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Rella R, Conti M, Borghetti A, Belli P, Morciano F, Rossati C, Caneva A, Di Leone A, Franceschini G, Gori E, Fornasa F, Tommasini O, Romanucci G. Atypical ductal hyperplasia on vacuum-assisted breast biopsy: a scoring system to predict the risk of upgrade to malignancy. LA RADIOLOGIA MEDICA 2024; 129:38-47. [PMID: 37874442 PMCID: PMC10808485 DOI: 10.1007/s11547-023-01740-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 10/05/2023] [Indexed: 10/25/2023]
Abstract
RATIONALE AND OBJECTIVES Our multicentric study analysed clinical, radiologic and pathologic features in patients with atypical ductal hyperplasia (ADH) diagnosed with vacuum-assisted biopsy (VAB), to identify factors associated with the risk of upgrade, to develop a scoring system to support decision making. MATERIALS AND METHODS Patients with ADH on VAB under stereotactic/tomosynthesis guidance (2012-2022) were eligible. Inclusion criteria were availability of surgical histopathological examination of the entire lesion or radiologic follow-up (FUP) ≥ 24 months. VAB results were compared with surgical pathological results or with imaging FUP evolution to assess upgrade. A backward stepwise linear regression was used to identify predictors of upgrade. The discriminatory power of the model was calculated through the area under the receiver operating curve (ROC-AUC); the Hosmer-Lemeshow test was used to assess model calibration. The points system was developed based on the selected risk factors, and the probability of upgrade associated with each point total was determined. RESULTS 112 ADH lesions were included: 91 (91/112, 81.3%) underwent surgical excision with 20 diagnosis of malignancy, while 21 (21/112, 18.7%) underwent imaging FUP with one interval change (mean FUP time 48 months). Overall upgrade rate was 18.7% (21/112). Age, menopausal status, concurrent breast cancer, BIRADS classification and number of foci of ADH were identified as risk factors for upgrade. Our model showed an AUC = 0.85 (95% CI 0.76-0.94). The points system showed that the risk of upgrade is < 2% when the total score is ≤ 1. CONCLUSION Our scoring system seemed a promising easy-to-use decision support tool for management of ADH, decreasing unnecessary surgeries, reducing patients' overtreatment and healthcare costs.
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Affiliation(s)
- Rossella Rella
- UOC Diagnostica per Immagini, Ospedale G.B. Grassi, Via Gian Carlo Passeroni, 28, 00122, Rome, Italy
| | - Marco Conti
- UOC di Radiologia Toracica e Cardiovascolare, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli 8, 00168, Rome, Italy.
| | - Alberto Borghetti
- UOC Malattie Infettive, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli 8, 00168, Rome, Italy
| | - Paolo Belli
- UOC di Radiologia Toracica e Cardiovascolare, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli 8, 00168, Rome, Italy
- Facoltà di Medicina e Chirurgia, Università Cattolica Sacro Cuore, Largo F. Vito 1, 00168, Rome, Italy
| | - Francesca Morciano
- Facoltà di Medicina e Chirurgia, Università Cattolica Sacro Cuore, Largo F. Vito 1, 00168, Rome, Italy
| | - Claudia Rossati
- UOSD Breast Unit ULSS9, Ospedale di Marzana, Piazzale Lambranzi, 1, 37142, Verona, Italy
| | - Andrea Caneva
- Divisione di Patologia, ULSS9 Scaligera, Ospedale G. Fracastoro, San Bonifacio, 37047, Verona, Italy
| | - Alba Di Leone
- Multidisciplinary Breast Centre, Dipartimento Scienze della Salute della Donna e del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168, Rome, Italy
| | - Gianluca Franceschini
- Multidisciplinary Breast Centre, Dipartimento Scienze della Salute della Donna e del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168, Rome, Italy
| | - Elisabetta Gori
- Facoltà di Medicina e Chirurgia, Università Cattolica Sacro Cuore, Largo F. Vito 1, 00168, Rome, Italy
| | - Francesca Fornasa
- UOSD Breast Unit ULSS9, Ospedale di Marzana, Piazzale Lambranzi, 1, 37142, Verona, Italy
| | - Oscar Tommasini
- UOC Diagnostica per Immagini, Ospedale G.B. Grassi, Via Gian Carlo Passeroni, 28, 00122, Rome, Italy
| | - Giovanna Romanucci
- UOSD Breast Unit ULSS9, Ospedale di Marzana, Piazzale Lambranzi, 1, 37142, Verona, Italy
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2
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Fraker JL, Clune CG, Sahni SK, Yaganti A, Vegunta S. Prevalence, Impact, and Diagnostic Challenges of Benign Breast Disease: A Narrative Review. Int J Womens Health 2023; 15:765-778. [PMID: 37223067 PMCID: PMC10202205 DOI: 10.2147/ijwh.s351095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 05/05/2023] [Indexed: 05/25/2023] Open
Abstract
Benign breast diseases, which are commonly seen in clinical practice, have various clinical presentations and implications, as well as management strategies. This article describes common benign breast lesions, presentations of these lesions, and typical radiographic and histologic findings. Also included in this review are the most recent data and guideline-based recommendations for the management of benign breast diseases at diagnosis, including surgical referral, medical management, and ongoing surveillance.
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Affiliation(s)
- Jessica L Fraker
- Division of Women’s Health Internal Medicine, Mayo Clinic, Scottsdale, AZ, USA
| | - Caroline G Clune
- Center for Breast Care, Mayo Clinic Health System — Southwest Wisconsin Region, La Crosse, WI, USA
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Sabrina K Sahni
- Jacoby Center for Breast Health, Mayo Clinic, Jacksonville, FL, USA
| | - Avani Yaganti
- Southern Illinois University School of Medicine, Springfield, IL, USA
| | - Suneela Vegunta
- Division of Women’s Health Internal Medicine, Mayo Clinic, Scottsdale, AZ, USA
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Sanford MF, Slanetz PJ, Lewin AA, Baskies AM, Bozzuto L, Branton SA, Hayward JH, Le-Petross HT, Newell MS, Scheel JR, Sharpe RE, Ulaner GA, Weinstein SP, Moy L. ACR Appropriateness Criteria® Evaluation of Nipple Discharge: 2022 Update. J Am Coll Radiol 2022; 19:S304-S318. [PMID: 36436958 DOI: 10.1016/j.jacr.2022.09.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 09/07/2022] [Indexed: 11/27/2022]
Abstract
The type of nipple discharge dictates the appropriate imaging study. Physiologic nipple discharge is common and does not require diagnostic imaging. Pathologic nipple discharge in women, men, and transgender patients necessitates breast imaging. Evidence-based guidelines were used to evaluate breast imaging modalities for appropriateness based on patient age and gender. For an adult female or male 40 years of age or greater, mammography or digital breast tomosynthesis (DBT) is performed initially. Breast ultrasound is usually performed at the same time with rare exception. For males or females 30 to 39 years of age, mammography/DBT or breast ultrasound is performed based on institutional preference and individual patient considerations. For young women less than 30 years of age, ultrasound is performed first with mammography/DBT added if there are suspicious findings or if the patient is at elevated lifetime risk for developing breast cancer. There is a high incidence of breast cancer in males with pathologic discharge. Men 25 years and older should be evaluated using mammography/DBT and ultrasound added when indicted. In transfeminine (male-to-female) patients, mammography/DBT and ultrasound are useful due to the increased incidence of breast cancer. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer-reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer-reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.
