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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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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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Berry JS, Trappey AF, Vreeland TJ, Pattyn AR, Clifton GT, Berry EA, Schneble EJ, Kirkpatrick AD, Saenger JS, Peoples GE. Analysis of Clinical and Pathologic Factors of Pure, Flat Epithelial Atypia on Core Needle Biopsy to Aid in the Decision of Excision or Observation. J Cancer 2016; 7:1-6. [PMID: 26722353 PMCID: PMC4679374 DOI: 10.7150/jca.12781] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2015] [Accepted: 08/30/2015] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND The optimal treatment of flat epithelial atypia (FEA) found on breast core needle biopsy (CNB) is controversial. We performed a retrospective review of our institutional experience with FEA to determine if excisional biopsy may be deferred. METHODS Surgical records from 2009 to 2012 were reviewed for FEA diagnosis. After exclusion for concomitant lesions, CNBs of pure FEA were classified using a previously agreed upon descriptor of "focal" versus "prominent". Data was analyzed with the Fisher's Exact and Student-t test as appropriate. RESULTS Of 71 CNBs evaluated, pure FEA was identified on 27 CNBs. Final excisional biopsy was benign in 24 of 27 cases (88%) with associated ductal carcinoma in-situ (DCIS) in 3 of 27 cases (11%). Eighteen of 27 (67%) CNBs were classified as focal while 9 (33%) were described as prominent. Zero of the 18 focal patients had a malignancy compared to 3 of the 9 in the prominent group (0% vs 33%, p=0.02). Of the 27 pure FEA CNBs, 6 patients had a personal history of breast carcinoma, five DCIS and one invasive ductal carcinoma. No malignancies were found in the 21 patients without a personal history of breast carcinoma versus three in the patients with a positive history (0/21 v 3/6, p=0.007). CONCLUSIONS Our data suggests those women who have adequate sampling and sectioning of CNBs, with focal, pure FEA on pathology, and are without a personal history of breast cancer may undergo a period of imaging surveillance. Conversely, patients with a history of breast cancer or pure, prominent FEA on CNB disease should proceed to excisional biopsy.
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Affiliation(s)
- John S Berry
- 1. Department of Surgery, San Antonio Military Medical Center, Fort Sam Houston, TX
| | - Alfred F Trappey
- 1. Department of Surgery, San Antonio Military Medical Center, Fort Sam Houston, TX
| | - Timothy J Vreeland
- 1. Department of Surgery, San Antonio Military Medical Center, Fort Sam Houston, TX
| | - Adam R Pattyn
- 2. Department of Surgery, Madigan Military Medical Center, Fort Lewis, WA
| | - Guy T Clifton
- 3. Department of Surgical Oncology, University of Texas, M.D. Anderson Cancer Center, Houston, TX
| | - Elizabeth A Berry
- 4. Qwest Care Associates, Intensive Care Unit, Metropolitan Methodist Hospital, San Antonio, TX
| | - Erika J Schneble
- 1. Department of Surgery, San Antonio Military Medical Center, Fort Sam Houston, TX
| | - Aaron D Kirkpatrick
- 5. Department of Radiology, San Antonio Military Medical Center, Fort Sam Houston, TX
| | - Jeffrey S Saenger
- 6. Department of Pathology, San Antonio Military Medical Center, Fort Sam Houston, TX
| | - George E Peoples
- 7. Director, Cancer Vaccine Development Program, San Antonio, TX, USA
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Maeda I, Kanemaki Y, Tozaki M, Koizumi H, Oana Y, Okanami Y, Tsuchiya K, Shimo A, Kojima Y, Hayami R, Nishikawa T, Kawamoto H, Yabuki Y, Tsugawa K, Takagi M. Positive predictive value for malignancy of pure flat epithelial atypia diagnosis by percutaneous needle biopsy of the breast: management of FEA in ultrasonography. Breast Cancer 2014; 22:634-40. [PMID: 24760612 DOI: 10.1007/s12282-014-0530-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2013] [Accepted: 04/07/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND Some reports suggest that the rate of definitive diagnosis of malignant tumors, namely, the final diagnosis being revised to a higher stage, in patients diagnosed as having flat epithelial atypia (FEA) by percutaneous needle biopsy of the breast (PNB) is as low as 0-3 %. However, other reports suggest that the rate is as high as 10 % or more, bringing confusion on this issue. We examined the positive predictive value for malignancy in the patients diagnosed as having pure FEA and the patients' radiolopathological characteristics observed in our hospital. METHODS Of the patients who underwent PNB in our facility, those who were diagnosed as having pure FEA were recruited as the subjects of this study. RESULTS Of the 4,197 consecutive patients who underwent PNB, 44 (1.0 %) were diagnosed as having pure FEA following a re-examination. Among 44 cases, 39 cases were selected as the subjects of this study. Among the 39 patients, six patients were diagnosed as having malignant lesions, two of whom had invasive carcinoma of no special type (papillotubular type), one had tubular carcinoma, one had ductal carcinoma in situ (DCIS) of high nuclear grade, one had DCIS of intermediate nuclear grade, and one had DCIS of low nuclear grade. The diameters of 6 malignant lesions were 10-30 mm at ultrasonography (US) examination. Five of the 39 patients had contralateral breast cancer. CONCLUSION The positive predictive value for malignancy of pure FEA was 15.7 %. The patients with pure FEA may make a follow up without an excisional biopsy when the lesion sizes less than 10 mm on US examination.
