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Laws A, Leonard S, Hershey E, Stokes S, Vincuilla J, Sharma E, Milliron K, Garber JE, Merajver SD, King TA, Pilewskie ML. Upgrade Rates and Breast Cancer Development Among Germline Pathogenic Variant Carriers with High-Risk Breast Lesions. Ann Surg Oncol 2024; 31:3120-3127. [PMID: 38261128 DOI: 10.1245/s10434-024-14947-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 01/04/2024] [Indexed: 01/24/2024]
Abstract
BACKGROUND High-risk lesions (HRL) of the breast are risk factors for future breast cancer development and may be associated with a concurrent underlying malignancy when identified on needle biopsy; however, there are few data evaluating HRLs in carriers of germline pathogenic variants (PVs) in breast cancer predisposition genes. METHODS We identified patients from two institutions with germline PVs in high- and moderate-penetrance breast cancer predisposition genes and an HRL in an intact breast, including atypical ductal hyperplasia (ADH), flat epithelial atypia (FEA), and lobular neoplasia (LN). We calculated upgrade rates at surgical excision and used Kaplan-Meier methods to characterize 3-year breast cancer risk in patients without upgrade. RESULTS Of 117 lesions in 105 patients, 65 (55.6%) were ADH, 48 (41.0%) were LN, and 4 (3.4%) were FEA. Most PVs (83.8%) were in the BRCA1/2, CHEK2 and ATM genes. ADH and FEA were excised in most cases (87.1%), with upgrade rates of 11.8% (95% confidence interval [CI] 5.5-23.4%) and 0%, respectively. LN was selectively excised (53.8%); upgrade rate in the excision group was 4.8% (95% CI 0.8-22.7%), and with 20 months of median follow-up, no same-site cancers developed in the observation group. Among those not upgraded, the 3-year risk of breast cancer development was 13.1% (95% CI 6.3-26.3%), mostly estrogen receptor-positive (ER +) disease (89.5%). CONCLUSIONS Upgrade rates for HRLs in patients with PVs in breast cancer predisposition genes appear similar to non-carriers. HRLs may be associated with increased short-term ER+ breast cancer risk in PV carriers, warranting strong consideration of surgical or chemoprevention therapies in this population.
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Affiliation(s)
- Alison Laws
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Saskia Leonard
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
- John A. Burns School of Medicine, University of Hawaii, Honolulu, HI, USA
| | - Emma Hershey
- Department of Surgery, Michigan Medicine, Ann Arbor, MI, USA
| | - Samantha Stokes
- Division of Cancer Genetics and Prevention, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Julie Vincuilla
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Eshita Sharma
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Kara Milliron
- Breast and Ovarian Cancer Risk Evaluation Program, Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI, USA
| | - Judy E Garber
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Division of Cancer Genetics and Prevention, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Sofia D Merajver
- Breast and Ovarian Cancer Risk Evaluation Program, Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI, USA
| | - Tari A King
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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Rubio IT, Wyld L, Marotti L, Athanasiou A, Regitnig P, Catanuto G, Schoones JW, Zambon M, Camps J, Santini D, Dietz J, Sardanelli F, Varga Z, Smidt M, Sharma N, Shaaban AM, Gilbert F. European guidelines for the diagnosis, treatment and follow-up of breast lesions with uncertain malignant potential (B3 lesions) developed jointly by EUSOMA, EUSOBI, ESP (BWG) and ESSO. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:107292. [PMID: 38061151 DOI: 10.1016/j.ejso.2023.107292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 11/17/2023] [Indexed: 01/16/2024]
Abstract
INTRODUCTION Breast lesions of uncertain malignant potential (B3) include atypical ductal and lobular hyperplasias, lobular carcinoma in situ, flat epithelial atypia, papillary lesions, radial scars and fibroepithelial lesions as well as other rare miscellaneous lesions. They are challenging to categorise histologically, requiring specialist training and multidisciplinary input. They may coexist with in situ or invasive breast cancer (BC) and increase the risk of subsequent BC development. Management should focus on adequate classification and management whilst avoiding overtreatment. The aim of these guidelines is to provide updated information regarding the diagnosis and management of B3 lesions, according to updated literature review evidence. METHODS These guidelines provide practical recommendations which can be applied in clinical practice which include recommendation grade and level of evidence. All sections were written according to an updated literature review and discussed at a consensus meeting. Critical appraisal by the expert writing committee adhered to the 23 items in the international Appraisal of Guidelines, Research and Evaluation (AGREE) tool. RESULTS Recommendations for further management after core-needle biopsy (CNB) or vacuum-assisted biopsy (VAB) diagnosis of a B3 lesion reported in this guideline, vary depending on the presence of atypia, size of lesion, sampling size, and patient preferences. After CNB or VAB, the option of vacuum-assisted excision or surgical excision should be evaluated by a multidisciplinary team and shared decision-making with the patient is crucial for personalizing further treatment. De-escalation of surgical intervention for B3 breast lesions is ongoing, and the inclusion of vacuum-assisted excision (VAE) will decrease the need for surgical intervention in further approaches. Communication with patients may be different according to histological diagnosis, presence or absence of atypia, or risk of upgrade due to discordant imaging. Written information resources to help patients understand these issues alongside with verbal communication is recommended. Lifestyle interventions have a significant impact on BC incidence so lifestyle interventions need to be suggested to women at increased BC risk as a result of a diagnosis of a B3 lesion. CONCLUSIONS These guidelines provide a state-of-the-art overview of the diagnosis, management and prognosis of B3 lesions in modern multidisciplinary breast practice.
