correlation between increasing tumour size and more malignant tumour degree (P ≤ .0001; r_s  = 0.195) could be demonstrated. In a number of cases, highly malignant tumours were found to arise within less malignant lesions, supporting the concept of a further progression within the malignant tumour subtypes. In patients with multiple tumours, mean tumour sizes for malignant tumours were significantly smaller compared to patients with only one tumour (1.67 vs 2.71 cm in mean, respectively; P < .0001). These findings suggest that mammary tumours progress not only from benign to malignant but also from low to highly malignant. An increase in diameter of only a few millimetres may therefore have a big impact on the patient's outcome.

Role of vacuum assisted excision in minimising overtreatment of ductal atypias

PURPOSE

B3 lesions are indeterminate lesions of uncertain malignant potential. They include lesions with and without epithelial atypia. Those with atypia include atypical intraductal epithelial proliferation (AIDEP)/atypical ductal hyperplasia (ADH) and flat epithelial atypia (FEA). They are traditionally managed with surgery. Vacuum assisted excision (VAE) allows larger samples to be obtained using a vacuum assisted biopsy (VAB) device, which equates to a surgical biopsy. We propose that VAE and mammographic surveillance is a safe alternative to surgery in managing the ductal atypias; (AIDEP/ADH and FEA).

METHOD

Retrospective analysis of prospectively collected data on B3 lesions (April 2009 - March 2016) from consecutive breast screening patients diagnosed with AIDEP/ADH or FEA on initial diagnostic core biopsy. Mammographic abnormality, breast density, size, management pathway and upgrade to cancer and types of cancer were also collected during the treatment pathway and 5 year surveillance period (April 2009 - April 2019).

RESULTS

273 cases of ductal atypia were identified. 187/273 (68.5 %) cases were managed with VAE only as no upgrade to malignancy and then 5 year mammographic surveillance. 34/273 (12.5 %) cases had a VAE diagnosing malignancy. 24/273 (8.8 %) cases had a VAE and then a surgical biopsy due to radiological or pathological concern, 8/24 upgraded to malignancy. 22/273 (8%) cases had a surgical diagnostic biopsy, 9/22 (41 %) cases were upgraded to malignancy. In total 51/273 (19 %) cases were diagnosed with cancer on the new pathway (13 invasive (all ER positive and Her2 negative) and 38 non-invasive, (34 ductal carcinoma in situ (DCIS) and 4 cases of lobular carcinoma in situ (LCIS)). While 17/273 (6.2 %) cases developed malignancy (12 invasive (all HER2 negative) and 4 DCIS and 1 LCIS) during the 5 year surveillance period.

CONCLUSIONS

VAE is a safe alternative to surgery in managing ductal atypias. 187/273 (68.5 %) women avoided surgery. While 34/51 cancers (66.7 %) were diagnosed preoperatively using VAE, allowing the women to have a single therapeutic procedure.

Three-year Trends in Diagnosis of B3 Breast Lesions and Their Upgrade Rates to Malignant Lesions

BACKGROUND

B3 breast lesions are a heterogeneous group with uncertain malignant potential and, as such, provide a source of diagnostic difficulty. We calculated the prevalence of B3 lesions at our center along with the upgrade rates (positive predictive value) to in situ or invasive malignancy.

MATERIALS AND METHODS

We searched our pathology database over a 3-year period to include all B3 biopsies. The subsequent excision for each biopsy was reviewed, and the rate of upgrade was calculated by subtype. These results were compared against data published in large United Kingdom studies.

RESULTS

A total of 9206 breast biopsies were identified, of which 614 (6.7%) were classified as B3. Lesions displaying epithelial atypia were the most common subtype of lesion, with a prevalence of 39.6%. Lesions displaying epithelial atypia were upgraded to malignancy in 35.7% of cases. Among non-atypical cases, papillary lesions were the most common diagnosis (32.1%) with an upgrade rate of 2%. In situ lobular neoplasia (10.4%) was the third most frequently encountered diagnosis, and was upgraded to malignancy in 10.9% of cases. The upgrade rate in the remaining non-atypical lesions was invariably low (0%-2.6%).

CONCLUSIONS

Herein, we have shown an overall B3 rate in keeping with published data, whereas lesions displaying epithelial atypia showed upgrade rates to malignancy comparable with that of large United Kingdom studies. In our study, lesions without epithelial atypia showed very low rates of upgrade. A wide range of upgrade rates is seen in cases of lobular neoplasia, which highlights the need for uniformity of nomenclature and reporting within this subtype to accurately ascertain the true risk of upgrade associated with these lesions.

