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Xie CL, Whitman GJ, Middleton LP, Bevers TB, Bedrosian I, Chung HL. Isolated Flat Epithelial Atypia: Upgrade Outcomes After Multidisciplinary Review-Based Management Using Excision or Imaging Surveillance. JOURNAL OF BREAST IMAGING 2023; 5:575-584. [PMID: 37744722 PMCID: PMC10516722 DOI: 10.1093/jbi/wbad049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Indexed: 09/26/2023]
Abstract
Objective To compare flat epithelial atypia (FEA) upgrade rates after excision versus surveillance and to identify variables associated with upgrade. Methods This single-institution retrospective study identified isolated FEA cases determined by percutaneous biopsy from April 2005 through July 2022 with excision or ≥2 years surveillance. All cases were recommended for excision or surveillance based on multidisciplinary discussion of clinical, imaging, and pathologic variables with emphasis on sampling adequacy and significant atypia. Truth was determined by pathology at excision or the absence of cancer on surveillance. Upgrade was defined as cancer occurring ≤2 cm from the biopsy site. Demographic, imaging, and biopsy variables were compared between those that did and did not upgrade. Results Among 112 cases of isolated FEA, imaging findings included calcifications in 81.3% (91/112), MRI lesions in 11.6% (13/112), and distortions or masses in 7.1% (8/112). Excision was recommended in 12.5% (14/112) and surveillance in 87.5% (98/112) of cases. Among those recommended for excision, 28.6% (4/14) of cases were upgraded, all to ductal carcinoma in situ. In those recommended for surveillance, 1.0% (1/98) were upgraded to invasive cancer. Overall, FEA had a 4.5% (5/112) upgrade rate, and 2.7% (3/112) also developed cancer >2 cm from the FEA. There were no significant differences in demographic, imaging, and biopsy variables between those that did and did not upgrade to cancer. Conclusion Multidisciplinary management of isolated FEA distinguishes those at higher risk of upgrade to cancer (28.6%) in whom surgery is warranted from those at low risk of upgrade (1.0%) who can be managed non-operatively.
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Affiliation(s)
- Charlies L Xie
- MD Anderson Cancer Center, Department of Breast Imaging, Houston, TX, USA
| | - Gary J Whitman
- MD Anderson Cancer Center, Department of Breast Imaging, Houston, TX, USA
| | | | - Therese B Bevers
- MD Anderson Cancer Center, Department of Clinical Cancer Prevention, Houston, TX, USA
| | - Isabelle Bedrosian
- MD Anderson Cancer Center, Department of Breast Surgical Oncology, Houston, TX, USA
| | - Hannah L Chung
- MD Anderson Cancer Center, Department of Breast Imaging, Houston, TX, USA
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Strickland S, Turashvili G. Are Columnar Cell Lesions the Earliest Non-Obligate Precursor in the Low-Grade Breast Neoplasia Pathway? Curr Oncol 2022; 29:5664-5681. [PMID: 36005185 PMCID: PMC9406596 DOI: 10.3390/curroncol29080447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 08/09/2022] [Accepted: 08/09/2022] [Indexed: 11/16/2022] Open
Abstract
Columnar cell lesions (CCLs) of the breast comprise a spectrum of morphologic alterations of the terminal duct lobular unit involving variably dilated and enlarged acini lined by columnar epithelial cells. The World Health Organization currently classifies CCLs without atypia as columnar cell change (CCC) and columnar cell hyperplasia (CCH), whereas flat epithelial atypia (FEA) is a unifying term encompassing both CCC and CCH with cytologic atypia. CCLs have been increasingly recognized in stereotactic core needle biopsies (CNBs) performed for the assessment of calcifications. CCLs are believed to represent the earliest non-obligate precursor of low-grade invasive breast carcinomas as they share molecular alterations and often coexist with entities in the low-grade breast neoplasia pathway. Despite this association, however, the risk of progression of CCLs to invasive breast carcinoma appears low and may not exceed that of concurrent proliferative lesions. As the reported upgrade rates of pure CCL/FEA when identified as the most advanced high-risk lesion on CNB vary widely, the management of FEA diagnosed on CNB remains controversial. This review will include a historical overview of CCLs and will examine histologic diagnostic criteria, molecular alterations, prognosis and issues related to upgrade rates and clinical management.
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Affiliation(s)
- Sarah Strickland
- Department of Pathology and Laboratory Medicine, Faculty of Medicine, University of Ottawa, Ottawa, ON K1N 6N5, Canada
| | - Gulisa Turashvili
- Department of Pathology and Laboratory Medicine, Emory University Hospital, Emory University School of Medicine, Atlanta, GA 30322, USA
- Correspondence:
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Mohrmann S, Maier-Bode A, Dietzel F, Reinecke P, Krawczyk N, Kaleta T, Kreimer U, Antoch G, Fehm TN, Roth KS. Malignancy Rate and Malignancy Risk Assessment in Different Lesions of Uncertain Malignant Potential in the Breast (B3 Lesions): An Analysis of 192 Cases from a Single Institution. Breast Care (Basel) 2022; 17:159-165. [PMID: 35702494 PMCID: PMC9149469 DOI: 10.1159/000517109] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Accepted: 05/02/2021] [Indexed: 02/26/2024] Open
Abstract
BACKGROUND The question of how to deal with B3 lesions is of emerging interest. METHODS In the breast diagnostics of 192 patients between 2009 and 2016, a minimally invasive biopsy revealed a B3 lesion with subsequent resection. This study investigates the malignancy rate of different B3 subgroups and the risk factors that play a role in obtaining a malignant finding. RESULTS The distribution of B3 lesions after minimally invasive biopsy was as follows: atypical ductal hyperplasia (ADH), 7.3%; flat epithelial atypia (FEA), 7.8%; lobular neoplasia (LN), 7.8%; papilloma (Pa), 49.5%; phylloidal tumour (PT), 8.9%; radial sclerosing scar (RS), 3.1%; mixed findings, 10.4%; and other B3 lesions, 5.2%. Most B3 lesions were detected by stereotactic vacuum-assisted biopsy (44.3%), 36.5% by ultrasound-assisted biopsy, and 19.3% by magnetic resonance imaging-assisted biopsy. Most B3 lesions (55.2%) were verified by surgical resection, whereas 30.7% were downgraded to a benign lesion. About 14.1% of the cases were upgraded to malignant lesions, 9.4% to ductal carcinoma in situ and 4.7% to invasive carcinoma. In relation to individual B3 lesions, the following malignancy rates were found: 28.6% (ADH), 13.3% (FEA), 33.3% (LN), 12.6% (Pa), 5.9% (PT), and 0% (RS). The most important risk factor was increasing age. Postmenopausal status was considered an increased risk for an upgrade (p = 0.015). A known malignancy in the ipsilateral breast was a significant risk factor for a malignant upgrade (p = 0.003). CONCLUSION Increasing knowledge about B3 lesions allows us to develop a "lesion-specific" therapy approach in the heterogeneous group of B3 lesions, with follow-up imaging for some lesions with less malignant potential and concordance with imaging or further surgical resection in cases of disconcordance with imaging or higher malignant potential.