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Affiliation(s)
- Isabel T Rubio
- Breast Surgical Oncology, Clinica Universidad de Navarra, Madrid, Spain; European Society of Breast Cancer Specialists (EUSOMA), Florence, Italy; European Society of Surgical Oncology (ESSO), Brussels, Belgium.
| | - Lynda Wyld
- Department of Oncology and Metabolism, University of Sheffield Medical School, Beech Hill Road, Sheffield, S10 2RX, UK; Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust, Doncaster, UK
| | - Lorenza Marotti
- European Society of Breast Cancer Specialists (EUSOMA), Florence, Italy
| | | | - Peter Regitnig
- Diagnostic and Research Institute of Pathology, Medical University of Graz, Graz, Austria
| | - Giuseppe Catanuto
- Humanitas-Istituto Clinico Catanese Misterbianco, Italy; Fondazione G.Re.T.A., ETS, Napoli, Italy
| | - Jan W Schoones
- Research Policy & Graduate School Advisor, Leiden University Medical Center Leiden, the Netherlands
| | - Marzia Zambon
- Europa Donna - The European Breast Cancer Coalition, Milan, Italy
| | - Julia Camps
- Breast Health Units in Ribera Salud Hospitals.Valencia, Spain
| | - Donatella Santini
- Department of Pathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy
| | - Jill Dietz
- The American Society of Breast Surgeons, Columbia, MD, USA
| | - Francesco Sardanelli
- Department of Biomedical Sciences for Health, Università Degli Studi di Milano, Milan, Italy; Unit of Radiology, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Zsuzsanna Varga
- Department of Pathology and Molecular Pathology, University Hospital Zurich, Zurich, Switzerland
| | - Marjolein Smidt
- GROW-School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, the Netherlands; Department of Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Nisha Sharma
- Breast Unit, Level 1 Chancellor Wing, St James Hospital, Beckett Street Leeds, West Yorkshire, LS9 7TF, UK
| | - Abeer M Shaaban
- Cellular Pathology, Queen Elizabeth Hospital Birmingham, Birmingham, UK; Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Fiona Gilbert
- Department of Radiology, University of Cambridge, Cambridge Biomedical Campus, UK.