Upgrade Rate of Percutaneously Diagnosed Pure Atypical Ductal Hyperplasia: Systematic Review and Meta-Analysis of 6458 Lesions

Background Management of percutaneously diagnosed pure atypical ductal hyperplasia (ADH) is an unresolved clinical issue. Purpose To calculate the pooled upgrade rate of percutaneously diagnosed pure ADH. Materials and Methods A search of MEDLINE and EMBASE databases was performed in October 2018. Preferred Reporting Items for Systematic Reviews and Meta-Analyses, or PRISMA, guidelines were followed. A fixed- or random-effects model was used, along with subgroup and meta-regression analyses. The Newcastle-Ottawa scale was used for study quality, and the Egger test was used for publication bias. Results Of 521 articles, 93 were analyzed, providing data for 6458 ADHs (5911 were managed with surgical excision and 547 with follow-up). Twenty-four studies used core-needle biopsy; 44, vacuum-assisted biopsy; 21, both core-needle and vacuum-assisted biopsy; and four, unspecified techniques. Biopsy was performed with stereotactic guidance in 29 studies; with US guidance in nine, with MRI guidance in nine, and with mixed guidance in eight. Overall heterogeneity was high (I² = 80%). Subgroup analysis according to management yielded a pooled upgrade rate of 29% (95% confidence interval [CI]: 26%, 32%) for surgically excised lesions and 5% (95% CI: 4%, 8%) for lesions managed with follow-up (P < .001). Heterogeneity was entirely associated with surgically excised lesions (I² = 78%) rather than those managed with follow-up (I² = 0%). Most variability was explained by guidance and needle caliper (P = .15). At subgroup analysis of surgically excised lesions, the pooled upgrade rate was 42% (95% CI: 31%, 53%) for US guidance, 23% (95% CI: 19%, 27%) for stereotactic biopsy, and 32% (95% CI: 22%, 43%) for MRI guidance, with heterogeneity (52%, 63%, and 56%, respectively) still showing the effect of needle caliper. When the authors considered patients with apparent complete lesion removal after biopsy (subgroups in 14 studies), the pooled upgrade rate was 14% (95% CI: 8%, 23%). Study quality was low to medium; the risk of publication bias was low (P = .10). Conclusion Because of a pooled upgrade rate higher than 2% (independent of biopsy technique, needle size, imaging guidance, and apparent complete lesion removal), atypical ductal hyperplasia diagnosed with percutaneous needle biopsy should be managed with surgical excision. © RSNA, 2019 Online supplemental material is available for this article. See also the editorial by Brem in this issue.

Gail Model Underestimates Breast Cancer Risk in Thai Population

Background: The Gail model is the most widely used method for breast cancer risk estimation. This model has been studied and verified for its validity in many groups but there has yet to be a study to validate the Gail model in a Thai population. This study aims to evaluate whether the Gail model can accurately calculate the risk of breast cancer among Thai women. Methods: The subjects were recruited from the Division of Head, Neck, and Breast Surgery, Department of Surgery, Siriraj Hospital. The patients attending the division were asked to enroll in the study and complete questionnaires. Gail model scores were then calculated. Relationships between parameters were examined using the Pearson’s chi-square test, Fisher’s exact test, and independent-samples t-test. Results: There were 514 women recruited. Age, parity, age at first-live birth, and history of atypical ductal hyperplasia (ADH) were significant risk factors for breast cancer. The 5-year and lifetime risk score for breast cancer calculated by the Gail model were not significantly different between the patient and the control subjects. The proportions of the subjects with lifetime risk ≥20% were significantly higher in breast cancer patients (p=0.049). Conclusion: The Gail model underestimated the risk of breast cancer in Thai women. Calibration of the model is still required before adoption in Thai population.

An audit of mammographic screen detected lesions of uncertain malignant potential (B3) diagnosed on initial image guided needle biopsy: how has our practice changed over 10 years?

AIM

To review all cases of B3 lesion diagnosed at initial image-guided needle biopsy over two 5-year cohorts to identify upgrade rates to malignancy and the effect of changing guidance on the management of such lesions.

MATERIALS AND METHODS

Data was collected retrospectively. Mammographic features, biopsy type and management were recorded for each lesion. Upgrade rates for each B3 histological category were quantified. Statistical analysis was performed using SPSS.