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Affiliation(s)
- Ichiro Maeda
- Department of Pathology, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, 216-8511, Japan. .,Department of Breast and Endocrine Surgery, St. Marianna University School of Medicine, Kawasaki, Japan.
| | - Yoshihide Kanemaki
- Department of Radiology, St. Marianna University School of Medicine, Kawasaki, Japan.,Department of Breast and Endocrine Surgery, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Mitsuhiro Tozaki
- Breast Center, Kameda Medical Center, Kamogawa, Japan.,Department of Breast and Endocrine Surgery, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Hirotaka Koizumi
- Department of Pathology, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, 216-8511, Japan.,Department of Breast and Endocrine Surgery, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Yoshiyasu Oana
- Department of Pathology, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, 216-8511, Japan.,Department of Breast and Endocrine Surgery, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Yuko Okanami
- Department of Pathology, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, 216-8511, Japan.,Department of Breast and Endocrine Surgery, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Kyoko Tsuchiya
- Breast Center, Kameda Medical Center, Kamogawa, Japan.,Department of Breast and Endocrine Surgery, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Arata Shimo
- Breast Center, Kameda Medical Center, Kamogawa, Japan.,Department of Breast and Endocrine Surgery, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Yasuyuki Kojima
- Breast Center, Kameda Medical Center, Kamogawa, Japan.,Department of Breast and Endocrine Surgery, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Ryousuke Hayami
- Breast Center, Kameda Medical Center, Kamogawa, Japan.,Department of Breast and Endocrine Surgery, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Toru Nishikawa
- Breast Center, Kameda Medical Center, Kamogawa, Japan.,Department of Breast and Endocrine Surgery, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Hisanori Kawamoto
- Breast Center, Kameda Medical Center, Kamogawa, Japan.,Department of Breast and Endocrine Surgery, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Yukari Yabuki
- Breast Center, Kameda Medical Center, Kamogawa, Japan.,Department of Breast and Endocrine Surgery, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Koichiro Tsugawa
- Breast Center, Kameda Medical Center, Kamogawa, Japan.,Department of Breast and Endocrine Surgery, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Masayuki Takagi
- Department of Pathology, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, 216-8511, Japan.,Department of Breast and Endocrine Surgery, St. Marianna University School of Medicine, Kawasaki, Japan
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Abe E, Suzuki K, Hayashi N, Yang Y, Li CP, Uno M, Akiyama F, Yamauchi H, Nakamura S, Tsugawa K, Tsunoda H, Ohde S, Sasano H. Clinicopathological significance of 'atypical ductal proliferation' in core needle biopsy of the breast. Pathol Int 2014; 64:58-66. [PMID: 24629173 DOI: 10.1111/pin.12135] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2013] [Accepted: 01/13/2014] [Indexed: 11/30/2022]
Abstract
Atypical ductal proliferation or ADP has been used in histopathological diagnosis of core needle biopsy (CNB) but its details have not been well studied. Therefore, we examined the clinicopathological characteristics of the initial CNB cases diagnosed as 'ADP ' who subsequently turned out to be malignant, and compared the findings to those that did not. Among 101 cases initially diagnosed as ADP in CNB, the second biopsy revealed no carcinoma (38), ductal carcinoma in situ (DCIS) (45) and invasive carcinoma (18). Significant differences were detected between those which turned out to be carcinoma and those that did not, in the status of myoepithelial cells identified by p63 immunohistochemistry (P = 0.026) and ultrasound (US) categories (P < 0.001). We further compared the histopathological characteristics of those initially diagnosed as ADP and subsequently as DCIS or invasive ductal carcinoma (IDC) with those initially diagnosed as such. DCIS or IDC cases initially diagnosed as ADP had significantly lower Ki67 labeling index (P < 0.01, P < 0.01) and histological grade using Van nuys prognostic index (P < 0.01) or Nottingham histological grades (P < 0.01) respectively than those initially as DCIS or IDC. An assessment of myoepithelial components with US findings might contribute to determine the subsequent clinical algorithm of the patients diagnosed as ADP at initial CNB.
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Affiliation(s)
- Eriko Abe
- Department of Pathology, St. Luke's International Hospital, Tokyo; Department of Pathology, Tohoku University Hospital, Sendai
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