Atypical lobular hyperplasia and lobular carcinoma in situ at core breast biopsy: use of careful radiologic-pathologic correlation to recommend excision or observation

Upgrade Rates of Variant Lobular Carcinoma In Situ Compared to Classic Lobular Carcinoma In Situ Diagnosed in Core Needle Biopsies: A 10-Year Single Institution Retrospective Study

The primary aim of this study was to determine the upgrade rates of variant lobular carcinoma in situ (V-LCIS, ie, combined florid [F-LCIS] and pleomorphic [P-LCIS]) compared with classic LCIS (C-LCIS) when diagnosed on core needle biopsy (CNB). The secondary goal was to determine the rate of progression/development of invasive carcinoma on long-term follow-up after primary excision. After institutional review board approval, our institutional pathology database was searched for patients with "pure" LCIS diagnosed on CNB who underwent subsequent excision. Radiologic findings were reviewed, radiologic-pathologic (rad-path) correlation was performed, and follow-up patient outcome data were obtained. One hundred twenty cases of LCIS were identified on CNB (C-LCIS = 97, F-LCIS = 18, and P-LCIS = 5). Overall upgrade rates after excision for C-LCIS, F-LCIS, and P-LCIS were 14% (14/97), 44% (8/18), and 40% (2/5), respectively. Of the total cases, 79 (66%) were deemed rad-path concordant. Of these, the upgrade rate after excision for C-LCIS, F-LCIS, and P-LCIS was 7.5% (5 of 66), 40% (4 of 10), and 0% (0 of 3), respectively. The overall upgrade rate for V-LCIS was higher than for C-LCIS (P = .004), even for the cases deemed rad-path concordant (P value: .036). Most upgraded cases (23 of 24) showed pT1a disease or lower. With an average follow-up of 83 months, invasive carcinoma in the ipsilateral breast was identified in 8/120 (7%) cases. Six patients had died: 2 of (contralateral) breast cancer and 4 of other causes. Because of a high upgrade rate, V-LCIS diagnosed on CNB should always be excised. The upgrade rate for C-LCIS (even when rad-path concordant) is higher than reported in many other studies. Rad-path concordance read, surgical consultation, and individualized decision making are recommended for C-LCIS cases. The risk of developing invasive carcinoma after LCIS diagnosis is small (7% with ∼7-year follow-up), but active surveillance is required to diagnose early-stage disease.

Management of screening-detected lobular neoplasia in the era of digital breast tomosynthesis: A preliminary study

PURPOSE

The purpose of this study is to determine upgrade rates of lobular neoplasia detected by screening digital breast tomosynthesis (DBT) and to determine imaging and clinicopathological features that may influence risk of upgrade.

METHODS

Medical records were reviewed of consecutive women who presented with screening DBT-detected atypical lobular hyperplasia (ALH) and/or lobular carcinoma in situ (LCIS) from January 1, 2013, to June 30, 2020. Included patients underwent needle biopsy and had surgery or at least two-year imaging follow-up. Imaging and clinicopathological features were compared between upgraded and nonupgraded cases of lobular neoplasia using the Pearson's chi-squared test and the Wilcoxon signed-rank test.

RESULTS

During the study period, 107 women (mean age 55 years, range 40-88 years) with 110 cases of ALH and/or LCIS underwent surgery (80.9%, n = 89) or at least two-year imaging follow-up (19.1%, n = 21). The overall upgrade rate to cancer was 5.5% (6/110), and the upgrade rate to invasive cancer was 3.6% (4/110). The upgrade rate of ALH to cancer was 4.1% (3/74), whereas the upgrade rate of LCIS to cancer was 9.4% (3/32) (p = .28). The upgrade rate of cases presenting as calcifications was 4.2% (3/71), whereas the upgrade rates of cases presenting as noncalcified findings was 7.7% (3/39) (p = .44).

CONCLUSIONS

The upgrade rate of screening DBT-detected lobular neoplasia is less than 6%. Surveillance rather than surgery can be considered for lobular neoplasia, particularly in patients with ALH and in those with screening-detected calcifications leading to the diagnosis.

Does Non-Classic Lobular Carcinoma In Situ at the Lumpectomy Margin Increase Local Recurrence?

BACKGROUND

The clinical significance of nonclassic, lobular carcinoma in situ (NC-LCIS) at the surgical margin of excisions for invasive cancer is unknown. We sought to determine whether NC-LCIS at or near the margin in the setting of a concurrent invasive carcinoma is associated with risk of ipsilateral breast tumor recurrence (IBTR) and locoregional recurrence (LRR).