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Affiliation(s)
- Svjetlana Mohrmann
- Department of Gynecology and Obstetrics, Medical Faculty, Interdisciplinary Breast Centre, University of Düsseldorf, Düsseldorf, Germany
| | - Anna Maier-Bode
- Department of Gynecology and Obstetrics, Medical Faculty, Interdisciplinary Breast Centre, University of Düsseldorf, Düsseldorf, Germany
| | - Frederic Dietzel
- Department of Diagnostic and Interventional Radiology, Medical Faculty, University of Düsseldorf, Düsseldorf, Germany
| | - Petra Reinecke
- Institute of Pathology, Medical Faculty, University of Düsseldorf, Düsseldorf, Germany
| | - Natalia Krawczyk
- Department of Gynecology and Obstetrics, Medical Faculty, Interdisciplinary Breast Centre, University of Düsseldorf, Düsseldorf, Germany
| | - Thomas Kaleta
- Department of Gynecology and Obstetrics, Medical Faculty, Interdisciplinary Breast Centre, University of Düsseldorf, Düsseldorf, Germany
| | - Ulrike Kreimer
- Department of Gynecology and Obstetrics, Medical Faculty, Interdisciplinary Breast Centre, University of Düsseldorf, Düsseldorf, Germany
| | - Gerald Antoch
- Department of Diagnostic and Interventional Radiology, Medical Faculty, University of Düsseldorf, Düsseldorf, Germany
| | - Tanja N. Fehm
- Department of Gynecology and Obstetrics, Medical Faculty, Interdisciplinary Breast Centre, University of Düsseldorf, Düsseldorf, Germany
| | - Katrin Sabine Roth
- Department of Diagnostic and Interventional Radiology, Medical Faculty, University of Düsseldorf, Düsseldorf, Germany
- ZRN Rheinland, Center for Radiology and Nuclear Medicine, Korschenbroich, Germany
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4
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Ferre R, Kuzmiak CM. Upgrade rate of percutaneously diagnosed pure flat epithelial atypia: systematic review and meta-analysis of 1,924 lesions. J Osteopath Med 2022; 122:253-262. [PMID: 35150124 DOI: 10.1515/jom-2021-0206] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Accepted: 12/14/2021] [Indexed: 12/29/2022]
Abstract
CONTEXT Management remains controversial due to the risk of upgrade for malignancy from flat epithelial atypia (FEA). Data about the frequency and malignancy upgrade rates are scant. Namely, observational follow-up is advised by many studies in cases of pure FEA on core biopsy and in the absence of an additional surgical excision. For cases of pure FEA, the American College of Surgeons no longer recommends surgical excision but rather recommends observation with clinical and imaging follow-up. OBJECTIVES The aim of this study is to perform a systematic review and meta-analysis to calculate the pooled upgrade of pure FEA following core needle biopsies. METHODS A search of MEDLINE and Embase databases were conducted in December 2020. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. A fixed- or random-effects model was utilized. Heterogeneity among studies was estimated by utilizing the I2 statistic and considered high if the I2 was greater than 50%. The random-effects model with the DerSimonian and Laird method was utilized to calculate the pooled upgrade rate and its 95% confidence interval. RESULTS A total of 1924 pure FEA were analyzed among 59 included studies. The overall pooled upgrade rate to malignancy was 8.8%. The pooled upgrade rate for mammography only was 8.9%. The pooled upgrade rate for ultrasound was 14%. The pooled upgrade rate for mammography and ultrasound combined was 8.8%. The pooled upgrade rate for MRI-only cases was 27.3%. CONCLUSIONS Although the guidelines for the management of pure FEA are variable, our data support that pure FEA diagnosed at core needle biopsy should undergo surgical excision since the upgrade rate >2%.
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Affiliation(s)
- Romuald Ferre
- Centre hospital de la Sarre, 679 Route 111, La Sarre, QC J9Z 2Y9, Canada
- Department of Radiology, Hopital du Grand Portage, Riviere du Loup, QC, Canada
| | - Cherie M Kuzmiak
- Department of Radiology, UNC School of Medicine, Chapel Hill, NC, USA
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Anderson S, Parker E, Rahbar H, Scheel JR. IV Ductal Carcinoma In Situ, Including its Histologic Subtypes and Grades. CURRENT BREAST CANCER REPORTS 2021. [DOI: 10.1007/s12609-021-00439-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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6
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Flat epithelial atypia: What the radiologist needs to know in 2021. Clin Imaging 2021; 75:150-156. [PMID: 33592394 DOI: 10.1016/j.clinimag.2021.01.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Revised: 01/10/2021] [Accepted: 01/28/2021] [Indexed: 11/22/2022]
Abstract
The World Health Organization defines flat epithelial atypia (FEA), as a "presumably neoplastic intraductal alteration characterized by the replacement of native epithelial cells by a single layer or three to five layers of mildly atypical cells.". In this article, we will review FEA and compare its characteristics and differences with other atypical high-risk breast lesions. In addition, the imaging appearance of FEA will be described. Finally, we will discuss current outcomes and provide an update on its management based on the last recommendations.
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7
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Wahab RA, Lee SJ, Mulligan ME, Zhang B, Mahoney MC. Upgrade Rate of Pure Flat Epithelial Atypia Diagnosed at Core Needle Biopsy: A Systematic Review and Meta-Analysis. Radiol Imaging Cancer 2021; 3:e200116. [PMID: 33778758 PMCID: PMC7983762 DOI: 10.1148/rycan.2021200116] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 11/11/2020] [Accepted: 11/19/2020] [Indexed: 11/11/2022]
Abstract
Purpose To perform a systematic review and meta-analysis to calculate the pooled upgrade rate of pure flat epithelial atypia (FEA) diagnosed at core needle biopsy (CNB). Materials and Methods A PubMed and Embase database search was performed in December 2019. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. Study quality and publication bias were assessed. The upgrade rate of pure FEA to cancer, invasive carcinoma, and ductal carcinoma in situ (DCIS), as well as the co-occurrence rate of atypical ductal hyperplasia (ADH), with 95% CIs were calculated. A random effect model was used to integrate the proportions and their corresponding 95% CI. Study heterogeneity was calculated using τ2 and I 2 . Results A total of 2482 cases of pure FEA across 42 studies (mean age range, 46-59 years) met inclusion criteria to be analyzed. Significant study heterogeneity was identified (τ2 = 0.001, I 2 = 67%). The pooled upgrade rates reported for pure FEA were 5% (95% CI: 3%, 6%) for breast cancer, 1% (95% CI: 0%, 2%) for invasive carcinoma, and 2% (95% CI: 1%, 3%) for DCIS. When more than 90% of calcifications were removed at CNB, the pooled upgrade rate was 0% (95% CI: 0%, 2%). The pooled co-occurrence rate of ADH at surgical excision was 17% (95% CI: 12%, 21%). Study quality was medium to high with a risk of publication bias (P < .01). Conclusion Pure FEA diagnosed at CNB should be surgically excised due to the pooled upgrade rate of 5% for breast cancer. If more than 90% of the targeted calcifications are removed by CNB for pure FEA, close imaging follow-up is recommended.Keywords: Biopsy/Needle Aspiration, Breast, MammographySupplemental material is available for this article.© RSNA, 2021.