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Harper LK, Carnahan MB, Bhatt AA, Simmons CL, Patel BK, Downs E, Pockaj BA, Yancey K, Eversman SE, Sharpe RE. Imaging Characteristics of and Multidisciplinary Management Considerations for Atypical Ductal Hyperplasia and Flat Epithelial Atypia: Review of Current Literature. Radiographics 2023; 43:e230016. [PMID: 37768862 DOI: 10.1148/rg.230016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/30/2023]
Abstract
High-risk lesions of the breast are frequently encountered in percutaneous biopsy specimens. While benign, these lesions have historically undergone surgical excision due to their potential to be upgraded to malignancy. However, there is emerging evidence that a tailored management approach should be considered to reduce overtreatment of these lesions. Flat epithelial atypia (FEA) and atypical ductal hyperplasia (ADH) are two of the most commonly encountered high-risk lesions. FEA has been shown to have a relatively low rate of progression to malignancy, and some guidelines are now recommending observation over routine excision in select cases. Selective observation may be reasonable in cases where the target lesion is small and completely removed at biopsy and when there are no underlying risk factors, such as a history of breast cancer or genetic mutation or concurrent ADH. ADH has the highest potential upgrade rate to malignancy of all the high-risk lesions. Most society guidelines continue to recommend surgical excision of this lesion. More recently, some literature suggests that ADH lesions that appear completely removed at biopsy, involve limited foci (less than two or three) with no necrosis or significant atypia, manifest as a small group of mammographic calcifications, or demonstrate no enhancement at MRI may be reasonable for observation. Ultimately, management of all high-risk lesions must be based on a multidisciplinary approach that considers all patient, radiologic, clinical, and histopathologic factors. ©RSNA, 2023 Quiz questions for this article are available in the supplemental material.
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Affiliation(s)
- Laura K Harper
- From the Departments of Radiology (L.K.H., M.B.C., B.K.P., K.Y., S.E.E., R.E.S.), Pathology (E.D.), and Surgery (B.A.P.), Mayo Clinic, 5777 E Mayo Blvd, Phoenix, AZ 85054; Department of Radiology, Mayo Clinic, Rochester, Minn (A.A.B.); and Department of Radiology, Phoenix Children's Hospital, Phoenix, Ariz (C.L.S.)
| | - Molly B Carnahan
- From the Departments of Radiology (L.K.H., M.B.C., B.K.P., K.Y., S.E.E., R.E.S.), Pathology (E.D.), and Surgery (B.A.P.), Mayo Clinic, 5777 E Mayo Blvd, Phoenix, AZ 85054; Department of Radiology, Mayo Clinic, Rochester, Minn (A.A.B.); and Department of Radiology, Phoenix Children's Hospital, Phoenix, Ariz (C.L.S.)
| | - Asha A Bhatt
- From the Departments of Radiology (L.K.H., M.B.C., B.K.P., K.Y., S.E.E., R.E.S.), Pathology (E.D.), and Surgery (B.A.P.), Mayo Clinic, 5777 E Mayo Blvd, Phoenix, AZ 85054; Department of Radiology, Mayo Clinic, Rochester, Minn (A.A.B.); and Department of Radiology, Phoenix Children's Hospital, Phoenix, Ariz (C.L.S.)
| | - Curtis L Simmons
- From the Departments of Radiology (L.K.H., M.B.C., B.K.P., K.Y., S.E.E., R.E.S.), Pathology (E.D.), and Surgery (B.A.P.), Mayo Clinic, 5777 E Mayo Blvd, Phoenix, AZ 85054; Department of Radiology, Mayo Clinic, Rochester, Minn (A.A.B.); and Department of Radiology, Phoenix Children's Hospital, Phoenix, Ariz (C.L.S.)
| | - Bhavika K Patel
- From the Departments of Radiology (L.K.H., M.B.C., B.K.P., K.Y., S.E.E., R.E.S.), Pathology (E.D.), and Surgery (B.A.P.), Mayo Clinic, 5777 E Mayo Blvd, Phoenix, AZ 85054; Department of Radiology, Mayo Clinic, Rochester, Minn (A.A.B.); and Department of Radiology, Phoenix Children's Hospital, Phoenix, Ariz (C.L.S.)
| | - Erinn Downs
- From the Departments of Radiology (L.K.H., M.B.C., B.K.P., K.Y., S.E.E., R.E.S.), Pathology (E.D.), and Surgery (B.A.P.), Mayo Clinic, 5777 E Mayo Blvd, Phoenix, AZ 85054; Department of Radiology, Mayo Clinic, Rochester, Minn (A.A.B.); and Department of Radiology, Phoenix Children's Hospital, Phoenix, Ariz (C.L.S.)
| | - Barbara A Pockaj
- From the Departments of Radiology (L.K.H., M.B.C., B.K.P., K.Y., S.E.E., R.E.S.), Pathology (E.D.), and Surgery (B.A.P.), Mayo Clinic, 5777 E Mayo Blvd, Phoenix, AZ 85054; Department of Radiology, Mayo Clinic, Rochester, Minn (A.A.B.); and Department of Radiology, Phoenix Children's Hospital, Phoenix, Ariz (C.L.S.)