METHODS

Patients with stage 0-III breast cancer and NC-LCIS who underwent lumpectomy between January 2010 and January 2022 at a single institution were retrospectively identified. NC-LCIS margins were stratified as <2 mm, ≥2 mm, or within shave margin. Rates of IBTR and LRR were examined.

RESULTS

A total of 511 female patients (median age 60 years [interquartile range (IQR) 52-69]) with NC-LCIS and an associated ipsilateral breast cancer with a median follow-up of 3.4 years (IQR 2.0-5.9) were identified. Final margins for NC-LCIS were ≥2 mm in 348 patients (68%), <2 mm in 37 (7.2%), and within shave margin in 126 (24.6%). Crude incidence of IBTR was 3.3% (n = 17) and that of LRR was 4.9% (n = 25). There was no difference in the crude rate of IBTR by NC-LCIS margin status (IBTR rate: 3.7% ≥2 mm, 0% <2 mm, 3.2% within shave margin, p = 0.8) nor in LRR (LRR rate: 4.9% ≥2 mm, 2.7% <2 mm, 5.6% within shave margin, p = 0.9).

CONCLUSIONS

For completely excised invasive breast cancers associated with NC-LCIS, extent of margin width for NC-LCIS was not associated with a difference in IBTR or LRR. These data suggest that the decision to perform reexcision of margin after lumpectomy should be driven by the invasive cancer, rather than the NC-LCIS margin.

Update on Lobular Neoplasia

Lobular neoplasia (LN) is a histopathologic entity that encompasses both lobular carcinoma in situ (LCIS) and atypical lobular hyperplasia (ALH). Management of LN is known to be variable and institutionally dependent. The variability in approach after a diagnosis of LN at percutaneous breast biopsy derives in part from heterogeneity in the literature, resulting in a range of reported upgrade rates to malignancy after initial identification at percutaneous biopsy, and also from historical shifts in understanding of the natural history of LN. It has become increasingly recognized that not all LN is the same and that distinct variants of LN such as pleomorphic LCIS and florid LCIS have distinct natural histories and distinct likelihoods of upgrade to malignancy. In addition, it is also increasingly understood that appropriate management of LN relies on scrupulous radiologic-pathologic correlation. This review details the imaging features and histopathologic nature of ALH, classic-type LCIS, and the LCIS variants; addresses changes in the historical understanding of this entity contributing to confusion regarding its management; and discusses the importance of performing radiologic-pathologic correlation after percutaneous biopsy to help guide appropriate management steps when LN is encountered. In addition to the short-term implications of an LN diagnosis in terms of upgrade and surgical outcomes, the long-term implications of an LN diagnosis regarding risk of developing a later breast cancer are examined. ©RSNA, 2023 Quiz questions for this article are available through the Online Learning Center.

Factors Indicating Surgical Excision in Classical Type of Lobular Neoplasia of the Breast

PURPOSE

Classical type of lobular neoplasia (LN) encompassing both atypical lobular hyperplasia and classical lobular carcinoma in situ of the breast is a lesion with uncertain malignant potential and has been the topic of several studies with conflicting outcome results. The aim of our study was to clarify outcome-relevant factors and treatment options of classical LN.

METHODS

We performed a pathological re-evaluation of the preoperative biopsy specimens and a retrospective clinical and radiological data analysis of 160 patients with LN from the Breast Center Zurich. Open surgery was performed in 65 patients, vacuum-assisted biopsy (VAB) in 79 patients, and surveillance after breast core needle biopsy (CNB) in 16 patients.

RESULTS

The upgrade rate into ductal carcinoma in situ/invasive cancer was the highest in case of imaging/histology discordance (40%). If the number of foci in the biopsy specimen was ≥3, the upgrade rate in the consecutive surgical specimens was increased (p = 0.01). The association of classical LN with histological microcalcification correlated with shortened disease-free survival (p < 0.01), whereas other factors showed no impact on follow-up.

CONCLUSIONS

Surveillance or subsequent VAB after CNB of LN is sufficient in most cases. Careful consideration of individual radiological and histological factors is required to identify patients with a high risk of upgrade into malignancy. In those cases, surgical excision is indicated.