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Affiliation(s)
- Matthew F Sanford
- Lead Interpreting Physician, Sanford Health of Northern Minnesota, Bemidji, Minnesota.
| | - Priscilla J Slanetz
- Panel Chair, Boston University School of Medicine, Boston, Massachusetts; Vice Chair, Academic Affairs, Department of Radiology, Associate Program Director, BMC Diagnostic Radiology Residency and Program Director, Academic Writing Program Boston Medical Center, Boston, Massachusetts
| | - Alana A Lewin
- Panel Vice-Chair, New York University School of Medicine, New York, New York
| | - Arnold M Baskies
- Virtua Willingboro Hospital, Willingboro, New Jersey; American College of Surgeons; Clinical Professor, Surgery, Rowan School of Medicine, Stratford, New Jersey
| | - Laura Bozzuto
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin; American College of Obstetricians and Gynecologists
| | - Susan A Branton
- Medical Directo, Breast Health Center and Medical Staff President, UPMC North Central, Pittsburgh, Pennsylvania; American College of Surgeons
| | | | - Huong T Le-Petross
- Breast MRI Director, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - John R Scheel
- Vice-Chair, Global Health, University of Washington, Seattle, Washington
| | | | - Gary A Ulaner
- James & Pamela Muzzy Endowed Chair, Molecular Imaging and Therapy, Hoag Family Cancer Institute, Newport Beach, California
| | - Susan P Weinstein
- Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania; Associate Chair for Radiology Network Strategic Projects
| | - Linda Moy
- Specialty Chair, NYU Clinical Cancer Center, New York, New York
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Harbhajanka A, Gilmore HL, Calhoun BC. High-risk and selected benign breast lesions diagnosed on core needle biopsy: Evidence for and against immediate surgical excision. Mod Pathol 2022; 35:1500-1508. [PMID: 35654997 DOI: 10.1038/s41379-022-01092-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 04/18/2022] [Accepted: 04/18/2022] [Indexed: 11/09/2022]
Abstract
The vast majority of image-detected breast abnormalities are diagnosed by percutaneous core needle biopsy (CNB) in contemporary practice. For frankly malignant lesions diagnosed by CNB, the standard practice of excision and multimodality therapy have been well-defined. However, for high-risk and selected benign lesions diagnosed by CNB, there is less consensus on optimal patient management and the need for immediate surgical excision. Here we outline the arguments for and against the practice of routine surgical excision of commonly encountered high-risk and selected benign breast lesions diagnosed by CNB. The entities reviewed include atypical ductal hyperplasia, atypical lobular hyperplasia, lobular carcinoma in situ, intraductal papillomas, and radial scars. The data in the peer-reviewed literature confirm the benefits of a patient-centered, multidisciplinary approach that moves away from the reflexive "yes" or "no" for routine excision for a given pathologic diagnosis.
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Affiliation(s)
- Aparna Harbhajanka
- Department of Pathology, Case Western University School of Medicine, Cleveland, OH, 44106, USA
| | - Hannah L Gilmore
- Department of Pathology, Case Western University School of Medicine, Cleveland, OH, 44106, USA
| | - Benjamin C Calhoun
- Department of Pathology and Laboratory Medicine, The University of North Carolina School of Medicine, Chapel Hill, NC, 27599, USA.
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Nicosia L, Latronico A, Addante F, De Santis R, Bozzini AC, Montesano M, Frassoni S, Bagnardi V, Mazzarol G, Pala O, Lazzeroni M, Lissidini G, Mastropasqua MG, Cassano E. Atypical Ductal Hyperplasia after Vacuum-Assisted Breast Biopsy: Can We Reduce the Upgrade to Breast Cancer to an Acceptable Rate? Diagnostics (Basel) 2021; 11:diagnostics11061120. [PMID: 34205428 PMCID: PMC8259513 DOI: 10.3390/diagnostics11061120] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Revised: 06/16/2021] [Accepted: 06/17/2021] [Indexed: 12/02/2022] Open
Abstract
(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.
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Affiliation(s)
- Luca Nicosia
- Department of Breast Radiology, IEO European Institute of Oncology, IRCCS, 20141 Milan, Italy; (L.N.); (A.L.); (A.C.B.); (M.M.); (E.C.)
| | - Antuono Latronico
- Department of Breast Radiology, IEO European Institute of Oncology, IRCCS, 20141 Milan, Italy; (L.N.); (A.L.); (A.C.B.); (M.M.); (E.C.)
| | - Francesca Addante
- Department of Emergency and Organ Transplantation, Section of Anatomic Pathology, School of Medicine, University “Aldo Moro”, 70124 Bari, Italy;
| | - Rossella De Santis
- Postgraduate School in Radiology, University of Milan, 20122 Milan, Italy;
| | - Anna Carla Bozzini
- Department of Breast Radiology, IEO European Institute of Oncology, IRCCS, 20141 Milan, Italy; (L.N.); (A.L.); (A.C.B.); (M.M.); (E.C.)
| | - Marta Montesano
- Department of Breast Radiology, IEO European Institute of Oncology, IRCCS, 20141 Milan, Italy; (L.N.); (A.L.); (A.C.B.); (M.M.); (E.C.)
| | - Samuele Frassoni
- Department of Statistics and Quantitative Methods, University of Milan-Bicocca, 20126 Milan, Italy; (S.F.); (V.B.)
| | - Vincenzo Bagnardi
- Department of Statistics and Quantitative Methods, University of Milan-Bicocca, 20126 Milan, Italy; (S.F.); (V.B.)
| | - Giovanni Mazzarol
- Division of Pathology and Laboratory Medicine, IEO European Institute of Oncology, IRCCS, 20141 Milan, Italy; (G.M.); (O.P.)
| | - Oriana Pala
- Division of Pathology and Laboratory Medicine, IEO European Institute of Oncology, IRCCS, 20141 Milan, Italy; (G.M.); (O.P.)
| | - Matteo Lazzeroni
- Division of Cancer Prevention and Genetics, IEO European Institute of Oncology IRCCS, 20141 Milan, Italy;
| | - Germana Lissidini
- Division of Breast Surgery, IEO European Institute of Oncology, IRCCS, 20141 Milan, Italy;
| | - Mauro Giuseppe Mastropasqua
- Department of Emergency and Organ Transplantation, Section of Anatomic Pathology, School of Medicine, University “Aldo Moro”, 70124 Bari, Italy;
- Correspondence: ; Tel.: +39-0805594414
| | - Enrico Cassano
- Department of Breast Radiology, IEO European Institute of Oncology, IRCCS, 20141 Milan, Italy; (L.N.); (A.L.); (A.C.B.); (M.M.); (E.C.)