| | - Kristina Yancey
- From the Departments of Radiology (L.K.H., M.B.C., B.K.P., K.Y., S.E.E., R.E.S.), Pathology (E.D.), and Surgery (B.A.P.), Mayo Clinic, 5777 E Mayo Blvd, Phoenix, AZ 85054; Department of Radiology, Mayo Clinic, Rochester, Minn (A.A.B.); and Department of Radiology, Phoenix Children's Hospital, Phoenix, Ariz (C.L.S.)
| | - Sarah E Eversman
- From the Departments of Radiology (L.K.H., M.B.C., B.K.P., K.Y., S.E.E., R.E.S.), Pathology (E.D.), and Surgery (B.A.P.), Mayo Clinic, 5777 E Mayo Blvd, Phoenix, AZ 85054; Department of Radiology, Mayo Clinic, Rochester, Minn (A.A.B.); and Department of Radiology, Phoenix Children's Hospital, Phoenix, Ariz (C.L.S.)
| | - Richard E Sharpe
- From the Departments of Radiology (L.K.H., M.B.C., B.K.P., K.Y., S.E.E., R.E.S.), Pathology (E.D.), and Surgery (B.A.P.), Mayo Clinic, 5777 E Mayo Blvd, Phoenix, AZ 85054; Department of Radiology, Mayo Clinic, Rochester, Minn (A.A.B.); and Department of Radiology, Phoenix Children's Hospital, Phoenix, Ariz (C.L.S.)
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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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Grabenstetter A, Brennan SB, Sevilimedu V, Kuba MG, Giri DD, Wen HY, Morrow M, Brogi E. Is Surgical Excision of Focal Atypical Ductal Hyperplasia Warranted? Experience at a Tertiary Care Center. Ann Surg Oncol 2023; 30:4087-4094. [PMID: 36905438 PMCID: PMC10542905 DOI: 10.1245/s10434-023-13319-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 02/12/2023] [Indexed: 03/12/2023]
Abstract
BACKGROUND The core-needle biopsy (CNB) diagnosis of atypical ductal hyperplasia (ADH) generally mandates follow-up excision, but controversy exists on whether small foci of ADH require surgical management. This study evaluated the upgrade rate at excision of focal ADH (fADH), defined as 1 focus spanning ≤ 2 mm. METHODS We retrospectively identified in-house CNBs with ADH as the highest-risk lesion obtained between January 2013 and December 2017. A radiologist assessed radiologic-pathologic concordance. All CNB slides were reviewed by two breast pathologists, and ADH was classified as fADH and nonfocal ADH based on extent. Only cases with follow-up excision were included. The slides of excision specimens with upgrade were reviewed. RESULTS The final study cohort consisted of 208 radiologic-pathologic concordant CNBs, including 98 fADH and 110 nonfocal ADH. The imaging targets were calcifications (n = 157), a mass (n = 15), nonmass enhancement (n = 27), and mass enhancement (n = 9). Excision of fADH yielded seven (7%) upgrades (5 ductal carcinoma in situ (DCIS), 2 invasive carcinoma) versus 24 (22%) upgrades (16 DCIS, 8 invasive carcinoma) at excision of nonfocal ADH (p = 0.01). Both invasive carcinomas found at excision of fADH were subcentimeter tubular carcinomas away from the biopsy site and deemed incidental. CONCLUSIONS Our data show a significantly lower upgrade rate at excision of focal ADH than nonfocal ADH. This information can be valuable if nonsurgical management of patients with radiologic-pathologic concordant CNB diagnosis of focal ADH is being considered.
