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Catanzariti F, Avendano D, Cicero G, Garza-Montemayor M, Sofia C, Venanzi Rullo E, Ascenti G, Pinker-Domenig K, Marino MA. High-risk lesions of the breast: concurrent diagnostic tools and management recommendations. Insights Imaging 2021; 12:63. [PMID: 34037876 PMCID: PMC8155169 DOI: 10.1186/s13244-021-01005-6] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 05/04/2021] [Indexed: 12/14/2022] Open
Abstract
Breast lesions with uncertain malignant behavior, also known as high-risk or B3 lesions, are composed of a variety of pathologies with differing risks of associated malignancy. While open excision was previously preferred to manage all high-risk lesions, tailored management has been increasingly favored to reduce overtreatment and spare patients from unnecessary anxiety or high healthcare costs associated with surgical excision. The purpose of this work is to provide the reader with an accurate overview focused on the main high-risk lesions of the breast: atypical intraductal epithelial proliferation (atypical ductal hyperplasia), lobular neoplasia (including the subcategories lobular carcinoma in situ and atypical lobular hyperplasia), flat epithelial atypia, radial scar and papillary lesions, and phyllodes tumor. Beyond merely presenting the radiological aspects of these lesions and the recent literature, information about their potential upgrade rates is discussed in order to provide a useful guide for appropriate clinical management while avoiding the risks of unnecessary surgical intervention (overtreatment).
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Affiliation(s)
- Francesca Catanzariti
- Department of Biomedical Sciences and Morphologic and Functional Imaging, University of Messina, Messina, Italy
| | - Daly Avendano
- Department of Breast Imaging, Breast Cancer Center TecSalud, ITESM Monterrey, Nuevo Leon, Mexico
| | - Giuseppe Cicero
- Department of Biomedical Sciences and Morphologic and Functional Imaging, University of Messina, Messina, Italy
| | | | - Carmelo Sofia
- Department of Biomedical Sciences and Morphologic and Functional Imaging, University of Messina, Messina, Italy
| | - Emmanuele Venanzi Rullo
- Unit of Infectious Diseases, Department of Clinical and Experimental Medicine, University of Messina, 98124, Messina, Italy
| | - Giorgio Ascenti
- Department of Biomedical Sciences and Morphologic and Functional Imaging, University of Messina, Messina, Italy
| | - Katja Pinker-Domenig
- Department of Radiology, Breast Imaging Service, Memorial Sloan Kettering Cancer Center, Suite 705, 300 E 66th Street, New York, NY, 10065, USA. .,Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria.
| | - Maria Adele Marino
- Department of Biomedical Sciences and Morphologic and Functional Imaging, University of Messina, Messina, Italy
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Eghtedari M, Le-Petross H, Babiera GV, Albarracin CT, Hess KR, Woodtichartpreecha P, Whitman GJ. Not all patients with a diagnosis of a radial scar require excision. Breast J 2019; 25:792-794. [PMID: 31087426 DOI: 10.1111/tbj.13329] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Revised: 03/13/2018] [Accepted: 03/13/2018] [Indexed: 11/27/2022]
Affiliation(s)
- Mohammad Eghtedari
- Department of Diagnostic Radiology, University of California San Diego Health, La Jolla, California
| | - Huong Le-Petross
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Gildy V Babiera
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Constance T Albarracin
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Kenneth R Hess
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Piyanoot Woodtichartpreecha
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, Texas.,Breast Imaging Section, Tanyawej Breast Center, Songklanagarind Hospital, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Gary J Whitman
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, Texas
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Rageth CJ, O'Flynn EAM, Pinker K, Kubik-Huch RA, Mundinger A, Decker T, Tausch C, Dammann F, Baltzer PA, Fallenberg EM, Foschini MP, Dellas S, Knauer M, Malhaire C, Sonnenschein M, Boos A, Morris E, Varga Z. Second International Consensus Conference on lesions of uncertain malignant potential in the breast (B3 lesions). Breast Cancer Res Treat 2018; 174:279-296. [PMID: 30506111 PMCID: PMC6538569 DOI: 10.1007/s10549-018-05071-1] [Citation(s) in RCA: 154] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Accepted: 11/23/2018] [Indexed: 11/24/2022]
Abstract
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.
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Affiliation(s)
- Christoph J Rageth
- Département de Gynécologie et d'Obstétrique, Centre du sein, Hôpitaux Universitaires de Genève, Bd de la Cluse 30, 1211, Geneva 14, Switzerland. .,, Ringlikerstrasse 53, 8142, Uitikon Waldegg, Switzerland.