RESULTS

There were 224 cases in 2005-2010 and 240 cases in 2010-2015. Mammographically 211 lesions were microcalcifications, 182 masses, 65 distortions and six asymmetric densities with no difference in the mammographic features in the two cohorts. Two hundred and eight 14 G core biopsies and 256 initial vacuum-assisted biopsies were performed. There was a statistically significant reduction in benign surgical biopsies and an increase in second-line vacuum biopsy/excision in the latter cohort, with no significant change in the upgrade rate. There was an overall 6% upgrade to invasive malignancy and 13% upgrade to ductal carcinoma in situ (DCIS). The upgrade rates for the following histological categories were atypical intraductal epithelial proliferation (AIDEP) 33.2% (21/63); classical (not pleomorphic) in situ lobular neoplasia (ISLN) 18.2% (6/33); flat epithelial hyperplasia (FEA) 21.7% (20/92); papilloma with atypia 53.8% (7/13), without atypia 12.1% (8/66); and radial scar/complex sclerosing lesion with atypia 16.7% (2/12), and without atypia 7.9% (6/76).

CONCLUSION

Upgrade rates remain high for some histological categories even with first-line use of vacuum biopsy. Management of borderline lesions should be considered carefully in a multidisciplinary meeting. In many cases, the need for diagnostic surgical excision has been replaced by image-guided vacuum sampling.

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

Purpose

The second International Consensus Conference on B3 lesions was held in Zurich, Switzerland, in March 2018, organized by the International Breast Ultrasound School to re-evaluate the consensus recommendations.

Methods

This study (1) evaluated how management recommendations of the first Zurich Consensus Conference of 2016 on B3 lesions had influenced daily practice and (2) reviewed current literature towards recommendations to biopsy.

Results

In 2018, the consensus recommendations for management of B3 lesions remained almost unchanged: For flat epithelial atypia (FEA), classical lobular neoplasia (LN), papillary lesions (PL) and radial scars (RS) diagnosed on core-needle biopsy (CNB) or vacuum-assisted biopsy (VAB), excision by VAB in preference to open surgery, and for atypical ductal hyperplasia (ADH) and phyllodes tumors (PT) diagnosed at VAB or CNB, first-line open surgical excision (OE) with follow-up surveillance imaging for 5 years. Analyzing the Database of the Swiss Minimally Invasive Breast Biopsies (MIBB) with more than 30,000 procedures recorded, there was a significant increase in recommending more frequent surveillance of LN [65% in 2018 vs. 51% in 2016 (p = 0.004)], FEA (72% in 2018 vs. 62% in 2016 (p = 0.005)), and PL [(76% in 2018 vs. 70% in 2016 (p = 0.04)] diagnosed on VAB. A trend to more frequent surveillance was also noted also for RS [77% in 2018 vs. 67% in 2016 (p = 0.07)].

Conclusions

Minimally invasive management of B3 lesions (except ADH and PT) with VAB continues to be appropriate as an alternative to first-line OE in most cases, but with more frequent surveillance, especially for LN.

Review on current treatment options for lesions of uncertain malignant potential (B3 lesions) of the breast: do B3 papillary lesions need to be removed in any case by open surgery?

BACKGROUND

In breast tissue, pre-malignant lesions are classified as BIRADS 3. The treatment of this heterogeneous group varies with expertise and tools available.

MATERIALS AND METHODS

With the example of two case reports, the literature is reviewed on current treatment options for BIRADS 3 breast lesions.

RESULTS

About 7% of all B-type breast biopsies fall into the B3 category. Approximately 35% of these B3 lesions are due to FEA, 20% to PLs and another 20% to ADH. Due to improvement in diagnostics, the incidence is increasing, while their value as a predictive factor for malignancy has steadily been fallen.

CONCLUSION

Depending on the histology of the needle biopsy, a complete resection with vacuum-assisted biopsy may be a treatment alternative to open biopsy.

Atypical Ductal Lesions of the Breast: Criteria, Significance, and Laboratory Updates

Context.—

Atypical ductal hyperplasia (ADH) is a challenging diagnosis defined by cytologic and architectural features that carries an increased risk of subsequent carcinoma when diagnosed in isolation. In addition, ADH may secondarily involve benign breast lesions, wherein it carries variable clinical significance.

Objectives.—

To review the diagnostic criteria and clinical significance of ADH in isolation and as it involves benign breast lesions, and to review the evolving literature on its molecular signature.