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Affiliation(s)
- Anne Grabenstetter
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| | - Sandra B Brennan
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Varadan Sevilimedu
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - M Gabriela Kuba
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Dilip D Giri
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Hannah Yong Wen
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Monica Morrow
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Edi Brogi
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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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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Calle C, Zhong E, Hanna MG, Ventura K, Friedlander MA, Morrow M, Cody H, Brogi E. Changes in the Diagnoses of Breast Core Needle Biopsies on Second Review at a Tertiary Care Center: Implications for Surgical Management. Am J Surg Pathol 2023; 47:172-182. [PMID: 36638314 PMCID: PMC10464622 DOI: 10.1097/pas.0000000000002002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Core needle biopsy (CNB) of breast lesions is routine for diagnosis and treatment planning. Despite refinement of diagnostic criteria, the diagnosis of breast lesions on CNB can be challenging. At many centers, including ours, confirmation of diagnoses rendered in other laboratories is required before treatment planning. We identified CNBs first diagnosed elsewhere that were reviewed in our department over the course of 1 year because the patients sought care at our center and in which a change in diagnosis had been recorded. The outside and in-house CNB diagnoses were then classified based on Breast WHO Fifth Edition diagnostic categories. The impact of the change in diagnosis was estimated based on the subsequent surgical management. Findings in follow-up surgical excisions (EXCs) were used for validation. In 2018, 4950 outside cases with CNB were reviewed at our center. A total of 403 CNBs diagnoses were discrepant. Of these, 147 had a change in the WHO diagnostic category: 80 (54%) CNBs had a more severe diagnosis and 44 (30%) a less severe diagnosis. In 23 (16%) CNBs, the change of diagnostic category had no impact on management. Intraductal proliferations (n=54), microinvasive carcinoma (n=18), and papillary lesions (n=35) were the most disputed diagnoses. The in-house CNB diagnosis was confirmed in most cases with available excisions. Following CNB reclassification, 22/147 (15%) lesions were not excised. A change affecting the surgical management at our center occurred in 2.5% of all CNBs. Our results support routine review of outside breast CNB as a clinically significant practice before definitive treatment.
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Affiliation(s)
- Catarina Calle
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York City, New York, 10065 USA
- Faculdade de Ciencias da Saude da Universidade da Beira Interior, Covilha, Portugal
| | - Elaine Zhong
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York City, New York, 10065 USA
| | - Matthew G. Hanna
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York City, New York, 10065 USA
| | - Katia Ventura
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York City, New York, 10065 USA
| | - Maria A. Friedlander
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York City, New York, 10065 USA
| | - Monica Morrow
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York City, New York, USA
| | - Hiram Cody
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York City, New York, USA
| | - Edi Brogi
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York City, New York, 10065 USA
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Varga Z, Sinn P, Lebeau A. [B3 lesions of the breast: histological, clinical, and epidemiological aspects : Update]. PATHOLOGIE (HEIDELBERG, GERMANY) 2023; 44:5-16. [PMID: 36635403 PMCID: PMC9877091 DOI: 10.1007/s00292-022-01180-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 12/22/2022] [Indexed: 01/14/2023]
Abstract
B3 lesions of the breast are a heterogeneous group of lesions with uncertain malignant potential encompassing a broad spectrum of histologically distinct alterations that often pose challenging decisions if diagnosed on the preoperative core or vacuum biopsies. B3 lesions are mostly detected due to mammographic calcifications or mass lesions and, in most cases, encompass a spectrum of atypical lesions such as atypical ductal hyperplasia, classic lobular neoplasia, flat epithelial atypia, papillomas, fibroepithelial tumors, and rarely other lesions such as mucocele-like lesions, atypical apocrine lesions, and rare stromal proliferations. The use of immunohistochemical stains (estrogen receptors, basal cytokeratin, myoepithelial markers, and stromal marker panel) is useful in the differentiation of these lesions and allowing proper classification. Regarding clinical management of B3 lesions, the radiological-pathological correlation of the given entity plays the most important key element for the proper next diagnostic and therapeutic step.