| | - Elizabeth A M O'Flynn
- The Rose Centre, St George's University Hospitals NHS Foundation Trust, Perimeter Road, London, SW17 0QT, UK
| | - Katja Pinker
- Breast Imaging Service, Department of Radiology, Memorial Sloan Kettering Cancer Center, 300 E 66th St, New York, NY, 10065, USA
| | - Rahel A Kubik-Huch
- Department of Medical Services, Institute of Radiology, Kantonsspital Baden, im Ergel, 5404, Baden, Switzerland
| | - Alexander Mundinger
- Zentrum Radiologie der Niels-Stensen-Kliniken; Marienhospital Osnabrück, Bischofsstraße 1, 49074, Osnabrück, Germany
| | - Thomas Decker
- Institut für Pathologie am Dietrich-Bonhoeffer-Klinikum, Salvador-Allende-Straße 30, 17036, Neubrandenburg, Germany
| | - Christoph Tausch
- Brust-Zentrum Zürich, Seefeldstr. 214, 8008, Zurich, Switzerland
| | - Florian Dammann
- Interventional and Pediatric Radiology, Department of Diagnostic, Inselspital, University Hospital Bern, Freiburgstrasse 10, 3010, Bern, Switzerland
| | - Pascal A Baltzer
- Department of Biomedical Imaging and Image-guided Therapy, Allgemeines Krankenhaus, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Eva Maria Fallenberg
- Department of Radiology, University Hospital, Ludwig Maximilian University Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Maria P Foschini
- Department of Biomedical and Neuromotor Sciences, Unit of Anatomic Pathology at Bellaria Hospital, University of Bologna, Via Altura 3, 40139, Bologna, Italy
| | - Sophie Dellas
- Clinic of Radiology and Nuclear Medicine, University Hospital Basel, University of Basel, Petersgraben 4, 4031, Basel, Switzerland
| | - Michael Knauer
- Breast Center St. Gallen, Cantonal Hospital St. Gallen, Rorschacher Str. 95, 9007, St. Gallen, Switzerland
| | - Caroline Malhaire
- Imaging Department, Institut Curie, PSL Research University, Paris, France
| | - Martin Sonnenschein
- Division of Radiology, Breast Center Bern (Brustzentrum Bern), Klinik Engeried, Lindenhofgruppe AG, Riedweg 15, 3012, Bern, Switzerland
| | - Andreas Boos
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, Rämistr. 100, 8091, Zurich, Switzerland
| | - Elisabeth Morris
- Breast Imaging Service, Department of Radiology, Memorial Sloan Kettering Cancer Center, 300 E 66th St, New York, NY, 10065, USA
| | - Zsuzsanna Varga
- Institute of Pathology and Molecular Pathology, University Hospital Zurich, Switzerland Schmelzbergstrasse 12., 8091, Zurich, Switzerland
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Farshid G, Buckley E. Meta-analysis of upgrade rates in 3163 radial scars excised after needle core biopsy diagnosis. Breast Cancer Res Treat 2018; 174:165-177. [PMID: 30460464 DOI: 10.1007/s10549-018-5040-3] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 11/02/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Since concurrent malignancy may be associated with radial scars (RS) in up to 45% of RS diagnosed on core biopsy, surgical excision is usually advised. Recent very low upgrade rates have caused a re-evaluation of the need for routine surgery. We aimed to find subsets of RS at such low risk of upgrade, as to render imaging surveillance a plausible alternative to surgery. DESIGN We performed a systematic review of the Pubmed, Cochrane and Embase databases, focusing on the following eligibility criteria: full papers, published after 1998, in English, included at least 5 RS, provided information on needle biopsy gauge and upgrade rates based on the excised lesion. For the meta-analysis, studies were grouped by the presence of histologic atypia and the core needle gauge. Study-specific and pooled upgrade rates were calculated for each subgroup. RESULTS 49 studies that included 3163 RS with surgical outcomes are included. There were 217 upgrades to malignancies, 71 (32.7%) invasive and 144 (66.4%) DCIS. The random-effects pooled estimate was 7% (95% CI 5, 9%). Among the pre-planned subgroups, in RS assessed by 14G NCB the upgrade rates were: without atypia - 5% (95% CI 3, 8%), mixed or presence of atypia not specified - 15% (95% CI 10, 20%), with atypia - 29% (95% CI 20, 38%). For RS assessed by a mix of 8-16G cores the respective upgrade rates were 2% (95% CI 1, 4%), 12% (95% CI 6, 18%) and 11% (95% CI 3, 23%) and for RS assessed by 8-11 vacuum assisted biopsies 1% (95% CI 0, 4%), 5% (95% CI 0, 11%) and 18% for the one study of RS with atypia assessed by VAB. Surgery after VAB excision showed no upgrades. The difference across all subgroups was statistically significant. CONCLUSION When stratified by atypia and biopsy gauge, upgrade rates in RS are consistent and predictable. RS assessed by VABs and lacking atypia have a 1% (95% CI 0, 4%) upgrade rate to DCIS. Other groups have upgrade rates of 2-28%. This risk may be reduced by VAB excision. The results of this meta-analysis provide a decision aid and evidence-based selection criteria for surgery after a needle biopsy diagnosis of RS.