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Affiliation(s)
- Rifat A. Wahab
- From the Department of Radiology, University of Cincinnati Medical Center, 234 Goodman St, ML 0761, Cincinnati, OH 45267-0761 (R.A.W., S.J.L., M.E.M., M.C.M.); and Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio (B.Z.)
| | - Su-Ju Lee
- From the Department of Radiology, University of Cincinnati Medical Center, 234 Goodman St, ML 0761, Cincinnati, OH 45267-0761 (R.A.W., S.J.L., M.E.M., M.C.M.); and Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio (B.Z.)
| | - Margaret E. Mulligan
- From the Department of Radiology, University of Cincinnati Medical Center, 234 Goodman St, ML 0761, Cincinnati, OH 45267-0761 (R.A.W., S.J.L., M.E.M., M.C.M.); and Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio (B.Z.)
| | - Bin Zhang
- From the Department of Radiology, University of Cincinnati Medical Center, 234 Goodman St, ML 0761, Cincinnati, OH 45267-0761 (R.A.W., S.J.L., M.E.M., M.C.M.); and Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio (B.Z.)
| | - Mary C. Mahoney
- From the Department of Radiology, University of Cincinnati Medical Center, 234 Goodman St, ML 0761, Cincinnati, OH 45267-0761 (R.A.W., S.J.L., M.E.M., M.C.M.); and Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio (B.Z.)
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8
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Lucioni M, Rossi C, Lomoro P, Ballati F, Fanizza M, Ferrari A, Garcia-Etienne CA, Boveri E, Meloni G, Sommaruga MG, Ferraris E, Lasagna A, Bonzano E, Paulli M, Sgarella A, Di Giulio G. Positive predictive value for malignancy of uncertain malignant potential (B3) breast lesions diagnosed on vacuum-assisted biopsy (VAB): is surgical excision still recommended? Eur Radiol 2020; 31:920-927. [PMID: 32816199 DOI: 10.1007/s00330-020-07161-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 06/20/2020] [Accepted: 08/06/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE Breast lesions classified as of "uncertain malignant potential" represent a heterogeneous group of abnormalities with an increased risk of associated malignancy. Clinical management of B3 lesions diagnosed on vacuum-assisted breast biopsy (VABB) is still challenging: surgical excision is no longer the only available treatment and VABB may be sufficient for therapeutic excision. The aim of the present study is to evaluate the positive predictive value (PPV) for malignancy in B3 lesions that underwent surgical excision, identifying possible upgrading predictive factors and characterizing the malignant lesions eventually diagnosed. These results are compared with a subset of patients with B3 lesions who underwent follow-up. METHODS A total of 1250 VABBs were performed between January 2006 and December 2017 at our center. In total, 150 B3 cases were diagnosed and 68 of them underwent surgical excision. VABB findings were correlated with excision histology. A PPV for malignancy for each B3 subtype was derived. RESULTS The overall PPV rate was 28%, with the highest upgrade rate for atypical ductal hyperplasia (41%), followed by classical lobular neoplasia (29%) and flat epithelial atypia (11%). Only two cases of carcinoma were detected in the follow-up cohort, both associated with atypical ductal hyperplasia at VABB. CONCLUSION Open surgery is recommended in case of atypical ductal hyperplasia while, for other B3 lesions, excision with VABB only may be an acceptable alternative if radio-pathological correlation is assessed, if all microcalcifications have been removed by VABB, and if the lesion lacks high-risk cytological features. KEY POINTS • Surgical treatment is strongly recommended in case of ADH, while the upgrade rate in case of pure FEA, especially following complete microcalcification removal by VABB, may be sufficiently low to advice surveillance as a management strategy. • The use of 11-G- or 8-G-needle VABB, resulting in possible complete diagnostic excision of the lesion, can be an acceptable alternative in case of RS, considering open surgery only for selected high-risk patients. • LN management is more controversial: surgical excision may be recommended following classical LN diagnosis on breast biopsy if an additional B3 lesion is concurrently detected while in the presence of isolated LN with adequate radiological-pathological correlation follow-up alone could be an acceptable option.
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Affiliation(s)
- Marco Lucioni
- Anatomic Pathology Section, Department of Human Pathology, University of Pavia, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Chiara Rossi
- Anatomic Pathology Section, Department of Human Pathology, University of Pavia, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Pascal Lomoro
- Breast Imaging Department, Valduce Hospital, Via Dante Alighieri 11, 22100, Como, Italy.
| | - Francesco Ballati
- Breast Imaging Department, University of Pavia, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Marianna Fanizza
- Breast Imaging Department, University of Pavia, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Alberta Ferrari
- Breast Surgery Department, Fondazione IRCCS Policlinico San Matteo, Università degli Studi di Pavia, Pavia, Italy
| | - Carlos A Garcia-Etienne
- Breast Surgery Department, Fondazione IRCCS Policlinico San Matteo, Università degli Studi di Pavia, Pavia, Italy
| | - Emanuela Boveri
- Anatomic Pathology Section, Department of Human Pathology, University of Pavia, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Giulia Meloni
- Breast Imaging Department, University of Pavia, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Maria Grazia Sommaruga
- Breast Imaging Department, University of Pavia, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Elisa Ferraris
- Medical Oncology, Fondazione IRCCS Policlinico San Matteo and, Università degli Studi, Pavia, Italy
| | - Angioletta Lasagna
- Medical Oncology, Fondazione IRCCS Policlinico San Matteo and, Università degli Studi, Pavia, Italy
| | - Elisabetta Bonzano
- University of Pavia and Department of Radiation Oncology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Marco Paulli
- Anatomic Pathology Section, Department of Human Pathology, University of Pavia, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Adele Sgarella
- Breast Surgery Department, Fondazione IRCCS Policlinico San Matteo, Università degli Studi di Pavia, Pavia, Italy
| | - Giuseppe Di Giulio
- Breast Imaging Department, University of Pavia, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
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9
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Miller-Ocuin JL, Fowler BB, Coldren DL, Chiba A, Levine EA, Howard-McNatt M. Is Excisional Biopsy Needed for Pure FEA Diagnosed on a Core Biopsy? Am Surg 2020; 86:1088-1090. [PMID: 32816560 DOI: 10.1177/0003134820943546] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The management of flat epithelial atypia (FEA) on core needle biopsy remains controversial. The upstaging rates after surgical excision are variable. In this study, we seek to determine the upstaging rate of FEA at our institution. METHODS Patients with a diagnosis of FEA were identified from the institution's pathology database from 2009 to 2018. Patients were included in the study if FEA alone, without atypia or cancer, was identified on core needle biopsy. Patient demographics, imaging, management, and pathology characteristics were obtained. Statistical analysis performed using IBM SPSS 26.0 (Armonk, NY, USA). RESULTS FEA was diagnosed on core needle biopsy in 235 patients from 2009 to December 2018. Forty-eight patients met the inclusion criteria. The majority of patients presented with calcifications on mammogram (n = 21, 64%) with the remainder as masses (n = 6, 18%) or architectural distortion (n = 6, 18%). Of those, 15 (31%) patients declined surgical excision, of which none developed cancer over a mean follow-up of 4.4 years. Of the 33 (69%) patients undergoing excisional biopsy, 17 (52%) confirmed FEA, 11 (33%) had benign findings, and 3 (9%) demonstrated atypical ductal hyperplasia on final pathology. One (3%) case revealed ductal carcinoma in situ (DCIS) and 1 (3%) was upgraded to invasive cancer for an overall upstaging rate of 4% (2/48). After a mean follow-up of 3.4 years, none of the excisional biopsy patients developed invasive breast cancer. Adjuvant therapy was used in the cases of DCIS and invasive cancer; however, chemoprevention with raloxifene or tamoxifen was not chosen by any of the remaining patients. CONCLUSION In our cohort, expectant management of FEA alone appears to be a safe option as our upstaging rate to DCIS or invasive cancer for FEA diagnosed on core biopsy was only 4%. Our study suggests that close follow-up is a safe and feasible option for pure FEA without a radiographic discordance found on core biopsy.