Intercepting Premalignant, Preinvasive Breast Lesions Through Vaccination

Breast cancer (BC) prevention remains the ultimate cost-effective method to reduce the global burden of invasive breast cancer (IBC). To date, surgery and chemoprevention remain the main risk-reducing modalities for those with hereditary cancer syndromes, as well as high-risk non-hereditary breast lesions such as ADH, ALH, or LCIS. Ductal carcinoma in situ (DCIS) is a preinvasive malignant lesion of the breast that closely mirrors IBC and, if left untreated, develops into IBC in up to 50% of lesions. Certain high-risk patients with DCIS may have a 25% risk of developing recurrent DCIS or IBC, even after surgical resection. The development of breast cancer elicits a strong immune response, which brings to prominence the numerous advantages associated with immune-based cancer prevention over drug-based chemoprevention, supported by the success of dendritic cell vaccines targeting HER2-expressing BC. Vaccination against BC to prevent or interrupt the process of BC development remains elusive but is a viable option. Vaccination to intercept preinvasive or premalignant breast conditions may be possible by interrupting the expression pattern of various oncodrivers. Growth factors may also function as potential immune targets to prevent breast cancer progression. Furthermore, neoantigens also serve as effective targets for interception by virtue of strong immunogenicity. It is noteworthy that the immune response also needs to be strong enough to result in target lesion elimination to avoid immunoediting as it may occur in IBC arising from DCIS. Overall, if the issue of vaccine targets can be solved by interrupting premalignant lesions, there is a potential to prevent the development of IBC.

Pure Radial Scars Do Not Require Surgical Excision When Concordant and Benign at Image-guided Breast Biopsy

OBJECTIVE

To determine the best management option (surgical excision versus imaging surveillance) following the diagnosis of pure radial scars (RSs) and RSs with associated additional high-risk lesions (HRLs) encountered on percutaneous core-needle breast biopsy.

METHODS

An IRB-approved retrospective review of the breast imaging reporting system database was performed to identify all cases of pure RS alone or RS plus an additional HRL (papilloma, atypia, lobular neoplasia) diagnosed on core-needle biopsy, from 2007 to 2016, at four breast centers in our institution. Cases with associated malignancy, discordant radiologic-pathologic results, or those lost to follow-up were excluded. The remaining cases were evaluated to determine results of either subsequent surgical excision or long-term follow-up imaging (minimum of two years). Additional data recorded included clinical presentation, breast density, personal and family history of breast cancer, lesion imaging characteristics, and biopsy method.

RESULTS

The study cohort included 111 patients with 111 lesions: 56.8% (63/111) with RS alone (pure) and 43.2% (48/111) with RS plus additional HRL(s). Out of the 63 radiologic-pathologic concordant pure RSs, there were no upgrades to malignancy in 51 subsequent surgical excisions or 12 long-term surveillance cases (0/63, 0%). Out of the 48 RSs plus additional HRL(s), there were 2 upgrades to malignancy (2/48, 4.2%).

CONCLUSION

Cases of radiologic-pathologic concordant pure RS diagnosed at core-needle biopsy do not require surgical excision. On the other hand, surgical excision should be considered for RS plus additional HRLs diagnosed at core-needle biopsy.

High-risk lesions of the breast: concurrent diagnostic tools and management recommendations

Breast lesions with uncertain malignant behavior, also known as high-risk or B3 lesions, are composed of a variety of pathologies with differing risks of associated malignancy. While open excision was previously preferred to manage all high-risk lesions, tailored management has been increasingly favored to reduce overtreatment and spare patients from unnecessary anxiety or high healthcare costs associated with surgical excision. The purpose of this work is to provide the reader with an accurate overview focused on the main high-risk lesions of the breast: atypical intraductal epithelial proliferation (atypical ductal hyperplasia), lobular neoplasia (including the subcategories lobular carcinoma in situ and atypical lobular hyperplasia), flat epithelial atypia, radial scar and papillary lesions, and phyllodes tumor. Beyond merely presenting the radiological aspects of these lesions and the recent literature, information about their potential upgrade rates is discussed in order to provide a useful guide for appropriate clinical management while avoiding the risks of unnecessary surgical intervention (overtreatment).