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6
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High-Risk Lesions Detected by MRI-Guided Core Biopsy: Upgrade Rates at Surgical Excision and Implications for Management. AJR Am J Roentgenol 2021; 216:622-632. [PMID: 33439046 DOI: 10.2214/ajr.20.23040] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
OBJECTIVE. The purpose of our study was to evaluate the upgrade rates of high-risk lesions (HRLs) diagnosed by MRI-guided core biopsy and to assess which clinical and imaging characteristics are predictive of upgrade to malignancy. MATERIALS AND METHODS. A retrospective review was performed of all women who presented to an academic breast radiology center for MRI-guided biopsy between January 1, 2015, and November 30, 2018. Histopathologic results from each biopsy were extracted. HRLs-that is, atypical ductal hyperplasia (ADH), lobular carcinoma in situ (LCIS), atypical lobular hyperplasia (ALH), radial scar, papilloma, flat epithelial atypia (FEA), benign vascular lesion (BVL), and mucocelelike lesion-were included for analysis. Clinical history, imaging characteristics, surgical outcome, and follow-up data were recorded. Radiologic-pathologic correlation was performed. RESULTS. Of 810 MRI-guided biopsies, 189 cases (23.3%) met the inclusion criteria for HRLs. Of the 189 HRLs, 30 cases were excluded for the following reasons: 15 cases were lost to follow-up, six cases were in patients who received neoadjuvant chemotherapy after biopsy, two lesions that were not excised had less than 2 years of imaging follow-up, and seven lesions had radiologic-pathologic discordance at retrospective review. Of the 159 HRLs in our study cohort, 13 (8.2%) were upgraded to carcinoma. Surgical upgrade rates were high for ADH (22.5%, 9/40) and FEA (33.3%, 1/3); moderate for LCIS (6.3%, 3/48); and low for ALH (0.0%, 0/11), radial scar (0.0%, 0/28), papilloma (0.0%, 0/26), and BVL (0.0%, 0/3). Of the upgraded lesions, 69.2% (9/13) were upgraded to ductal carcinoma in situ (DCIS) or well-differentiated carcinoma. ADH lesions were significantly more likely to be upgraded than non-ADH lesions (p = .005). CONCLUSION. ADH diagnosed by MRI-guided core biopsy warrants surgical excision. The other HRLs, however, may be candidates for imaging follow-up rather than excision, especially after meticulous radiologic-pathologic correlation.
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Li X, Wang H, Sun Z, Fan C, Jin F, Mao X. A retrospective observational study of intraductal breast papilloma and its coexisting lesions: A real-world experience. Cancer Med 2020; 9:7751-7762. [PMID: 32822113 PMCID: PMC7571817 DOI: 10.1002/cam4.3308] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 06/09/2020] [Accepted: 06/20/2020] [Indexed: 12/30/2022] Open
Abstract
Background Breast intraductal papilloma is a heterogeneous group. The aim of the study is to investigate the intraductal breast papilloma and its coexisting lesions retrospectively in real‐world practice. Methods We retrospectively identified 4450 intraductal breast papilloma and its coexisting lesions. Results About 18.36% of intraductal papilloma coexisted with malignant lesions of the breast, 37.33% coexisted with atypia hyperplasia (AH), 25.24% coexisted with benign lesions, and only 19.10% coexisted without concomitant lesions. In addition, 36.80% of intraductal breast papilloma had nipple discharge, 51.46% had a palpable breast mass, and 16.45% had both nipple discharge and a palpable breast mass. About 28.18% experienced discomfort or were asymptomatic. Furthermore, 98.99% had ultrasound abnormalities, and 53.06% had intraductal hypoechogenicity upon ultrasound. 31.89% had mammographic distortion, and 14.45% had microcalcification upon mammography. Intraductal breast papilloma with malignancy had significant correlations with clinical manifestations. Conclusion Coexisting malignancy was also related to ultrasound abnormality (BIRADS 4C and 5), mammographic distortion, and microcalcification upon mammography but was not related to the intraductal hypoechoic upon ultrasound. Coexisting atypical hyperplasia correlated with nipple discharge but not palpable mass, mammographic distortion, or intraductal hypoechoic upon ultrasound. The coexisting AH was also related to abnormality upon ultrasound or microcalcification compared with the benign lesions. The intraductal papilloma coexists with malignancy or AH accounted for more than 50%, and the clinical information on papilloma and its coexisting lesions is nonspecific. We recommended surgical treatment for benign intraductal papillary lesions.
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Affiliation(s)
- Xiaona Li
- Department of Breast Surgery, The First Affiliated Hospital of China Medical University & School of Fundamental Science, China Medical University, Shenyang, People's Republic of China
| | - Huan Wang
- Department of Gynecology, The First Affiliated Hospital of China Medical University, Shenyang, People's Republic of China
| | - Zhe Sun
- Department of Breast Surgery, The First Affiliated Hospital of China Medical University, Shenyang, People's Republic of China
| | - Chuifeng Fan
- Department of Pathology, The First Affiliated Hospital and College of Basic Medical Sciences of China Medical University, Shenyang, People's Republic of China
| | - Feng Jin
- Department of Breast Surgery, The First Affiliated Hospital of China Medical University, Shenyang, People's Republic of China
| | - Xiaoyun Mao
- Department of Breast Surgery, The First Affiliated Hospital of China Medical University, Shenyang, People's Republic of China
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Okamoto S, Chen ST, Covelli JD, DeMartini WB, Daniel BL, Ikeda DM. High-risk lesions diagnosed at MRI-guided vacuum-assisted breast biopsy: imaging characteristics, outcome of surgical excision or imaging follow-up. Breast Cancer 2019; 27:405-414. [PMID: 31838725 DOI: 10.1007/s12282-019-01032-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 12/04/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND To evaluate imaging characteristics, outcome of surgical excision or imaging follow-up on high-risk lesions diagnosed at MRI-guided vacuum-assisted breast biopsy (MRI-VABB). METHODS We retrospectively reviewed 598 lesions undergoing 9-gauge MRI-VABB from January 2015 to April 2018 to identify high risk breast lesions. We collected patient demographics, breast MRI BI-RADS descriptors, histopathological diagnosis at MRI-VABB and surgical excision, frequency of upgrade to malignancy and imaging follow-up of high-risk lesions. The x2 test and Fisher exact tests were performed for univariate analysis. RESULTS 114 patients with 124/598 findings (20.7%) had high-risk lesions at MRI-VABB, including atypical ductal hyperplasia (ADH) (21/124, 16.9%), lobular neoplasia (40/124, 32.3%), radial scar/complex sclerosing lesion (RS/CSL) (13/124, 10.5%), papillary lesions (49/124, 39.5%), and flat epithelial atypia (FEA) (1/124, 0.8%). 84/124 (67.7%) high-risk lesions were excised. 19/84 (22.6%) were upgraded to malignancy (7 invasive cancer, 12 DCIS). The upgrade rate for ADH and lobular neoplasia was 7/18 (38.9%) and 9/31 (29.0%), respectively. The upgrade rate for RS/CSL was 1/10 (10%). Of the 25 papillary lesions excised, 2 (8%) demonstrated pathologic atypia and were upgraded to DCIS. The other 23 papillary lesions had no upgrade or atypia. Excised high-risk lesions showing upgrade varied from 0.4 to 6 cm in length (mean 1.6 cm). There was a non-significant trend (p = 0.054) between larger lesion and upgrade to malignancy; however, there were no other specific imaging features to predict malignancy upgrade. CONCLUSIONS There were no specific MRI imaging characteristics of high-risk lesions to predict malignancy upgrade. Therefore, surgical excision is recommended for high-risk lesions, especially ADH or lobular neoplasia.