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Affiliation(s)
| | - Brett B Fowler
- 12280 Department of Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Daniel L Coldren
- 12280 Department of Pathology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Akiko Chiba
- 12280 Division of Surgical Oncology, Department of Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Edward A Levine
- 12280 Division of Surgical Oncology, Department of Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Marissa Howard-McNatt
- 12280 Division of Surgical Oncology, Department of Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
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10
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Mariscotti G, Durando M, Ruggirello I, Belli P, Caumo F, Nori J, Zuiani C, Tagliafico A, Bicchierai G, Romanucci G, Londero V, Campanino PP, Bussone R, Castellano I, Mule' A, Caneva A, Bianchi S, Di Loreto C, Bergamasco L, Calabrese M, Fonio P, Houssami N. Lesions of uncertain malignant potential of the breast (B3) on vacuum-assisted biopsy for microcalcifications: Predictors of malignancy. Eur J Radiol 2020; 130:109194. [PMID: 32795765 DOI: 10.1016/j.ejrad.2020.109194] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Revised: 07/04/2020] [Accepted: 07/21/2020] [Indexed: 12/31/2022]
Abstract
PURPOSE To investigate clinical, radiologic and pathologic features of B3 lesions diagnosed on VABB targeting microcalcifications, for identifying predictors of malignancy. METHOD This retrospective multi-centre study included consecutive VABBs performed over a 10-year period on suspicious microcalcifications not associated with other radiological signs diagnosed as B3 on histology from VABB, with outcomes ascertained by surgical excision. Clinical, demographic, radiological and histological (B3 subcategory) data were collected. For statistical analysis (univariate and binary logistic regression), the primary outcome variable was the upgrade rate to malignancy after surgery. Predictors of upgrade to malignancy were identified from clinical, demographic, radiological and pathological variables (including B3 subcategory). RESULTS Amongst 447 VABBs, there were 57(12.7 %) upgrades to malignancy at surgical histology (36 DCIS and 21 invasive cancer). At univariate analysis, variables significantly associated with increased risk of upgrade to malignancy were age>55 years (p = 0.01), lesion size>10 mm (p < 0.0001), BI-RADS 4b-c and 5 (p = 0.0001), and fine pleomorphic morphology (p = 0.002) of microcalcifications. Binary logistic regression confirmed as significant independent risk factors age, lesion size and BI-RADS category (p = 0.02, 0.02 and 0.0006 respectively). Amongst subcategories of B3 lesions, lobular neoplasia was significantly(p = 0.04) associated with upgrade, confirmed as an independent risk factor [p = 0.03, OR = 2.3(1.1-4.7)]. Flat epithelial atypia was significantly(p = 0.004) associated with reduced odds of upgrade, but binary logistic regression showed only borderline association [p = 0.052, OR = 0.4(0.2-1.01)]. CONCLUSIONS Across B3 lesions diagnosed on histology from VABB of suspicious microcalcifications, older age, size>10 mm, BI-RADS category≥ 4b on imaging, and lobular neoplasia were risk factors for upgrade to malignancy. This information can be used to discuss patients' tailored management options.
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Affiliation(s)
- Giovanna Mariscotti
- Radiology Institute, University of Turin, Department of Diagnostic Imaging and Radiotherapy, A. O. U. Citta della Salute e della Scienza di Torino - Presidio Ospedaliero Molinette, Via Genova 3, 10126, Torino, Italy.
| | - Manuela Durando
- Radiology Institute, University of Turin, Department of Diagnostic Imaging and Radiotherapy, A. O. U. Citta della Salute e della Scienza di Torino - Presidio Ospedaliero Molinette, Via Genova 3, 10126, Torino, Italy.
| | - Irene Ruggirello
- Radiology Institute, University of Turin, Department of Diagnostic Imaging and Radiotherapy, A. O. U. Citta della Salute e della Scienza di Torino - Presidio Ospedaliero Molinette, Via Genova 3, 10126, Torino, Italy.
| | - Paolo Belli
- Department of Radiological, Radiotherapic and Hematological Sciences, Fondazione Policlinico A. Gemelli IRCCS - Universita' Cattolica Sacro Cuore, Largo Agostino Gemelli 8, 00168, Rome, Italy.
| | - Francesca Caumo
- Radiology Department, Veneto Institute of Oncology IOV - IRCCS, Padua, Italy.
| | - Jacopo Nori
- Diagnostic Senology Unit, Azienda Ospedaliero-Universitaria Careggi, Largo G. A. Brambilla 3, 50134, Florence, Italy.
| | - Chiara Zuiani
- Institute of Radiology, Department of Medicine, University of Udine, University Hospital S. Maria della Misericordia, P.le S. Maria della Misericordia, 15, 33100, Udine, Italy.
| | - Alberto Tagliafico
- Department of Health Sciences (DISSAL), University of Genoa, Genova, Italy; Department of Radiology, IRCCS San Martino Hospital, 16132, Genova, Italy.
| | - Giulia Bicchierai
- Diagnostic Senology Unit, Azienda Ospedaliero-Universitaria Careggi, Largo G. A. Brambilla 3, 50134, Florence, Italy.
| | - Giovanna Romanucci
- UOSD Breast Unit ULSS9, Ospedale di Marzana, Piazzale Lambranzi, 1, 37034 Verona, Italy.
| | - Viviana Londero
- Institute of Radiology, Department of Medicine, University of Udine, University Hospital S. Maria della Misericordia, P.le S. Maria della Misericordia, 15, 33100, Udine, Italy.
| | - Pier Paolo Campanino
- Breast Imaging Service, Ospedale Koelliker, C.so Galileo Ferraris 256, 10100, Torino, Italy.
| | - Riccardo Bussone
- Breast Surgery, Presidio Sanitario Ospedale Cottolengo, Via S. Giuseppe Benedetto Cottolengo, 9, 10152, Torino, Italy.
| | | | - Antonino Mule'
- Department of Histopathology and Cytodiagnosis, Fondazione Policlinico A. Gemelli IRCCS -Universita' Cattolica Sacro Cuore, Largo Agostino Gemelli 8, 00168, Rome, Italy.
| | | | - Simonetta Bianchi
- Division of Pathological Anatomy, Department of medical and surgical critical care, University of Florence, Florence, Italy.
| | - Carla Di Loreto
- Anatomic Pathology Institute, Department of Medicine (DAME), University of Udine, Udine, Italy.
| | - Laura Bergamasco
- Department of Surgical Sciences, University of Torino, A. O. U. Citta della Salute e della Scienza di Torino - Presidio Ospedaliero Molinette, C.so Bramante 88, 10126, Torino, Italy.
| | - Massimo Calabrese
- Diagnostic Senology, IRCCS - Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, Italy.
| | - Paolo Fonio
- Radiology Institute, University of Turin, Department of Diagnostic Imaging and Radiotherapy, A. O. U. Citta della Salute e della Scienza di Torino - Presidio Ospedaliero Molinette, Via Genova 3, 10126, Torino, Italy.
| | - Nehmat Houssami
- Screening and Test Evaluation Program, School of Public Health, Sydney Medical School, University of Sydney, Sydney 2006, NSW, Australia.