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Affiliation(s)
- Zsuzsanna Varga
- Institut für Pathologie und Molekularpathologie, Universitätsspital Zürich, Schmelzbergstr. 12, 8091 Zürich, Schweiz
| | - Peter Sinn
- Pathologisches Institut, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - Annette Lebeau
- Institut für Pathologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland ,Gemeinschaftspraxis für Pathologie, Lübeck, Deutschland
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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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10
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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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11
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Tomosynthesis-Guided Vacuum-Assisted Breast Biopsy of Architectural Distortion Without a Sonographic Correlate: A Retrospective Review. AJR Am J Roentgenol 2021; 217:845-854. [PMID: 33147055 DOI: 10.2214/ajr.20.24740] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND. Digital breast tomosynthesis-guided vacuum-assisted breast biopsy (DBT VAB) allows biopsy of findings seen better or exclusively on digital breast tomosynthesis (DBT), including architectural distortion. Although architectural distortion with an associated sonographic mass correlate has a high risk of malignancy, limited data describe the radiologic-pathologic correlation of tomosynthesis-detected architectural distortion without a sonographic correlate. OBJECTIVE. This study evaluates the malignancy rate of architectural distortions without a sonographic correlate that undergo DBT VAB and provides radiologic-pathologic correlation for benign, high-risk, and malignant entities that are associated with architectural distortion. METHODS. We retrospectively reviewed imaging, as well as pathology slides and/or reports, for DBT VABs performed for architectural distortion without a sonographic correlate at a single institution between June 1, 2017, and January 15, 2020. According to the correlative histopathology, cases were categorized as benign, high risk, or malignant, and specific histopathologic diagnoses were summarized. RESULTS. During the study period, 142 patients (mean age, 59 years) underwent DBT VAB for 151 unique architectural distortions without a sonographic correlate. DBT VAB revealed a malignant diagnosis in 27 (18%), a high-risk lesion in 50 (33%), and a benign diagnosis in 74 (49%). Two cases of atypical ductal hyperplasia were upgraded to malignancy, resulting in a final malignancy rate of 19% (n = 29/151). Most malignant lesions were invasive carcinomas (83%, n = 24/29); most invasive carcinomas were of lobular subtype (54%, n = 13/24). Most high-risk lesions were radial scars/complex sclerosing lesions (62%, n = 31/50). Most benign results represented fibrocystic change (66%, n = 49/74). A subset (11%, n = 8/74) of benign results were considered discordant and subsequently excised, with none representing malignancy. CONCLUSION. The final malignancy rate of 19% in architectural distortion without a sonographic correlate justifies a recommendation for biopsy using DBT VAB. CLINICAL IMPACT. Our results highlight the utility of DBT VAB in the era of DBT. The detailed radiologic-pathologic correlations will assist radiologists in assessing concordance when performing DBT VAB for architectural distortions and provide a reference for future patient management.
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12
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Machine learning-based image analysis for accelerating the diagnosis of complicated preneoplastic and neoplastic ductal lesions in breast biopsy tissues. Breast Cancer Res Treat 2021; 188:649-659. [PMID: 33934277 DOI: 10.1007/s10549-021-06243-2] [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: 02/05/2021] [Accepted: 04/21/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE Diagnosis of breast preneoplastic and neoplastic lesions is difficult due to their similar morphology in breast biopsy specimens. To diagnose these lesions, pathologists perform immunohistochemical analysis and consult with expert breast pathologists. These additional examinations are time-consuming and expensive. Artificial intelligence (AI)-based image analysis has recently improved, and may help in ordinal pathological diagnosis. Here, we showed the significance of machine learning-based image analysis of breast preneoplastic and neoplastic lesions for facilitating high-throughput diagnosis. METHODS Images were obtained from normal mammary glands, hyperplastic lesions, preneoplastic lesions and neoplastic lesions, such as usual ductal hyperplasia (UDH), columnar cell lesion (CCL), ductal carcinoma in situ (DCIS), and DCIS with comedo necrosis (comedo DCIS) in breast biopsy specimens. The original enhanced convoluted neural network (CNN) system was used for analyzing the pathological images. RESULTS The AI-based image analysis provided the following area under the curve values (AUC): normal lesion versus DCIS, 0.9902; DCIS versus comedo DCIS, 0.9942; normal lesion versus CCL, 0.9786; and UDH versus DCIS, 1.000. Multiple comparison analysis showed precision and recall scores similar to those of single comparison analysis. Based on the gradient-weighted class activation mapping (Grad-CAM) used to visualize the important regions reflecting the result of CNN analysis, the ratio of stromal tissue in the whole weighted area was significantly higher in UDH and CCL than that in DCIS. CONCLUSIONS These analyses may provide a more accurate and rapid pathological diagnosis of patients. Moreover, Grad-CAM identifies uncharted important histological characteristics for newer pathological findings and targets of research for understanding diseases.