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Affiliation(s)
- Satoko Okamoto
- Department of Radiology, St. Marianna University School of Medicine, 2-16-1, Sugao, Miyamae-ku, Kawasaki, Kanagawa, 216-8511, Japan.
| | - Shu-Tian Chen
- Department of Diagnostic Radiology, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - James D Covelli
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA
| | - Wendy B DeMartini
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA
| | - Bruce L Daniel
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA
| | - Debra M Ikeda
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA
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9
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Atypical Ductal Hyperplasia and Lobular Neoplasia: Update and Easing of Guidelines. AJR Am J Roentgenol 2019; 214:265-275. [PMID: 31825261 DOI: 10.2214/ajr.19.21991] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
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.
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10
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Affiliation(s)
- Rachel F Brem
- From the Breast Imaging and Interventional Center, Department of Radiology, George Washington Cancer Center, George Washington University, 2300 M St NW, Room 822, Washington, DC 20037
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Falomo E, Adejumo C, Carson KA, Harvey S, Mullen L, Myers K. Variability in the Management Recommendations Given for High-risk Breast Lesions Detected on Image-guided Core Needle Biopsy at U.S. Academic Institutions. Curr Probl Diagn Radiol 2019; 48:462-466. [DOI: 10.1067/j.cpradiol.2018.06.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Revised: 06/01/2018] [Accepted: 06/20/2018] [Indexed: 11/22/2022]
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12
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Wang ZL, Liu G, He Y, Li N, Liu Y. Ultrasound-guided 7-gauge vacuum-assisted core biopsy: Could it be sufficient for the diagnosis and treatment of intraductal papilloma? Breast J 2019; 25:807-812. [PMID: 31131512 DOI: 10.1111/tbj.13342] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Revised: 04/08/2018] [Accepted: 04/24/2018] [Indexed: 11/27/2022]
Abstract
The aim of this study was to evaluate whether ultrasound-guided 7-gauge vacuum-assisted core biopsy is sufficient for the diagnosis and treatment of intraductal papilloma and to evaluate the lesion characteristics and histologic features affecting the excision rate of papilloma with vacuum-assisted core biopsy. Between March 2008 and October 2016, 2816 patients underwent US-guided, 7-gauge vacuum-assisted core biopsy (VACB). In them, 101 (3.6%) were demonstrated to have intraductal papilloma by pathology. The accurate diagnostic rate and excision rate of intraductal papilloma after vacuum-assisted core biopsy were evaluated by open surgical biopsy or follow-up US. The lesion characteristics and histologic features were analyzed to identify factors affecting the excision rate of papilloma after VACB. Of the 101 intraductal papillomas, 83 (82.2%) cases were benign papilloma. Two cases were intraductal papilloma accompanied by invasive carcinoma. Sixteen (15.8%) cases were with signs of atypical hyperplasia. In them, one intraductal papilloma accompanied by severe atypical hyperplasia underwent further surgery, and it was demonstrated to have intraductal papilloma accompanied by invasive carcinoma. The accurate diagnostic rate of intraductal papillomas by 7-gauge VACB was 99.0% (100/101). There was no recurrence or malignant transformation in 85.1% (86/101) intraductal papillomas after 7-gauge vacuum-assisted core biopsy. Intraductal papilloma with largest diameter <1 cm, with clear margin, without branch involvement or calcification had a significantly higher excision rate. Seven-gauge VACB is an effective method for the diagnosis of intraductal papilloma of the breast. If histopathological examination confirms a benign character of the lesion, surgery may be avoided but regular follow-up is recommended. If histopathological examination confirms a papilloma with moderate to severe atypical hyperplasia, it was strongly recommended for surgical excision. Lesion characteristics and histologic features could affect the excision rate of intraductal papillomas with VACB.
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Affiliation(s)
- Zhi Li Wang
- Department of Ultrasound, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Gang Liu
- Department of Radiology, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Yan He
- Department of Ultrasound, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Nan Li
- Department of Ultrasound, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Yuan Liu
- Department of Ultrasound, Chinese People's Liberation Army General Hospital, Beijing, China
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Use of Breast Magnetic Resonance Imaging in Women Diagnosed With Atypical Ductal Hyperplasia at Core Needle Biopsy Helps Select Women for Surgical Excision. Can Assoc Radiol J 2018; 69:240-247. [PMID: 29958833 DOI: 10.1016/j.carj.2018.03.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Revised: 12/22/2017] [Accepted: 03/10/2018] [Indexed: 11/24/2022] Open
Abstract
PURPOSE The study sought to investigate the role of breast magnetic resonance imaging (MRI) in patients diagnosed with atypical ductal hyperplasia (ADH) at core needle biopsy (CNB). METHODS The breast MRI database at our centre was queried for studies performed between January 2010 and December 2016 for the clinical indication of ADH diagnosed at CNB. Medical files were reviewed for demographic data, clinical information, and radiology and pathology reports. Pathological results of the surgical specimens were considered the gold standard for comparison with breast MRI findings. In women not undergoing excision, at least 2 years of follow-up was used to ascertain the benign nature of the finding. RESULTS Fifty patients were included in the study. Thirty-one (62%) patients had surgical excision of the ADH lesion, and 7 (23%) were upgraded to malignancy. Breast MRI accurately identified 6 of the 7 cases. Six of the 12 women (50%) with positive MRI findings at the biopsy site were upgraded to malignancy on surgical pathology, compared with only 1 of 19 (5%) with negative MRI findings. Forty-nine percent of the women with a negative MRI did not undergo surgical excision of the ADH lesion, compared with 8% of the women with a positive MRI (P = .009), with no cancer diagnosed during follow-up. The sensitivity, specificity, negative predictive value, and positive predictive value of breast MRI for predicting upgrade to malignancy were 86%, 83%, 97%, and 46%, respectively. CONCLUSIONS MRI may have a role in the management of women diagnosed with ADH on CNB, to minimize diagnostic excisional biopsies.
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Gao Y, Albert M, Young Lin LL, Lewin AA, Babb JS, Heller SL, Moy L. What Happens after a Diagnosis of High-Risk Breast Lesion at Stereotactic Vacuum-assisted Biopsy? An Observational Study of Postdiagnosis Management and Imaging Adherence. Radiology 2018; 287:423-431. [DOI: 10.1148/radiol.2017171665] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Yiming Gao
- From the Department of Radiology, New York University–Langone Medical Center, 160 E 34th St, New York, NY 10016 (Y.G., M.A., L.L.Y.L., A.A.L., J.S.B., S.L.H.); and Center for Advanced Imaging Innovation and Research, New York University School of Medicine, New York, NY (J.S.B., L.M.)
| | - Marissa Albert
- From the Department of Radiology, New York University–Langone Medical Center, 160 E 34th St, New York, NY 10016 (Y.G., M.A., L.L.Y.L., A.A.L., J.S.B., S.L.H.); and Center for Advanced Imaging Innovation and Research, New York University School of Medicine, New York, NY (J.S.B., L.M.)
| | - Leng Leng Young Lin
- From the Department of Radiology, New York University–Langone Medical Center, 160 E 34th St, New York, NY 10016 (Y.G., M.A., L.L.Y.L., A.A.L., J.S.B., S.L.H.); and Center for Advanced Imaging Innovation and Research, New York University School of Medicine, New York, NY (J.S.B., L.M.)