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11
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Flat Epithelial Atypia in Breast Core Needle Biopsies With Radiologic-Pathologic Concordance: Is Excision Necessary? Am J Surg Pathol 2020; 44:182-190. [PMID: 31609784 DOI: 10.1097/pas.0000000000001385] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Flat epithelial atypia (FEA) is an alteration of terminal duct lobular units by a proliferation of ductal epithelium with low-grade atypia. No consensus exists on whether the diagnosis of FEA in core needle biopsy (CNB) requires excision (EXC). We retrospectively identified all in-house CNBs obtained between January 2012 and July 2018 with FEA. We reviewed all CNB slides and assessed radiologic-pathologic concordance. An upgrade was defined as invasive carcinoma (IC) and/or ductal carcinoma in situ in the EXC. The EXC slides of all upgraded cases were rereviewed. Out of ∼15,700 consecutive CNBs in the study period, 106 CNBs from 106 patients yielded FEA alone or with classic lobular neoplasia (LN). We excluded 52 CNBs (40 patients with prior/concurrent carcinoma and 12 without EXC). After rereview, we reclassified 14 cases (2 marked nuclear atypia, 10 focal atypical ductal hyperplasia, 2 benign). The final FEA study cohort consisted of 40 CNBs from 40 women. The CNB targeted mammographic calcifications in 36 (90%) cases, magnetic resonance imaging nonmass enhancement in 3 (8%), and 1 (2%) sonographic mass. All CNBs were deemed radiologic-pathologic concordant. FEA was present alone in 34 CNBs and with LN in 6. EXC yielded 2 low-grade IC, each spanning <2 mm, identified in tissue sections without biopsy site changes. The remaining 38 cases had no upgrade. Classic LN did not affect the upgrade. The upgrade rate of FEA was 5%; both minute, low-grade "incidental" IC. We conclude that nonsurgical management may be considered in patients without prior/concurrent carcinoma and radiologic-pathologic concordant CNB diagnosis of FEA.
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Liu C, Dingee CK, Warburton R, Pao JS, Kuusk U, Bazzarelli A, Sidhu R, McKevitt EC. Pure flat epithelial atypia identified on core needle biopsy does not require excision. Eur J Surg Oncol 2020; 46:235-239. [DOI: 10.1016/j.ejso.2019.10.029] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Revised: 09/09/2019] [Accepted: 10/23/2019] [Indexed: 11/30/2022] Open
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13
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DiPasquale A, Silverman S, Farag E, Peiris L. Flat epithelial atypia: are we being too aggressive? Breast Cancer Res Treat 2019; 179:511-517. [PMID: 31701300 DOI: 10.1007/s10549-019-05481-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Accepted: 10/21/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE The malignant upgrade rate of flat epithelial atypia (FEA) diagnosed on core needle biopsy varies between 0 and 30%. Excision versus observation with radiological follow-up for these lesions remains controversial. We hypothesize that the local rate of FEA is low and that close radiological surveillance is a reasonable treatment option for patients diagnosed with pure FEA on breast needle core needle biopsy. METHODS This study was a retrospective review of a prospectively collated provincial pathology database. Patients diagnosed with FEA alone on needle core biopsy between 2006 and 2016 were included in our analysis. Patients who had FEA present together with either in situ or invasive carcinoma within the same biopsy cores were excluded. Along with patient demographics, the size of the lesion on preoperative imaging, the method of extraction, and the presence of co-existing benign and malignant pathology on final excision biopsy were analyzed. An independent pathological review was performed to confirm our results and help reduce inter-observer bias. RESULTS The local rate of malignant upgrade when pure FEA is diagnosed on a breast needle core biopsy is 12%. Age at time of diagnosis, size of original lesion on mammogram, presence of atypical ductal hyperplasia (ADH) or atypical lobular hyperplasia on core needle biopsy, the use of vacuum-assisted biopsy (VAB), or concordant imaging did not significantly correlate with malignant upgrade risk. None of the patients who were managed with radiological follow-up had malignant upgrade during follow-up. Patients undergoing radiological follow-up alone were more likely to have a VAB, concordant imaging, and no concurrent ADH. CONCLUSION Our local malignant upgrade rate is consistent with published literature. We suggest radiological follow-up is a safe alternative in patients with pure flat epithelial atypia and concordant imaging, particularly those patients with small lesions in which microcalcifications can be removed completely with vacuum-assisted biopsy.
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Affiliation(s)
| | - Sveta Silverman
- Department of Laboratory Medicine, Covenant Health, Misericordia Community Hospital, University of Alberta, Edmonton, AB, Canada
| | - Erene Farag
- Department of Laboratory Medicine, Covenant Health, Misericordia Community Hospital, University of Alberta, Edmonton, AB, Canada
| | - Lashan Peiris
- Department of Surgery, Covenant Health, Misericordia Community Hospital, University of Alberta, Edmonton, AB, Canada
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14
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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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15
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Winer LK, Hinrichs BH, Lu S, Hanseman D, Huang Y, Reyna C, Lewis J, Shaughnessy EA. Flat epithelial atypia and the risk of sampling error: Determining the value of excision after image-guided core-needle biopsy. Am J Surg 2019; 218:730-736. [PMID: 31399195 DOI: 10.1016/j.amjsurg.2019.07.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Revised: 04/26/2019] [Accepted: 07/16/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND We determined the sampling error rate of flat epithelial atypia (FEA) and evaluated current guidelines recommending excisional biopsy. METHODS A retrospective review of consecutive excisional biopsies after image-guided core-needle biopsy identified patients with isolated FEA diagnosed between 2014 and 2018. Clinical and pathologic parameters were evaluated. RESULTS Twenty-five women with 27 biopsies were included. Based on pathologic review of original core specimens, 44.4% (N = 12) were accurately diagnosed as FEA. Upon excision, lesions were upgraded to ductal carcinoma in situ (N = 2) or invasive ductal carcinoma (N = 1) in 11.1% of cases. Older age, black race, hormone replacement, and calcifications in the image-guided biopsy specimen were associated with the presence of high-risk or malignant lesions in the excisional biopsy (all p ≤ 0.05). CONCLUSIONS In this study, FEA was frequently overcalled. However, lesions suspicious for FEA warrant excision due to their association with malignancy or high-risk lesions, which may necessitate further surgical management and/or risk-reducing strategies.