Management of Lobular Neoplasia Found on Core Needle Biopsy Performed for Calcifications Using Precise Radiologic-Pathologic Correlation

OBJECTIVE. The purpose of our study was to evaluate the upgrade rate of calcified lobular neoplasia (LN) versus incidental noncalcified classic LN found on core needle biopsy performed for the evaluation of suspicious calcifications. MATERIALS AND METHODS. This retrospective study included 390 consecutive image-guided breast core needle biopsies with microcalcifications as the target that were performed between December 2009 and July 2017. In 81 of the 390 core biopsies, the highest-risk lesion was LN that then underwent either excision or imaging follow-up. Core biopsy results were compared with excision and imaging follow-up findings. An upgrade of LN was defined as ductal carcinoma in situ or invasive ductal or lobular carcinoma. RESULTS. Of 81 LN diagnosed on core biopsy performed for calcifications, 16 had calcifications within the LN. Fifteen of these 16 cases underwent surgical excision, and three (3/15, 20.0%) were upgraded on excision. Of the 64 core biopsies showing incidental noncalcified LN with benign concordant entities containing calcifications, 42 underwent surgical excision, and one LN (1/42, 2.4%) was upgraded. Twenty-three total lesions (one calcified LN and 22 noncalcified LN) were followed with imaging rather than excision. No cancers were detected among the follow-up group. One case was deemed to have discordant findings on radiologic-pathologic review and was sent for excision, which showed invasive cancer with tubulolobular and lobular features. CONCLUSION. Women undergoing stereotactic core needle biopsy for calcifications revealing noncalcified incidental classic LN and a benign concordant entity that could explain the presence of the target calcifications have a low risk of upgrade and may be followed with imaging. Surgical excision should be offered to women who have LN with calcifications.

Lobular carcinoma in situ: diagnostic criteria and molecular correlates

Lobular neoplasia (LN) is an atypical proliferation of small, dyscohesive epithelial cells within the terminal duct lobular unit (TDLU), with or without pagetoid extension and encompasses both lobular carcinoma in situ (LCIS) and atypical lobular hyperplasia (ALH). LN is a non-obligate precursor of invasive breast carcinoma and the diagnosis of LN confers an increased risk of invasive carcinoma development, compared to the general population. Diagnostic challenges arise in the accurate classification of LCIS into classic, pleomorphic and florid subtypes, in distinguishing between LCIS and ductal carcinoma in situ (DCIS) and in the appropriate use and interpretation of E-cadherin immunohistochemistry. Due to the paucity of robust data on the natural history of LCIS, and hence its clinical significance, the management is often pragmatic rather than entirely evidence-based and requires a multidisciplinary approach. In this review, we discuss the clinicopathologic and molecular features of LCIS and address the key challenges that arise in the diagnosis and management of LCIS.

A risk stratification algorithm for lesions of uncertain malignant potential diagnosed by vacuum-assisted breast biopsy (VABB) of mammographic microcalcifications

PURPOSE

To investigate a risk stratification strategy for lesions of uncertain malignant potential (B3) diagnosed by vacuum-assisted breast biopsy (VABB) of mammographic microcalcifications.

METHODS

Patients who underwent VABB for microcalcification-only lesions with a diagnosis of B3 and subsequent surgery were included in this retrospective, IRB-approved study. Seventy-six B3-lesions (final histology: 66 benign, 10 malignant) were included (Tr). Data on B3 lesion type and presence of atypia, microcalcification characteristics (BI-RADS), removal at biopsy and concomitant lesions were collected. After univariate analysis (Chi-square test), data were combined into a risk stratification algorithm by using a ten-fold, cross-validated Classification and Regression Tree analysis (CRT). The algorithm was tested on a testing dataset (Te) of 23 B3-lesions (six malignant, 17 benign).

RESULTS

Malignancy was more frequent in women with a concomitant cancer (P < 0.001) and highly suspicious microcalcifications (P < 0.001). The CRT algorithm retained three characteristics: morphology; presence of atypia; presence of concomitant cancer. The algorithm identified 25/76 (32.9 %,Tr) and 6/23 (26.1 %,Te) lesions at low risk of malignancy. No malignant cases were identified at surgery (0/31). There were 3/76 (3.9 %,Tr) and 1/23 (4.3 %,Te) lesions assigned as high-risk by the algorithm and confirmed at surgery (4/4). In the remaining lesions (48/76, 63.1 %,Tr; 16/23, 69.6 %,Te), malignancy rates varied between 9% and 88.4 %; thus, surgery could not have been avoided.

CONCLUSION

We constructed and tested a risk stratification algorithm for B3 microcalcifications, including clinical, imaging, and pathological features, to assign probabilities of malignancy, which has the potential to reduce unnecessary surgeries.