| | - Alana A. Lewin
- From the Department of Radiology, New York University–Langone Medical Center, 160 E 34th St, New York, NY 10016 (Y.G., M.A., L.L.Y.L., A.A.L., J.S.B., S.L.H.); and Center for Advanced Imaging Innovation and Research, New York University School of Medicine, New York, NY (J.S.B., L.M.)
| | - James S. Babb
- From the Department of Radiology, New York University–Langone Medical Center, 160 E 34th St, New York, NY 10016 (Y.G., M.A., L.L.Y.L., A.A.L., J.S.B., S.L.H.); and Center for Advanced Imaging Innovation and Research, New York University School of Medicine, New York, NY (J.S.B., L.M.)
| | - Samantha L. Heller
- From the Department of Radiology, New York University–Langone Medical Center, 160 E 34th St, New York, NY 10016 (Y.G., M.A., L.L.Y.L., A.A.L., J.S.B., S.L.H.); and Center for Advanced Imaging Innovation and Research, New York University School of Medicine, New York, NY (J.S.B., L.M.)
| | - Linda Moy
- From the Department of Radiology, New York University–Langone Medical Center, 160 E 34th St, New York, NY 10016 (Y.G., M.A., L.L.Y.L., A.A.L., J.S.B., S.L.H.); and Center for Advanced Imaging Innovation and Research, New York University School of Medicine, New York, NY (J.S.B., L.M.)
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Hammersley JA, Partridge SC, Blitzer GC, Deitch S, Rahbar H. Management of high-risk breast lesions found on mammogram or ultrasound: the value of contrast-enhanced MRI to exclude malignancy. Clin Imaging 2018; 49:174-180. [DOI: 10.1016/j.clinimag.2018.03.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Revised: 02/14/2018] [Accepted: 03/09/2018] [Indexed: 11/16/2022]
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16
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Lee SJ, Trikha S, Moy L, Baron P, diFlorio RM, Green ED, Heller SL, Holbrook AI, Lewin AA, Lourenco AP, Niell BL, Slanetz PJ, Stuckey AR, Vincoff NS, Weinstein SP, Yepes MM, Newell MS. ACR Appropriateness Criteria ® Evaluation of Nipple Discharge. J Am Coll Radiol 2018; 14:S138-S153. [PMID: 28473070 DOI: 10.1016/j.jacr.2017.01.030] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 01/18/2017] [Accepted: 01/20/2017] [Indexed: 10/19/2022]
Abstract
Appropriate imaging evaluation of nipple discharge depends the nature of the discharge. Imaging is not indicated for women with physiologic nipple discharge. For evaluation of pathologic nipple discharge, multiple breast imaging modalities are rated for evidence-based appropriateness under various scenarios. For women age 40 or older, mammography or digital breast tomosynthesis (DBT) should be the initial examination. Ultrasound is usually added as a complementary examination, with some exceptions. For women age 30 to 39, either mammogram or ultrasound may be used as the initial examination on the basis of institutional preference. For women age 30 or younger, ultrasound should be the initial examination, with mammography/DBT added when ultrasound shows suspicious findings or if the patient is predisposed to developing breast cancer. For men age 25 or older, mammography/DBT should be performed initially, with ultrasound added as indicated, given the high incidence of breast cancer in men with pathologic nipple discharge. Although MRI and ductography are not usually appropriate as initial examinations, each may be useful when the initial standard imaging evaluation is negative. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
| | - Su-Ju Lee
- Principal Author, University of Cincinnati Medical Center, Cincinnati, Ohio.
| | | | - Linda Moy
- Panel Vice-Chair, NYU Clinical Cancer Center, New York, New York
| | - Paul Baron
- Roper St. Francis Physician Partners Breast Surgery, Charleston, South Carolina; American College of Surgeons
| | | | - Edward D Green
- The University of Mississippi Medical Center, Jackson, Mississippi
| | | | | | - Alana A Lewin
- New York University School of Medicine, New York, New York
| | | | | | | | - Ashley R Stuckey
- Women and Infants Hospital, Providence, Rhode Island; American Congress of Obstetricians and Gynecologists
| | - Nina S Vincoff
- Hofstra Northwell School of Medicine, Manhasset, New York
| | - Susan P Weinstein
- Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Mary S Newell
- Panel Chair, Emory University Hospital, Atlanta, Georgia
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Abstract
Benign and atypical lesions associated with breast cancer risk are often encountered in core needle biopsies (CNBs) of the breast. For these lesions, the rate of "upgrade" to carcinoma in excision specimens varies widely in the literature. Many CNB studies are limited by a lack of radiological-pathological correlation, consistent criteria for excision, and clinical follow-up for patients who forego excision. This article highlights contemporary diagnostic criteria and outcome data that would support an evidence-based approach to the management of these nonmalignant lesions of the breast diagnosed on CNB.
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Affiliation(s)
- Benjamin C Calhoun
- Department of Pathology and Laboratory Medicine, University of North Carolina, Women's and Children's Hospitals, 3rd Floor, Room 30212, 101 Manning Drive, Chapel Hill, NC 27514, USA.
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Bahl M, Barzilay R, Yedidia AB, Locascio NJ, Yu L, Lehman CD. High-Risk Breast Lesions: A Machine Learning Model to Predict Pathologic Upgrade and Reduce Unnecessary Surgical Excision. Radiology 2018; 286:810-818. [DOI: 10.1148/radiol.2017170549] [Citation(s) in RCA: 94] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Manisha Bahl
- From the Division of Breast Imaging, Department of Radiology, Massachusetts General Hospital/Harvard Medical School, 55 Fruit St, WAC 240, Boston, MA 02114 (M.B., C.D.L.); and Department of Electrical Engineering and Computer Science, Massachusetts Institute of Technology, Cambridge, Mass (R.B., A.B.Y., N.J.L., L.Y.)
| | - Regina Barzilay
- From the Division of Breast Imaging, Department of Radiology, Massachusetts General Hospital/Harvard Medical School, 55 Fruit St, WAC 240, Boston, MA 02114 (M.B., C.D.L.); and Department of Electrical Engineering and Computer Science, Massachusetts Institute of Technology, Cambridge, Mass (R.B., A.B.Y., N.J.L., L.Y.)
| | - Adam B. Yedidia
- From the Division of Breast Imaging, Department of Radiology, Massachusetts General Hospital/Harvard Medical School, 55 Fruit St, WAC 240, Boston, MA 02114 (M.B., C.D.L.); and Department of Electrical Engineering and Computer Science, Massachusetts Institute of Technology, Cambridge, Mass (R.B., A.B.Y., N.J.L., L.Y.)
| | - Nicholas J. Locascio
- From the Division of Breast Imaging, Department of Radiology, Massachusetts General Hospital/Harvard Medical School, 55 Fruit St, WAC 240, Boston, MA 02114 (M.B., C.D.L.); and Department of Electrical Engineering and Computer Science, Massachusetts Institute of Technology, Cambridge, Mass (R.B., A.B.Y., N.J.L., L.Y.)
| | - Lili Yu
- From the Division of Breast Imaging, Department of Radiology, Massachusetts General Hospital/Harvard Medical School, 55 Fruit St, WAC 240, Boston, MA 02114 (M.B., C.D.L.); and Department of Electrical Engineering and Computer Science, Massachusetts Institute of Technology, Cambridge, Mass (R.B., A.B.Y., N.J.L., L.Y.)
| | - Constance D. Lehman
- From the Division of Breast Imaging, Department of Radiology, Massachusetts General Hospital/Harvard Medical School, 55 Fruit St, WAC 240, Boston, MA 02114 (M.B., C.D.L.); and Department of Electrical Engineering and Computer Science, Massachusetts Institute of Technology, Cambridge, Mass (R.B., A.B.Y., N.J.L., L.Y.)