Data Sources.—

Recently published studies that collectively examine ADH were reviewed.

Conclusions.—

Atypical ductal hyperplasia carries an increased risk of subsequent carcinoma in isolation and when it involves most benign breast lesions. Identifying which cases of ADH will be upgraded to carcinoma has been challenging, and new laboratory developments, such as EZH2 overexpression, may have a future role.

How Do We Approach Benign Proliferative Lesions?

PURPOSE OF REVIEW

The aim of this review is to summarize recently published literature addressing atypical ductal hyperplasia (ADH), lobular neoplasia (atypical lobular hyperplasia [ALH] and classic lobular carcinoma in situ [C-LCIS]), non-classic lobular carcinoma in situ (NC-LCIS), papillary lesions, and flat epithelial atypia (FEA).

RECENT FINDINGS

While ADH, ALN, and C-LCIS are well-established markers of an increased risk of future breast cancers, the risk implications are less clear for papillary lesions and FEA. NC-LCIS is the least well-characterized lesion, with scant published literature on its natural history and surgical management when encountered on needle biopsy. Recent data suggest that lobular neoplasia on core biopsy of a BI-RADS ≤ 4 concordant lesion does not require an excision, while ADH, atypical papillomas, and NC-LCIS should be excised. Evidence on FEA and papillomas without atypia suggests a low risk of upgrade on excision, and prospective studies on the upgrade of these lesions are ongoing.

Vacuum assisted breast biopsy (VAB) excision of subcentimeter microcalcifications as an alternative to open biopsy for atypical ductal hyperplasia

OBJECTIVE

Atypical ductal hyperplasia (ADH) is a proliferative lesion associated with a variable increased risk of breast malignancy, but the management of the patients is still not completely defined, with mandatory surgical excision in most cases. To report the results of the conservative management with mammographic checks of patients with ADH diagnosed by vacuum assisted breast biopsy (VAB), without residual calcifications.

METHODS

The authors accessed the institutional database of radiological, surgical and pathological anatomy. Inclusion criteria were: ADH diagnosed by VAB on a single group of microcalcifications, without residual post-procedure; follow-up at least of 12 months. Exclusion criteria were the presence of personal history of breast cancer or other high-risk lesions; association with other synchronous lesions, both more and less advanced proliferative lesions.

RESULTS

The 65 included patients were all females, with age range of 40-79 years (mean 54 years). The maximum diameter range of the groups of microcalcifications was 4-11 mm (mean 6.2 mm), all classified as BI-RADS 4b (Breast Imaging Reporting and Data System 4b) and defined as fine pleomorphic in 29 cases (45%) or amorphous in 36 cases (55%). The range of follow-up length was 12-156 months (mean 67 months). Only one patients developed new microcalcifications, in the same breast, 48 months after and 15 mm from the first VAB, interpreted as low-grade ductal carcinoma in situ (DCIS) at surgical excision.

CONCLUSION

These results could justify the conservative management, in a selected group of patients, being the malignancy rate lower than 2%, considered in the literature as the "probably benign" definition. Advances in knowledge: Increasing the length of follow-up of selected patients conservatively managed can improve the management of ADH cases.

Current Concepts in Diagnosis, Molecular Features, and Management of Lobular Carcinoma In Situ of the Breast With a Discussion of Morphologic Variants

Context.—

Lobular carcinoma in situ (LCIS) refers to a neoplastic proliferation of cells that characteristically shows loss of E-cadherin expression and has long been regarded as a risk factor for invasive breast cancer. Long-term outcome studies and molecular data have also implicated LCIS as a nonobligate precursor to invasive carcinoma. In the past few decades, pleomorphic and florid LCIS have been recognized as morphologic variants of LCIS with more-aggressive histopathologic features, less-favorable biomarker profiles, and more-complex molecular features compared with classic LCIS. There is still a lack of consensus regarding certain aspects of managing patients with LCIS.

Objectives.—

To review recently published literature on LCIS and to provide an overview of the current morphologic classification of LCIS, recent molecular advances, and trends in patient management.

Data Sources.—

Sources included peer-reviewed, published journal articles in PubMed (US National Library of Medicine, Bethesda, Maryland) and published guidelines from the National Comprehensive Cancer Network (Fort Washington, Pennsylvania).