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Affiliation(s)
- Leah K Winer
- Division of Surgical Oncology, Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way (ML 0558), Cincinnati, OH, 45267, USA
| | - Benjamin H Hinrichs
- Department of Pathology, University of Cincinnati College of Medicine, 234 Goodman Street, Suite 110, Cincinnati, OH, 45219, USA
| | - Sisi Lu
- Division of Surgical Oncology, Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way (ML 0558), Cincinnati, OH, 45267, USA
| | - Dennis Hanseman
- Division of Surgical Oncology, Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way (ML 0558), Cincinnati, OH, 45267, USA
| | - Yuan Huang
- Department of Pathology, University of Cincinnati College of Medicine, 234 Goodman Street, Suite 110, Cincinnati, OH, 45219, USA
| | - Chantal Reyna
- Division of Surgical Oncology, Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way (ML 0558), Cincinnati, OH, 45267, USA
| | - Jaime Lewis
- Division of Surgical Oncology, Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way (ML 0558), Cincinnati, OH, 45267, USA
| | - Elizabeth A Shaughnessy
- Division of Surgical Oncology, Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way (ML 0558), Cincinnati, OH, 45267, USA.
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16
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Ditsch N, Untch M, Thill M, Müller V, Janni W, Albert US, Bauerfeind I, Blohmer J, Budach W, Dall P, Diel I, Fasching PA, Fehm T, Friedrich M, Gerber B, Hanf V, Harbeck N, Huober J, Jackisch C, Kolberg-Liedtke C, Kreipe HH, Krug D, Kühn T, Kümmel S, Loibl S, Lüftner D, Lux MP, Maass N, Möbus V, Müller-Schimpfle M, Mundhenke C, Nitz U, Rhiem K, Rody A, Schmidt M, Schneeweiss A, Schütz F, Sinn HP, Solbach C, Solomayer EF, Stickeler E, Thomssen C, Wenz F, Witzel I, Wöckel A. AGO Recommendations for the Diagnosis and Treatment of Patients with Early Breast Cancer: Update 2019. Breast Care (Basel) 2019; 14:224-245. [PMID: 31558897 PMCID: PMC6751475 DOI: 10.1159/000501000] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 05/16/2019] [Indexed: 12/11/2022] Open
Affiliation(s)
- Nina Ditsch
- Brustzentrum, Klinik für Gynäkologie und Geburtshilfe, Klinikum der Ludwig-Maximilians-Universität, Munich, Germany
| | - Michael Untch
- Klinik für Gynäkologie und Geburtshilfe, Helios Klinikum Berlin-Buch, Berlin, Germany
| | - Marc Thill
- Klinik für Gynäkologie und Gynäkologische Onkologie, Agaplesion Markus Krankenhaus, Frankfurt am Main, Germany
| | - Volkmar Müller
- Klinik und Poliklinik für Gynäkologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Wolfgang Janni
- Klinik für Gynäkologie und Geburtshilfe, Universitätsklinikum Ulm, Ulm, Germany
| | - Ute-Susann Albert
- Klinik für Frauenheilkunde und Geburtshilfe, Klinikum Kassel, Kassel, Germany
| | | | - Jens Blohmer
- Klinik für Gynäkologie mit Brustzentrum der Charité, Berlin, Germany
| | - Wilfried Budach
- Strahlentherapie, Radiologie Düsseldorf, Universitätsklinikum Düsseldorf, Düsseldorf, Germany
| | - Peter Dall
- Frauenklinik Städtisches Klinikum Lüneburg, Lüneburg, Germany
| | - Ingo Diel
- Praxisklinik am Rosengarten, Mannheim, Germany
| | | | - Tanja Fehm
- Klinik für Gynäkologie und Geburtshilfe Universitätsklinikum Düsseldorf, Düsseldorf, Germany
| | - Michael Friedrich
- Klinik für Frauenheilkunde und Geburtshilfe Helios Klinikum Krefeld, Krefeld, Germany
| | - Bernd Gerber
- Universitätsfrauenklinik am Klinikum Südstadt, Rostock, Germany
| | - Volker Hanf
- Frauenklinik Nathanstift, Klinikum Fürth, Fürth, Germany
| | - Nadia Harbeck
- Brustzentrum, Klinik für Gynäkologie und Geburtshilfe, Klinikum der Ludwig-Maximilians-Universität, Munich, Germany
| | - Jens Huober
- Klinik für Gynäkologie und Geburtshilfe, Universitätsklinikum Ulm, Ulm, Germany
| | - Christian Jackisch
- Klinik für Gynäkologie und Geburtshilfe, Sana Klinikum Offenbach, Offenbach, Germany
| | | | | | - David Krug
- Klinik für Strahlentherapie, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Thorsten Kühn
- Klinik für Frauenheilkunde und Geburtshilfe, Klinikum Esslingen, Esslingen, Germany
| | - Sherko Kümmel
- Klinik für Senologie, Kliniken Essen Mitte, Essen, Germany
| | - Sibylle Loibl
- German Breast Group Forschungs GmbH, Neu-Isenburg, Germany
| | - Diana Lüftner
- Medizinische Klinik mit Schwerpunkt Hämatologie und Onkologie, Charité, Berlin, Germany
| | - Michael Patrick Lux
- Klinik für Gynäkologie und Geburtshilfe, St. Vinzenz-Krankenhaus GmbH Paderborn, Paderborn, Germany
| | - Nicolai Maass
- Klinik für Gynäkologie und Geburtshilfe, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Volker Möbus
- Klinik für Gynäkologie und Geburtshilfe, Klinikum Frankfurt Höchst GmbH, Frankfurt am Main, Germany
| | - Markus Müller-Schimpfle
- Klinik für Radiologie, Neuroradiologie und Nuklearmedizin, Klinikum Frankfurt Höchst GmbH, Frankfurt am Main, Germany
| | - Christoph Mundhenke
- Klinik für Gynäkologie und Geburtshilfe, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Ulrike Nitz
- Senologie, Evangelisches Krankenhaus Bethesda, Mönchengladbach, Germany
| | - Kerstin Rhiem
- Zentrum Familiärer Brust- und Eierstockkrebs, Universitätsklinikum Köln, Köln, Germany
| | - Achim Rody
- Klinik für Gynäkologie und Geburtshilfe, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Marcus Schmidt
- Klinik und Poliklinik für Geburtshilfe und Frauengesundheit der Johannes-Gutenberg-Universität Mainz, Mainz, Germany
| | - Andreas Schneeweiss
- Gynäkologische Onkologie, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Florian Schütz
- Klinik für Gynäkologie und Geburtshilfe, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Hans-Peter Sinn
- Sektion Gynäkopathologie, Pathologisches Institut, Heidelberg, Germany
| | - Christine Solbach
- Klinik für Frauenheilkunde und Geburtshilfe, Universitätsklinikum Frankfurt, Frankfurt am Main, Germany
| | - Erich-Franz Solomayer
- Klinik für Frauenheilkunde, Geburtshilfe und Reproduktionsmedizin, Universitätsklinikum des Saarlandes, Homburg/Saar, Germany
| | - Elmar Stickeler
- Klinik für Gynäkologie und Geburtsmedizin, Universitätsklinikum Aachen, Aachen, Germany
| | - Christoph Thomssen
- Universitätsfrauenklinik, Martin-Luther-Universität Halle-Wittenberg, Halle/Saale, Germany
| | | | - Isabell Witzel
- Klinik und Poliklinik für Gynäkologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Achim Wöckel
- Klinik für Gynäkologie und Geburtshilfe, Universitätsklinikum Würzburg, Würzburg, Germany
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Hugar SB, Bhargava R, Dabbs DJ, Davis KM, Zuley M, Clark BZ. Isolated Flat Epithelial Atypia on Core Biopsy Specimens Is Associated With a Low Risk of Upgrade at Excision. Am J Clin Pathol 2019; 151:511-515. [PMID: 30753261 DOI: 10.1093/ajcp/aqy175] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES We present a retrospective review of 111 breast core biopsy specimens with flat epithelial atypia (FEA) and corresponding excision to better understand rates of upgrade following this diagnosis. METHODS In total, 252 breast core biopsy specimens were identified. Cases were excluded if biopsy slides or excision results were unavailable, for ipsilateral carcinoma or other findings warranting excision, or biopsy performed for indications other than mammographically detected calcifications. Coincident atypical lobular hyperplasia was not excluded. Diagnoses were confirmed by breast pathologists, and mammographic images were reviewed. RESULTS Ultimately, 111 biopsy specimens with FEA were included. In subsequent excisions, one (1%) of 111 showed invasive carcinoma, 20 (18%) atypical ductal hyperplasia, 20 (18%) lobular neoplasia, 31 (28%) FEA, and 39 (35%) no atypical findings. CONCLUSIONS FEA on core biopsy specimens is associated with a low rate of upgrade to invasive carcinoma. Close follow-up may be a reasonable alternative to excision for isolated FEA on core needle biopsy specimens.