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Park VY, Kim EK, Moon HJ, Yoon JH, Kim MJ. Evaluating imaging-pathology concordance and discordance after ultrasound-guided breast biopsy. Ultrasonography 2017; 37:107-120. [PMID: 29169231 PMCID: PMC5885481 DOI: 10.14366/usg.17049] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Revised: 08/17/2017] [Accepted: 08/19/2017] [Indexed: 11/04/2022] Open
Abstract
Ultrasound (US)-guided breast biopsy has become the main method for diagnosing breast pathology, and it has a high diagnostic accuracy, approaching that of open surgical biopsy. However, methods for confirming adequate lesion retrieval after US-guided biopsy are relatively limited and false-negative results are unavoidable. Determining imaging-pathology concordance after US-guided biopsy is essential for validating the biopsy result and providing appropriate management. In this review article, we briefly present the results of US-guided breast biopsy; describe general aspects to consider when establishing imaging-pathology concordance; and review the various categories of imaging-pathology correlations and corresponding management strategies.
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Affiliation(s)
- Vivian Youngjean Park
- Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Eun-Kyung Kim
- Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hee Jung Moon
- Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jung Hyun Yoon
- Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Min Jung Kim
- Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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20
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Cassano E, Trentin C. Integrated Breast Biopsy for Best Radiological Diagnosis of Breast Cancer. Breast Cancer 2017. [DOI: 10.1007/978-3-319-48848-6_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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21
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Park VY, Kim EK, Kim MJ, Yoon JH, Moon HJ. Mammographically Occult Asymptomatic Radial Scars/Complex Sclerosing Lesions at Ultrasonography-Guided Core Needle Biopsy: Follow-Up Can Be Recommended. ULTRASOUND IN MEDICINE & BIOLOGY 2016; 42:2367-2371. [PMID: 27444865 DOI: 10.1016/j.ultrasmedbio.2016.06.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Revised: 05/31/2016] [Accepted: 06/02/2016] [Indexed: 06/06/2023]
Abstract
An increasing number of radial scars are detected by ultrasound (US), but their management is controversial. This study investigated the upgrade rate in mammographically occult radial scars/complex sclerosing lesions without epithelial atypia at US-guided 14-gauge core needle biopsy in asymptomatic patients. Nineteen mammographically occult benign radial scars/complex sclerosing lesions (median size, 7 mm; range, 3-23 mm) were included. Patients underwent surgical excision (n = 10) or vacuum-assisted excision, with follow-up US at least 6 mo after benign vacuum-assisted excision results (n = 8), or underwent US follow-up for 2 y after core needle biopsy (n = 1). Any cases with change in diagnosis to high-risk lesions or malignancy at excision were considered upgrades. The upgrade rate was 0.0%. Based on US findings, 15.8% (3/19) were Breast Imaging Reporting and Data System (BI-RADS) category 3, 68.4% (13/19) were BI-RADS category 4a and 15.8% (3/19) were BI-RADS category 4b. Follow-up with US can be considered for mammographically occult benign radial scar/complex sclerosing lesions diagnosed by US core needle biopsy in asymptomatic patients.
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Affiliation(s)
- Vivian Youngjean Park
- Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Eun-Kyung Kim
- Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Min Jung Kim
- Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jung Hyun Yoon
- Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hee Jung Moon
- Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.
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22
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Kim SY, Kim EK, Lee HS, Kim MJ, Yoon JH, Koo JS, Moon HJ. Asymptomatic Benign Papilloma Without Atypia Diagnosed at Ultrasonography-Guided 14-Gauge Core Needle Biopsy: Which Subgroup can be Managed by Observation? Ann Surg Oncol 2016; 23:1860-6. [DOI: 10.1245/s10434-016-5144-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2015] [Indexed: 11/18/2022]
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24
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Neal L, Sandhu NP, Hieken TJ, Glazebrook KN, Mac Bride MB, Dilaveri CA, Wahner-Roedler DL, Ghosh K, Visscher DW. Diagnosis and management of benign, atypical, and indeterminate breast lesions detected on core needle biopsy. Mayo Clin Proc 2014; 89:536-47. [PMID: 24684875 DOI: 10.1016/j.mayocp.2014.02.004] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2013] [Revised: 02/05/2014] [Accepted: 02/07/2014] [Indexed: 11/29/2022]
Abstract
Imaging abnormalities detected by mammographic screening often lead to diagnostic evaluations, with suspicious abnormalities subjected to image-guided core needle biopsy (CNB) to exclude malignancy. Most CNBs reveal benign pathological alterations, termed benign breast disease (BBD). Adoption of CNB presents challenges with pathologic classification of breast abnormalities and management of patients with benign or atypical histological findings. Patient management and counseling after CNB diagnosis of BBD depends on postbiopsy determination of radiologic-pathologic concordancy. Communication between radiologists and pathologists is crucial in patient management. Management is dependent on the histological type of BBD. Patients with concordant pathologic imaging results can be reassured of benign biopsy findings and advised about the future risk of developing breast cancer. Surgical consultation is advised for patients with discordant findings, symptomatic patients, and high-risk lesions. This review highlights benign breast lesions that are encountered on CNB and summarizes management strategies. For this review, we conducted a search of PubMed, with no date limitations, and used the following search terms (or a combination of terms): atypical ductal hyperplasia, atypical hyperplasia, atypical lobular hyperplasia, benign breast disease, cellular fibroepithelial lesions, columnar cell lesions, complex sclerosing lesion, core needle biopsy, fibroadenomas, flat epithelial atypia, lobular carcinoma in situ, lobular neoplasia, mucocele-like lesions, phyllodes tumor, pseudoangiomatous stromal hyperplasia, radial scar, and vascular lesions. The selection of references included in this review was based on study relevance and quality. We used additional articles culled from the bibliographies of retrieved articles to examine the published evidence for risk factors of BBD.
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Affiliation(s)
- Lonzetta Neal
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN.
| | - Nicole P Sandhu
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN
| | | | | | | | | | | | - Karthik Ghosh
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN
| | - Daniel W Visscher
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
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25
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Rendi MH. When is excision necessary for atypical lobular hyperplasia and lobular carcinoma in situ? BREAST CANCER MANAGEMENT 2014. [DOI: 10.2217/bmt.13.78] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
SUMMARY This management perspective briefly covers the histology and molecular features of lobular in situ neoplasia and provides an in-depth discussion of the need for surgical excision if lobular in situ neoplasia is diagnosed on core-needle biopsy. The management of lobular in situ neoplasia found on core-needle biopsy has been an area of recent study with varying results. Emerging data suggest that low-risk patients with a limited extent of isolated classic lobular in situ neoplasia found on core-needle biopsy may not require subsequent surgical excision. However, high-risk patients, those with extensive lobular in situ neoplasia, or other high-risk lesions noted on core-needle biopsy likely benefit from surgical excision. Most authors recommend surgical excision when pleomorphic lobular carcinoma in situ is found on core-needle biopsy due to its higher association with invasive carcinoma. However, the natural history of this more recently described variant of lobular carcinoma in situ is not fully defined, and the clinical management of pleomorphic lobular carcinoma in situ on excisional biopsy is yet to be determined.