Conclusions.—

Lobular carcinoma in situ represents a marker for increased risk of breast cancer, as well as a nonobligate precursor to invasive carcinoma. Morphologic variants of LCIS—florid and pleomorphic LCIS—are genetically more-complex lesions and are more likely to be associated with invasive carcinoma. Further investigation into which molecular alterations in LCIS are associated with progression to invasive carcinoma is needed to help guide medical and surgical management.

Atypical ductal hyperplasia: Our experience in the management and long term clinical follow-up in 71 patients

INTRODUCTION

Atypical ductal hyperplasia (ADH) is a high-risk benign lesion found in approximately 1-10% of breast biopsies and associated with a variable incidence of carcinoma after surgical excision. The main goal of our study is to present our experience in the management and long-term follow-up of 71 patients with ADH diagnosed on breast biopsy.

MATERIALS AND METHODS

Results of 3808 breast biopsy specimens from 1 January 2000 to 31 December 2005 were analyzed to identify all biopsies which resulted in a diagnosis of ADH. The histopathological results of the 45 patients who underwent surgery were analyzed. Long-term follow-up for the remaining patients was carried out.

RESULTS

45 of 71 (63.4%) patients with histological diagnosis of ADH on breast biopsy underwent surgery. Definitive histological results revealed invasive carcinoma in 7 cases (15.6%), high grade Ductal Carcinoma in situ (DCIS) in 10 (22.2%) patients, Lobular Carcinoma in situ (LCIS) in 4 cases (8.9%) and benign findings in 24 cases (53.3%). 12 of 71 (16.9%) patients underwent only long term follow-up; one (8,3%) of these developed invasive breast carcinoma after 6 years.

CONCLUSION

Atypical ductal hyperplasia diagnosed on breast biopsy is associated with a relatively high incidence of invasive carcinoma and high grade ductal carcinoma in situ at the time of surgical excision. Certain radiological and cytological criteria can be used to help determine which patients should forgo surgery and be followed up with good results. Long term follow-up is always crucial for patients who have not undergone surgery.

Characteristics of a Breast Pathology Consultation Practice

CONTEXT

- Intradepartmental consultation is a routine practice commonly used for new diagnoses. Expert interinstitutional case review provides insight into particularly challenging cases.

OBJECTIVE

- To investigate the practice of breast pathology consultation at a large tertiary care center.

DESIGN

- We reviewed breast pathology cases sent for private consultation and internal cases reviewed by multiple pathologists at a tertiary center. Requisitions and reports were evaluated for diagnostic reason for consultation, rate of multiple pathologist review at the tertiary center, use of immunohistochemistry, and, for private consultation cases, type of sender and concordance with the outside diagnosis.

RESULTS

- In the 985 private consultation cases, the most frequent reasons for review were borderline atypia (292 of 878; 33.3%), papillary lesion classification (151 of 878; 17.2%), evaluating invasion (123 of 878; 14%), subtyping carcinoma (75 of 878; 8.5%), and spindle cell (67 of 878; 7.6%) and fibroepithelial (65 of 878; 7.4%) lesion classification. Of 4981 consecutive internal cases, 358 (7.2%) were reviewed, most frequently for borderline atypia (90 of 358; 25.1%), subtyping carcinoma (63 of 358; 17.6%), staging/prognostic features (59 of 358; 16.5%), fibroepithelial lesion classification (45 of 358; 12.6%), evaluating invasion (37 of 358; 10.3%), and papillary (20 of 358; 5.6%) and spindle cell (18 of 358; 5.0%) lesion classification. Of all internal cases, those with a final diagnosis of atypia had a significantly higher rate of review (58 of 241; 24.1%) than those with benign (119 of 2933; 4.1%) or carcinoma (182 of 1807; 10.1%) diagnoses. Immunohistochemistry aided in diagnosis of 39.7% (391 of 985) and 21.2% (76 of 359) of consultation and internally reviewed cases, respectively.

CONCLUSIONS

- This study confirms areas of breast pathology that represent diagnostic challenge and supports that pathologists are appropriately using expert consultation.

The B3 conundrum-the radiologists' perspective

The management of B3 lesions is both controversial and complicated. There have been recent publications regarding how best to manage this heterogeneous group particularly in light of the Marmot Review and with the advent of vacuum-assisted biopsy technique. It is recognized that B3 lesions on core biopsy can be upgraded to malignancy in up to one-third of cases, but this is predominantly to ductal carcinoma in situ or low-grade invasive tumours. The upgrade rate is mainly associated with B3 lesions with epithelial atypia. This review summarizes the current management and focuses on the proposed future management of these B3 lesions.