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Affiliation(s)
- Sarah B Hugar
- University of Pittsburgh Medical Center, Pittsburgh, PA
| | | | - David J Dabbs
- University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Katie M Davis
- University of Pittsburgh Medical Center, Pittsburgh, PA
| | | | - Beth Z Clark
- University of Pittsburgh Medical Center, Pittsburgh, PA
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Alencherry E, Goel R, Gore S, Thompson C, Dubchuk C, Bomeisl P, Gilmore H, Dyhdalo K, Plecha DM. Clinical, imaging, and intervention factors associated with the upgrade of isolated flat epithelial atypia. Clin Imaging 2019; 54:21-24. [DOI: 10.1016/j.clinimag.2018.11.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Revised: 10/23/2018] [Accepted: 11/19/2018] [Indexed: 10/27/2022]
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19
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Flat epithelial atypia in directional vacuum-assisted biopsy of breast microcalcifications: surgical excision may not be necessary. Mod Pathol 2018; 31:1097-1106. [PMID: 29467479 DOI: 10.1038/s41379-018-0035-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2017] [Revised: 01/05/2018] [Accepted: 01/07/2018] [Indexed: 11/09/2022]
Abstract
The aim of this study was to analyze the clinicopathological features of patients with flat epithelial atypia, diagnosed in directional vacuum-assisted biopsy targeting microcalcifications, to identify upgrade rate to in situ ductal or invasive breast carcinoma, and determine factors predicting carcinoma in the subsequent excision. We retrospectively evaluated the histological, clinical, and mammographic features of 69 cases from 65 women, with directional vacuum-assisted biopsy-diagnosed flat epithelial atypia with or without atypical ductal hyperplasia or atypical lobular hyperplasia, which underwent subsequent surgical excision. The extent and percentage of microcalcifications sampled by directional vacuum-assisted biopsy were evaluated by mammography. All biopsy and surgical excision slides were reviewed. The age of the women ranged from 40 to 85 years (mean 57 years). All patients presented with mammographically detected microcalcifications only, except in one case that had associated architectural distortion. Extent of calcifications ranged from <1 cm (n = 47), 1-3 cm (n = 15) to > 3 cm (n = 6), and no measurement (n = 1). A mean of 11 cores (range 6-25) was obtained from each lesion. Post-biopsy mammogram revealed >90% removal of calcifications in 81% of cases. Pure flat epithelial atypia represented nearly two-thirds of directional vacuum-assisted biopsy specimens (n = 43, 62%), while flat epithelial atypia coexisted with atypical ductal hyperplasia (18 cases, 26%), or atypical lobular hyperplasia (8 cases, 12%). Upon excision, none of the cases were upgraded to in situ ductal or invasive breast cancer. In one case, however, an incidental, tubular carcinoma (4 mm) was found away from biopsy site. Excluding this case, the upgrade rate was 0%. Our study adds to the growing evidence that diagnosis of flat epithelial atypia on directional vacuum-assisted biopsy for microcalcifications as the only imaging finding is not associated with a significant upgrade to carcinoma on excision, and therefore, excision may not be necessary. Additionally, excision may not be necessary for flat epithelial atypia with atypical ductal hyperplasia limited to ≤2 terminal duct-lobular units, if at least 90% of calcifications have been removed on biopsy.
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20
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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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21
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Chan PMY, Chotai N, Lai ES, Sin PY, Chen J, Lu SQ, Goh MH, Chong BK, Ho BCS, Tan EY. Majority of flat epithelial atypia diagnosed on biopsy do not require surgical excision. Breast 2018; 37:13-17. [DOI: 10.1016/j.breast.2017.10.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Revised: 08/14/2017] [Accepted: 10/10/2017] [Indexed: 11/16/2022] Open
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22
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Lamb LR, Bahl M, Gadd MA, Lehman CD. Flat Epithelial Atypia: Upgrade Rates and Risk-Stratification Approach to Support Informed Decision Making. J Am Coll Surg 2017; 225:696-701. [DOI: 10.1016/j.jamcollsurg.2017.08.022] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2017] [Accepted: 08/24/2017] [Indexed: 10/18/2022]
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23
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Rudin AV, Hoskin TL, Fahy A, Farrell AM, Nassar A, Ghosh K, Degnim AC. Flat Epithelial Atypia on Core Biopsy and Upgrade to Cancer: a Systematic Review and Meta-Analysis. Ann Surg Oncol 2017; 24:3549-3558. [PMID: 28831724 DOI: 10.1245/s10434-017-6059-0] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Indexed: 11/18/2022]
Abstract
BACKGROUND No consensus exists on whether flat epithelial atypia (FEA) diagnosed percutaneously should be surgically excised. A systematic review and meta-analysis of the frequency of upgrade to cancer or an atypical ductal hyperplasia (ADH) at surgical excision of FEA was performed. METHODS Embase, MEDLINE, Scopus, and Web of Science databases from January 2003 to November 2015 were searched. The inclusion criteria required a manuscript in English with original data on FEA diagnosed percutaneously, data including the presence or absence of other concurrent high-risk lesions, and data including outcome of cancer at surgical excision. Studies were assessed for quality, and two reviewers extracted data. Random-effects meta-analysis was used to pool estimates. The impact of study-level characteristics was assessed by stratified meta-analysis and meta-regression. RESULTS The inclusion criteria was met by 32 studies. A total of 1966 core needle biopsies showed pure FEA, and 1517 (77%) showed surgical excision. The proportions of patients with upgrade to cancer varied from 0 to 42%, with an overall pooled estimate of 11.1%. Heterogeneity was observed, with the greatest impact based on whether a study included cases of FEA diagnosed before 2003. With restriction of the investigation to 16 higher-quality studies, the cancer upgrade pooled estimate was 7.5% (95% confidence interval [CI], 5.4-10.4%), and the rate of invasive cancer was 3% (95% CI 1.9-4.5%). For upgrade to ADH, data from 22 studies including 937 patients were analyzed. The proportion of patients upgraded to ADH ranged from 0 to 60%, with a pooled estimate of 17.9% overall and 18.6% among high-quality studies. CONCLUSIONS With patient management change potential for approximately 25% of patients, this analysis supports a general recommendation for surgical excision of FEA diagnosed by core biopsy.