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Affiliation(s)
- Mara H Rendi
- Department of Anatomic Pathology, University of Washington Medical Center, 1959 NE Pacific, Seattle, WA 98195, USA
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26
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Harms SE. Breast MR for Treatment Planning. Breast Cancer 2014. [DOI: 10.1007/978-1-4614-8063-1_8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Outcome of High-Risk Lesions at MRI-Guided 9-Gauge Vacuum- Assisted Breast Biopsy. AJR Am J Roentgenol 2014; 202:237-45. [DOI: 10.2214/ajr.13.10600] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Menes TS, Rosenberg R, Balch S, Jaffer S, Kerlikowske K, Miglioretti DL. Upgrade of high-risk breast lesions detected on mammography in the Breast Cancer Surveillance Consortium. Am J Surg 2014; 207:24-31. [PMID: 24112677 PMCID: PMC3865063 DOI: 10.1016/j.amjsurg.2013.05.014] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2013] [Revised: 04/24/2013] [Accepted: 05/16/2013] [Indexed: 11/30/2022]
Abstract
BACKGROUND Upgrade rates of high-risk breast lesions after screening mammography were examined. METHODS The Breast Cancer Surveillance Consortium registry was used to identify all Breast Imaging Reporting and Data System category 4 assessments followed by needle biopsies with high-risk lesions. Follow-up was performed for all women. RESULTS High-risk lesions were found in 957 needle biopsies, with excision documented in 53%. Most (n = 685) were atypical ductal hyperplasia (ADH), 173 were lobular neoplasia, and 99 were papillary lesions. Upgrade to cancer varied with type of lesion (18% in ADH, 10% in lobular neoplasia, and 2% in papillary lesions). In premenopausal women with ADH, upgrade was associated with family history. Cancers associated with ADH were mostly (82%) ductal carcinoma in situ, and those associated with lobular neoplasia were mostly (56%) invasive. During a further 2 years of follow-up, cancer was documented in 1% of women with follow-up surgery and in 3% with no surgery. CONCLUSIONS Despite low rates of surgery, low rates of cancer were documented during follow-up. Benign papillary lesions diagnosed on Breast Imaging Reporting and Data System category 4 mammograms among asymptomatic women do not justify surgical excision.
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Affiliation(s)
- Tehillah S Menes
- Department of Surgery, Tel Aviv Sourasky Medical Center, 6 Weizmann Street, 64239 Tel Aviv, Israel.
| | - Robert Rosenberg
- Radiology Associates of Albuquerque, Albuquerque, NM, USA; Department of Radiology, University of New Mexico, Albuquerque, NM, USA
| | - Steven Balch
- Group Health Research Institute, Group Health Cooperative, Seattle, WA, USA
| | - Shabnam Jaffer
- Department of Pathology, The Mount Sinai Medical Center, New York, NY, USA
| | - Karla Kerlikowske
- Departments of Medicine and Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
| | - Diana L Miglioretti
- Group Health Research Institute, Group Health Cooperative, Seattle, WA, USA; Division of Biostatistics, Department of Public Health Sciences, University of California Davis School of Medicine, Davis, CA, USA
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High Risk Lesions. Breast Cancer 2014. [DOI: 10.1007/978-1-4614-8063-1_14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Zuiani C, Londero V, Linda A, Girometti R, Bazzocchi M. MRI in B3 lesions, low grade DCIS, high DCIS: is MR selecting the dangerous cases? Eur J Radiol 2013; 81 Suppl 1:S189-91. [PMID: 23083586 DOI: 10.1016/s0720-048x(12)70078-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Chiara Zuiani
- Institute of Radiology, University of Udine, Piazzale S.Maria della Misericordia, Udine, Italy.
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Non-mass-associated intraductal papillomas: is excision necessary? Hum Pathol 2013; 45:583-8. [PMID: 24444467 DOI: 10.1016/j.humpath.2013.10.027] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2013] [Revised: 10/22/2013] [Accepted: 10/24/2013] [Indexed: 11/21/2022]
Abstract
Intraductal papillomas (IDPs) of the breast can be associated with a variety of clinical symptoms and radiologic findings. Surgical excision is often recommended based on the possibility of an associated high-grade lesion. Although the rate of upgrades has been extensively evaluated for IDPs, many studies are hindered by broad inclusion criteria, a lack of pathologic-radiologic concordance, and no standard definition of what constitutes an upgrade. In the current study, we evaluate the risk of upgrade for a specific subset of IDPs: non-mass-associated IDPs. We identified all breast needle core biopsies with a diagnosis of IDP between 2003 and 2010. Patients with associated masses, architectural distortion, or ipsilateral breast cancer were excluded. All needle core biopsy slides and relevant imaging studies were reviewed to ensure pathologic-radiologic concordance. Excision pathology was also reviewed; an upgrade was defined as the presence of ductal carcinoma in situ or invasive carcinoma in the excision. Seventy-nine IDPs that met inclusion criteria were identified and were further divided into 3 histologic categories: micropapilloma, fragmented IDP, and atypical IDP. Micropapillomas and fragmented IDPs had no upgrades (0/37). In patients who did not undergo excision, none subsequently developed ipsilateral breast cancer (follow-up, 50-61 months). This is in contrast to atypical IDPs that had a 33% upgrade rate. One patient with an unexcised atypical IDP developed ipsilateral breast cancer within 2 years. Our data suggest that conservative follow-up is reasonable for non-mass-associated IDPs without atypia regardless of microscopic size, provided that careful pathologic-radiologic correlation is achieved.
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Linda A, Zuiani C, Londero V, Bazzocchi M. What to do with B3 lesions at needle biopsy. Eur J Radiol 2013; 81 Suppl 1:S90-2. [PMID: 23083618 DOI: 10.1016/s0720-048x(12)70036-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Affiliation(s)
- Anna Linda
- Department of Diagnostic Radiology, University of Udine, Italy.
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Heller SL, Hernandez O, Moy L. Radiologic-pathologic correlation at breast MR imaging: what is the appropriate management for high-risk lesions? Magn Reson Imaging Clin N Am 2013; 21:583-99. [PMID: 23928247 DOI: 10.1016/j.mric.2013.03.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Breast magnetic resonance (MR) imaging is increasingly performed for a variety of indications, most commonly with the goal of detecting breast cancer. Percutaneous biopsy (usually under MR guidance or ultrasound if there is a correlating finding) is commonly used to evaluate suspicious imaging findings detected on MR imaging with the goal of identifying malignancy. It is important to be familiar with the characteristics and management of high-risk lesions detected or biopsied under MR guidance. This review focuses on the appearance of a variety of breast lesions detected on MR imaging that require excision with focus on pathologic correlation.