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Affiliation(s)
- Gelareh Farshid
- South Australian Pathology, Royal Adelaide Hospital, Adelaide, SA, Australia. .,BreastScreen South Australia, Flinders Street, Adelaide, SA, Australia. .,Discipline of Medicine, Adelaide University, North Terrace, Adelaide, SA, Australia.
| | - Elizabeth Buckley
- Cancer Epidemiology and Population Health Research Group, University of South Australia, Adelaide, Australia
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Ha SM, Cha JH, Shin HJ, Chae EY, Choi WJ, Kim HH, Oh HY. Radial scars/complex sclerosing lesions of the breast: radiologic and clinicopathologic correlation. BMC Med Imaging 2018; 18:39. [PMID: 30390667 PMCID: PMC6215659 DOI: 10.1186/s12880-018-0279-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 10/15/2018] [Indexed: 12/14/2022] Open
Abstract
Background We investigated the radiologic and clinical findings of radial scar and complex sclerosing lesions, and evaluated the rate of pathologic upgrade and predicting factors. Methods From review of our institution’s database from January 2006 to December 2012, we enrolled 82 radial scars/complex sclerosing lesions in 80 women; 51 by ultrasound guided core needle biopsy, 1 by mammography-guided stereotactic biopsy, and 38 by surgical excision. The initial biopsy pathology revealed that 53 lesions were without high risk lesions and 29 were with high risk lesions. Radiologic, clinical and pathological results were analyzed statistically and upgrade rates were calculated. Results Of the 82 lesions, 64 (78.0%) were surgically excised. After surgical excision, two were upgraded to DCIS and two were upgraded to lesions with high risk lesions. The rate of radial scar with high risk lesions was significantly higher in the surgical excision group (11.1% vs. 42.2%, p = 0.015), which also demonstrated larger lesion size (10.7 ± 6.5 vs. 7.1 ± 2.6 mm, p = 0.001). The diagnoses with high risk lesions on final pathological results showed older age (52.9 ± 6.0 years vs. 48.4 ± 6.7 years, p = 0.018). Conclusions Radial scars with and without high risk lesions showed no statistically significant differences in imaging, and gave relatively low cancer upgrade rates. Electronic supplementary material The online version of this article (10.1186/s12880-018-0279-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Su Min Ha
- Department of Radiology, Research Institute of Radiology, Chung-Ang University Hospital, Chung-Ang University College of Medicine, 84 Heukseok-Ro, Dongjak-Gu, Seoul, 06973, Republic of Korea
| | - Joo Hee Cha
- Department of Radiology, Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-Ro 43 Gil, Songpa-Gu, Seoul, 05505, Republic of Korea.
| | - Hee Jung Shin
- Department of Radiology, Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-Ro 43 Gil, Songpa-Gu, Seoul, 05505, Republic of Korea
| | - Eun Young Chae
- Department of Radiology, Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-Ro 43 Gil, Songpa-Gu, Seoul, 05505, Republic of Korea
| | - Woo Jung Choi
- Department of Radiology, Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-Ro 43 Gil, Songpa-Gu, Seoul, 05505, Republic of Korea
| | - Hak Hee Kim
- Department of Radiology, Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-Ro 43 Gil, Songpa-Gu, Seoul, 05505, Republic of Korea
| | - Ha-Yeon Oh
- Department of Radiology, Kangwon National University Hospital, 200-722 Baengnyeong-Ro 156, Chuncheon-Si, Republic of Korea
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Abstract
PURPOSE Radial scar's stellate appearance may mimic carcinoma mammographically and histologically. Management of radial scar (RS) found on breast core needle biopsies (CNB) ranges from excision to clinical observation due to the variation in reported upgrades to malignancy at surgical excision. We examined the upgrade rate in patients with RS detected on CNB at our institution and reviewed the current literature. METHODS A retrospective study was conducted of all cases with RS diagnosed on CNB between December 2006 and March 2017 at our institution. Inclusion criteria were patients with "pure" RS and RS associated with high-risk lesions (HRL). Upgrade was defined as invasive or non-invasive cancer in the excisional biopsy. RESULTS 157 cases were identified with RS on CNB, and 122 cases met inclusion criteria. Of these 122 cases, 91 (75%) had pure RS on CNB while 31 (25%) had associated atypia or HRL. 81 (66%) of patients proceeded to excisional biopsy and 41 (34%) did not. Two patients (1.6% of total) were found to have a low-grade invasive ductal carcinoma (0.6 and 0.8 cm) upon surgical excision. None of the remaining 120 patients developed an ipsilateral breast cancer with a mean of 32.3-month follow-up. CONCLUSIONS We found a very low upgrade rate to breast cancer when RS was found on CNB with or without associated HRL. Our results are consistent with other reported series. Our data do not support surgical excision for RS but rather close clinical follow-up for patients with RS on CNB.
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Radial Scars of the Breast Encountered at Core Biopsy: Review of Histologic, Imaging, and Management Considerations. AJR Am J Roentgenol 2017; 209:1168-1177. [PMID: 28813198 DOI: 10.2214/ajr.17.18156] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The purposes of this article are to place the controversy over the management of radial scars diagnosed at core biopsy in perspective and to define reasonable management options. CONCLUSION The management of radial scars after image-guided core biopsy of the breast for diagnosis remains controversial. Although current literature suggests no premalignant potential of these lesions, it does not fully explain the small but real percentage of these lesions that are upgraded to malignancy after surgical excision. This upgrade phenomenon is probably best explained by core biopsy sampling error. A recommendation minimizing this possibility based on lesion size seems reasonable.
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