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13
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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 DOI: 10.1148/rycan.2021200116] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [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
- 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
- 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
- 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
- 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
- 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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14
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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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15
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Li X, Ma Z, Styblo TM, Arciero CA, Wang H, Cohen MA. Management of high-risk breast lesions diagnosed on core biopsies and experiences from prospective high-risk breast lesion conferences at an academic institution. Breast Cancer Res Treat 2020; 185:573-581. [PMID: 33068196 DOI: 10.1007/s10549-020-05977-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 10/08/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND The management of high-risk breast lesions diagnosed on image-guided core biopsy remains controversial. We implemented a high-risk breast conference attended by breast pathologists, imagers, and surgeons to prospectively review all contemporary cases in order to provide a consensus recommendation to either surgically excise or follow on imaging at 6-month intervals for a minimum of 2 years. METHODS Between May, 2015 and June, 2019, 127 high-risk lesions were discussed. Of these 127 cases, 116 had concordant radiology-pathology (rad-path) findings. The remaining 11 patients had discordant rad-path findings. Of the 116 concordant cases, 6 were excluded due to lack of the first imaging follow-up until analysis. Of the remaining 110 patients, 43 had atypical ductal hyperplasia (ADH), 12 had lobular carcinoma in situ (LCIS), 19 had atypical lobular hyperplasia (ALH), 33 had radial scar (RS), 2 had flat epithelial atypia (FEA), and 1 had mucocele-like lesion (ML). We recommended excision for ADH if there were > 2 ADH foci or < 90% of the associated calcifications were removed. For patients with LCIS or ALH, we recommended excision if the LCIS or ALH was associated with microcalcifications or the LCIS was extensive. We recommended excision of RS when < 1/2 of the lesion was biopsied. We recommended all patients with FEA and ML for 6-month follow-up. RESULTS Following conference-derived consensus for excision, of the 27 ADH excised, 9 were upgraded to invasive carcinoma or ductal carcinoma in situ. Of the six LCIS cases recommended for excision, none were upgraded. Nine excised radial scars revealed no upgrades. Additionally, 3 patients with ADH, 2 with ALH, 1 with LCIS, and 2 with RS underwent voluntary excision, and none were upgraded. All other patients (13 with ADH, 5 LCIS, 17 ALH, 22 RS, 2 FEA and 1 ML) were followed with imaging, and none revealed evidence of disease progression during follow-up (187-1389 days). All 11 rad-path discordant cases were excised with 2 upgraded to carcinoma. CONCLUSIONS The results of this prospective study indicate that high-risk breast lesions can be successfully triaged to surgery versus observation following establishment of predefined firm guidelines and performance of rigorous rad-path correlation.
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Affiliation(s)
- Xiaoxian Li
- Department of Pathology and Laboratory Medicine, Emory University, 1364 Clifton Road, Atlanta, GA, 30322, USA.
| | - Zhongliang Ma
- Breast Disease Center, The Affiliated Hospital of Qingdao University, Qingdao, China
| | | | | | - Haibo Wang
- Breast Disease Center, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Michael A Cohen
- Department of Radiology and Imaging Sciences, Emory University, 1364 Clifton Road, Atlanta, GA, 30322, USA.
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Alvarado-Cabrero I, Valencia-Cedillo R, Estevez-Castro R. Preneoplasia of the Breast and Molecular Landscape. Arch Med Res 2020; 51:845-850. [PMID: 32972772 DOI: 10.1016/j.arcmed.2020.09.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 09/10/2020] [Indexed: 12/29/2022]
Abstract
The current model of human breast cancer progression proposes a linear multi-step process which initiates as flat epithelial atypia (FEA), progresses to atypical ductal hyperplasia (ADH), evolves into ductal carcinoma in situ (DCIS) and culminates in the potentially lethal stage of invasive ductal carcinoma. FEA commonly coexists with well-developed examples of ADH, low-grade DCIS, lobular neoplasia and tubular carcinoma. These findings and those of recent genetic studies suggest that FEA is a neoplastic lesion that may represent a precursor to or the earliest morphologic manifestation of ductal carcinoma in situ. At the same time, many of the genomic changes of ADH are also shared by common sporadic breast cancer, consistent with a high risk for future development of metachronous breast cancer.
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Affiliation(s)
- Isabel Alvarado-Cabrero
- Departamento de Patologia, Hospital de Oncología, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Ciudad de Mexico, Mexico.
| | - Raquel Valencia-Cedillo
- Departamento de Patologia, Hospital de Oncología, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Ciudad de Mexico, Mexico
| | - Rafael Estevez-Castro
- Departamento de Patologia, Hospital de Especialidades Dr. Bernardo Sepúlveda, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Ciudad de Mexico, Mexico
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