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Affiliation(s)
- Samantha L Heller
- Department of Radiology, St. George's Healthcare NHS Trust, London, UK
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Amarosa AR, McKellop J, Klautau Leite AP, Moccaldi M, Clendenen TV, Babb JS, Zeleniuch-Jacquotte A, Moy L, Kim S. Evaluation of the kinetic properties of background parenchymal enhancement throughout the phases of the menstrual cycle. Radiology 2013; 268:356-65. [PMID: 23657893 DOI: 10.1148/radiol.13121101] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
PURPOSE To develop and apply a semiautomatic method of segmenting fibroglandular tissue to quantify magnetic resonance (MR) imaging contrast material-enhancement kinetics of breast background parenchyma (BP) and lesions throughout the phases of the menstrual cycle in women with benign and malignant lesions. MATERIALS AND METHODS The institutional review board approved this retrospective HIPAA-compliant study, and informed consent was waived. From December 2008 to August 2011, 58 premenopausal women who had undergone contrast material-enhanced MR imaging and MR imaging-guided biopsy were identified. The longest time from the start of the last known period was 34 days. One lesion per patient (37 benign and 21 malignant) was analyzed. The patient groups were stratified according to the week of the menstrual cycle when MR imaging was performed. A method based on principal component analysis (PCA) was applied for quantitative analysis of signal enhancement in the BP and lesions by using the percentage of slope and percentage of enhancement. Linear regression and the Mann-Whitney U test were used to assess the association between the kinetic parameters and the week of the menstrual cycle. RESULTS In the women with benign lesions, percentages of slope and enhancement for both BP and lesions during week 2 were significantly (P < .05) lower than those in week 4. Percentage of enhancement in the lesion in week 2 was lower than that in week 3 (P < .05). The MR images of women with malignant lesions showed no significant difference between the weeks for any of the parameters. There was a strong positive correlation between lesion and BP percentage of slope (r = 0.72) and between lesion and BP percentage of enhancement (r = 0.67) in the benign group. There was also a significant (P = .03) difference in lesion percentage of slope between the benign and malignant groups at week 2. CONCLUSION The PCA-based method can quantify contrast enhancement kinetics of BP semiautomatically, and kinetics of BP and lesions vary according to the week of the menstrual cycle in benign but not in malignant lesions.
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Affiliation(s)
- Alana R Amarosa
- Department of Radiology, Center for Biomedical Imaging, New York University School of Medicine, 660 First Ave, 4th Floor, New York, NY 10016, USA.
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Swapp RE, Glazebrook KN, Jones KN, Brandts HM, Reynolds C, Visscher DW, Hieken TJ. Management of Benign Intraductal Solitary Papilloma Diagnosed on Core Needle Biopsy. Ann Surg Oncol 2013; 20:1900-5. [DOI: 10.1245/s10434-012-2846-9] [Citation(s) in RCA: 86] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2012] [Indexed: 11/18/2022]
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High-risk breast lesions at imaging-guided needle biopsy: usefulness of MRI for treatment decision. AJR Am J Roentgenol 2012; 199:W240-50. [PMID: 22826427 DOI: 10.2214/ajr.11.7869] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The purpose of this study is to evaluate the role of MRI for characterization of high-risk breast lesions diagnosed at imaging-guided needle biopsy. MATERIALS AND METHODS In this retrospective analysis of 220 patients, 227 high-risk lesions (94 papillomas, 64 radial sclerosing lesions, 46 lobular neoplasias, and 23 atypical ductal hyperplasias) found at 11-gauge vacuum-assisted or 14-gauge needle biopsy were studied with dynamic MRI (time resolution, 84 or 88 seconds; gadopentetate dimeglumine or gadobenate dimeglumine, 0.1 mmol/kg). When lesions showed contrast enhancement on subtracted images, they were considered suspicious for malignancy. The reference standard was histopathologic examination after surgical excision in 190 of 227 (84%) lesions and negative follow-up (≥ 24 months) in 37 of 227 (16%) lesions. Predictive values and likelihood ratios were calculated. RESULTS Of 227 lesions, 155 (68%) were contrast enhancing and 72 (32%) were not. Of 155 contrast-enhancing lesions, 28 (18%) were upgraded to malignancy after surgical excision (nine papillomas, one radial sclerosing lesion, 11 lobular neoplasias, and seven atypical ductal hyperplasias); there were 11 invasive carcinomas and 17 ductal carcinomas in situ, four of the latter being G3. Of 72 non-contrast-enhancing lesions, two (3%) were upgraded to malignancy after surgical excision (one radial sclerosing lesion and one lobular neoplasia), both of which were G1 ductal carcinoma in situ. Cancer probability was significantly higher for contrast-enhancing (18%) than for non-contrast-enhancing (3%) lesions (p = 0.001) and for nonmasslike (43%) than for masslike (14%) lesions (p = 0.005). The positive predictive value was 18% (28/155; 95% CI, 13-24%), the negative predictive value was 97% (70/72; 95% CI, 94-99%), the positive likelihood ratio was 1.448 (95% CI, 1.172-1.788), and the negative likelihood ratio was 0.188 (95% CI, 0.152-0.232). CONCLUSION The absence of enhancement at dynamic MRI allowed reliable exclusion of invasive cancers among high-risk lesions diagnosed at needle biopsy.
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Diagnosis and management of high-risk breast lesions: Aristotle's dilemma. AJR Am J Roentgenol 2012; 198:246-8. [PMID: 22268164 DOI: 10.2214/ajr.11.7269] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Imaging features and management of high-risk lesions on contrast-enhanced dynamic breast MRI. AJR Am J Roentgenol 2012; 198:249-55. [PMID: 22268165 DOI: 10.2214/ajr.11.7610] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Women at high risk for breast cancer and women with newly diagnosed breast cancer often undergo breast MRI. With the increasing availability of MRI-guided biopsy, high-risk lesions are not infrequently encountered. These high-risk lesions include atypical ductal hyperplasia, lobular carcinoma in situ, atypical lobular hyperplasia, papilloma, radial scar, and flat epithelial cell atypia. The management of these lesions is controversial and is often extended to high-risk lesions detected on mammography and ultrasound, with surgical excision usually recommended. The increasing use of MRI for suspicious lesions necessitates review of the imaging characteristics, frequency, and surgical outcome of high-risk lesions identified at MRI. This article addresses the frequency of high-risk lesions detected on breast MRI according to the current literature and discusses MRI features of high-risk lesions, including morphologic and enhancement kinetic characteristics. The surgical outcome for high-risk lesions identified at MRI-guided biopsy will be discussed. Finally, appropriate management guidelines for high-risk lesions identified on MRI-guided biopsy will be determined. CONCLUSION To our knowledge, no studies to date show definitive and specific characteristics for high-risk lesions. Underestimation of malignancy on MRI-guided biopsy currently warrants surgical management for all high-risk lesions. There is a need for prospective larger power studies.
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Nonsurgical Management of High-Risk Lesions Diagnosed at Core Needle Biopsy: Can Malignancy Be Ruled Out Safely With Breast MRI? AJR Am J Roentgenol 2012; 198:272-80. [DOI: 10.2214/ajr.11.7040] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Variations in Physician Recommendations for Surgery After Diagnosis of a High-Risk Lesion on Breast Core Needle Biopsy. AJR Am J Roentgenol 2012; 198:256-63. [DOI: 10.2214/ajr.11.7717] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Management of Patients Diagnosed With Lobular Carcinoma in Situ at Needle Core Biopsy at a Community-Based Outpatient Facility. AJR Am J Roentgenol 2012; 198:281-7. [DOI: 10.2214/ajr.11.7043] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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