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Affiliation(s)
| | - Tanya L Hoskin
- Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Aodhnait Fahy
- Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Ann M Farrell
- Mayo Clinic Libraries, Mayo Clinic, Rochester, MN, USA
| | - Aziza Nassar
- Laboratory Medicine and Pathology, Mayo Clinic, Jacksonville, FL, USA
| | - Karthik Ghosh
- Breast Clinic, General Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Amy C Degnim
- Department of Surgery, Mayo Clinic, Rochester, MN, USA.
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Racz JM, Carter JM, Degnim AC. Challenging Atypical Breast Lesions Including Flat Epithelial Atypia, Radial Scar, and Intraductal Papilloma. Ann Surg Oncol 2017; 24:2842-2847. [DOI: 10.1245/s10434-017-5980-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Indexed: 11/18/2022]
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25
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Samples LS, Rendi MH, Frederick PD, Allison KH, Nelson HD, Morgan TR, Weaver DL, Elmore JG. Surgical implications and variability in the use of the flat epithelial atypia diagnosis on breast biopsy specimens. Breast 2017; 34:34-43. [PMID: 28475933 DOI: 10.1016/j.breast.2017.04.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Revised: 03/31/2017] [Accepted: 04/06/2017] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVES Flat epithelial atypia (FEA) is a relatively new diagnostic term with uncertain clinical significance for surgical management. Any implied risk of invasive breast cancer associated with FEA is contingent upon diagnostic reproducibility, yet little is known regarding its use. MATERIALS AND METHODS Pathologists in the Breast Pathology Study interpreted one of four 60-case test sets, one slide per case, constructed from 240 breast biopsy specimens. An electronic data form with standardized diagnostic categories was used; participants were instructed to indicate all diagnoses present. We assessed participants' use of FEA as a diagnostic term within: 1) each test set; 2) 72 cases classified by reference as benign without FEA; and 3) six cases classified by reference as FEA. 115 pathologists participated, providing 6900 total independent assessments. RESULTS Notation of FEA ranged from 0% to 35% of the cases interpreted, with most pathologists noting FEA on 4 or more test cases. At least one participant noted FEA in 34 of the 72 benign non-FEA cases. For the 6 reference FEA cases, participant agreement with the case reference FEA diagnosis ranged from 17% to 52%; diagnoses noted by participating pathologists for these FEA cases included columnar cell hyperplasia, usual ductal hyperplasia, atypical lobular hyperplasia, and atypical ductal hyperplasia. CONCLUSIONS We observed wide variation in the diagnosis of FEA among U.S. pathologists. This suggests that perceptions of diagnostic criteria and any implied risk associated with FEA may also vary. Surgical excision following a core biopsy diagnosis of FEA should be reconsidered and studied further.
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Affiliation(s)
- Laura S Samples
- Department of Medicine, University of Washington School of Medicine, 325 Ninth Ave, Box 359780, Seattle, WA 98104, USA
| | - Mara H Rendi
- Department of Pathology, University of Washington School of Medicine, 1959 NE Pacific St., Box 356100, Seattle, WA, USA
| | - Paul D Frederick
- Department of Medicine, University of Washington School of Medicine, 325 Ninth Ave, Box 359780, Seattle, WA 98104, USA
| | - Kimberly H Allison
- Department of Pathology, Stanford University School of Medicine, 300 Pasteur Drive, Lane 235, Stanford, CA 94305, USA
| | - Heidi D Nelson
- Providence Cancer Center, Providence Health and Services Oregon, and Departments of Medical Informatics and Clinical Epidemiology and Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Mail Code FM, Portland, OR 97239, USA
| | - Thomas R Morgan
- Department of Medicine, University of Washington School of Medicine, 325 Ninth Ave, Box 359780, Seattle, WA 98104, USA
| | - Donald L Weaver
- Department of Pathology and University of Vermont Cancer Center, University of Vermont, Given Courtyard, 89 Beaumont Ave, Burlington, VT 05405, USA
| | - Joann G Elmore
- Department of Medicine, University of Washington School of Medicine, 325 Ninth Ave, Box 359780, Seattle, WA 98104, USA.
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Flat epithelial atypia on core needle biopsy, must we surgically excise? Am J Surg 2016; 212:1211-1213. [DOI: 10.1016/j.amjsurg.2016.09.019] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2016] [Revised: 09/06/2016] [Accepted: 09/06/2016] [Indexed: 11/23/2022]
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Upgrade rates of high-risk breast lesions diagnosed on core needle biopsy: a single-institution experience and literature review. Mod Pathol 2016; 29:1471-1484. [PMID: 27538687 DOI: 10.1038/modpathol.2016.127] [Citation(s) in RCA: 76] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2016] [Revised: 05/31/2016] [Accepted: 06/02/2016] [Indexed: 11/08/2022]
Abstract
Optimal management of high-risk breast lesions detected by mammogram yielding atypical ductal hyperplasia, flat epithelial atypia, atypical lobular hyperplasia, lobular carcinoma in situ, and radial scar without atypia on core needle biopsy is controversial. This is a single-institution retrospective review of 5750 core needle biopsy cases seen over 14.5 years, including 249 (4.3%), 72 (1.3%), 50 (0.9%), 37 (0.6%), and 54 (0.9%) cases of atypical ductal hyperplasia, flat epithelial atypia, atypical lobular hyperplasia, lobular carcinoma in situ, and radial scar without atypia, respectively. Patient age, radiologic characteristics, needle gauge, and excision diagnoses were recorded. Of 462 high-risk cases analyzed, 333 (72%) underwent excision. Upgrade rate to ductal carcinoma in situ, pleomorphic carcinoma in situ, or invasive mammary carcinoma was 18% for atypical ductal hyperplasia, 11% for flat epithelial atypia, 9% for atypical lobular hyperplasia, 28% for lobular carcinoma in situ, and 16% for radial scar. Carcinoma diagnosed on excision was more likely to be in situ than invasive, and if invasive, more likely to be low grade than high grade. Overall, cases that were benign (vs high risk or carcinoma) on excision were less likely to have residual calcifications after biopsy (17% vs 27%, P=0.013), and more likely to have a smaller mass size (<1 cm) (82% vs 50%, P=0.001). On subgroup analysis, atypical ductal hyperplasia cases that were benign (vs high risk or carcinoma) on excision were more likely to have smaller mass size (<1 cm) (P=0.025). Lobular neoplasia diagnosed incidentally (vs targeted) on core needle biopsy was less likely to upgrade on excision (5% vs 39%, P=0.002). A comprehensive literature review was performed, identifying 116 studies reporting high-risk lesion upgrade rates, and our upgrade rates were similar to those of more recent larger studies. Careful radiological-pathological correlation is needed to identify high-risk lesion subgroups that may not need excision.
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Calhoun BC, Collins LC. Recommendations for excision following core needle biopsy of the breast: a contemporary evaluation of the literature. Histopathology 2015; 68:138-51. [DOI: 10.1111/his.12852] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Affiliation(s)
| | - Laura C Collins
- Department of Pathology; Beth Israel Deaconess Medical Center and Harvard Medical School; Boston MA USA
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