Lobular neoplasia occult on conventional imaging and diagnosed on MRI-guided biopsy: can we estimate upgrade on surgical pathology?

PURPOSE

The goal of this study is to evaluate the frequency and imaging features of lobular neoplasia (LN) diagnosed on MRI-guided biopsy, determine the upgrade rate to malignancy, and assess for any features that may be associated with an upgrade on surgical excision.

MATERIALS AND METHODS

Research ethical board approved the review of consecutive patients with MRI-detected LN between January 2009 and December 2018 with differentiation between pure LN and LN with associated other high-risk lesions. The final outcome was determined by final pathology results from surgical excision or 24 months of follow-up. Appropriate statistical tests were used.

RESULTS

Out of 1250 MRI-guided biopsies performed, 76 lesions (6%) fulfilled the inclusion criteria and formed the study cohort. Of the 76 lesions, 54 (71%) were pure LN while the rest had coexistent high-risk lesion. Non-mass enhancement (NME) was the most common lesion type (62, 82%). Fifty-nine lesions (78%) were surgically excised, the other 17 had benign follow-up. Overall, 8 lesions (11%) were upgraded to malignancy on final pathology. Malignant outcome was associated with larger lesion size (5.5 versus 1.9 cm, P < 0.001) and a clumped NME pattern (75% versus 24%, P = 0.006). Lesion size and clumped NME remained significantly associated with upgrade on sub-analysis of the pure LN group.

CONCLUSION

Larger lesion size and clumped NME are imaging findings associated with upgrade of LN diagnosed by MRI-guided biopsy. This may influence patient management in this clinical setting. Additional larger studies are needed to consolidate our results and to potentially detect additional factors associated with upgrade.

Risk for Upgrade to Malignancy After Breast Core Needle Biopsy Diagnosis of Lobular Neoplasia: A Systematic Review and Meta-Analysis

PURPOSE

Lobular neoplasia (LN) detected on breast core needle biopsy is frequently managed with surgical excision because of concern for undersampled malignancy. The authors performed a systematic review and meta-analysis to estimate the risk for upgrade to malignancy in the setting of imaging-concordant classic LN diagnosed on core biopsy.

METHODS

PubMed and Embase were searched for original articles published from 1998 to 2020 that reported rates of upgrade to malignancy for classic LN, including atypical lobular hyperplasia (ALH) and classic lobular carcinoma in situ (LCIS). Two reviewers extracted study data and assessed the following quality criteria: exclusion of variant LCIS, exclusion of imaging-discordant lesions, and outcome reporting for ≥70% of lesions. For studies meeting all criteria, pooled risks for upgrade to any malignancy (invasive carcinoma or ductal carcinoma in situ) and invasive malignancy for all LN, ALH, and LCIS were estimated using random-effects models.

RESULTS

For 65 full-text articles included in the review, the risk for upgrade to any malignancy ranged from 0% to 45%. Among the 16 studies that met all quality criteria for the meta-analysis, pooled risks for upgrade to any malignancy were 3.1% (95% confidence interval [CI], 1.8%-5.2%) for all LN, 2.5% (95% CI, 1.6%-3.9%) for ALH, and 5.8% (95% CI, 2.9%-11.3%) for LCIS. Risks for upgrade to invasive malignancy were 1.3% (95% CI, 0.7%-2.4%) for all LN, 0.4% (95% CI, 0.0%-4.2%) for ALH, and 3.5% (95% CI, 2.0%-5.9%) for LCIS.

CONCLUSIONS

The risk for upgrade to malignancy for LN found on breast biopsy is low. Imaging surveillance can likely be offered as an alternative to surgical management for LN, particularly for ALH.

Upgrade at excisional biopsy after a core needle biopsy diagnosis of classic lobular carcinoma in situ

BACKGROUND

Management of patients with classic lobular carcinoma in situ diagnosed on core needle biopsy remains controversial, in part because of clinicopathologic overlap with atypical lobular hyperplasia. Although atypical lobular hyperplasia on core needle biopsy is observed because of its low upgrade rate (~1%), consensus is lacking for lobular carcinoma in situ. Therefore, we evaluated lobular carcinoma in situ upgrade rates.

METHODS

With institutional review board approval, we identified 90 patients (from October 2008 to December 2019) with lobular carcinoma in situ on core needle biopsy as their highest-risk lesion. We excluded patients with concurrent ipsilateral cancer. Variables associated with upgrade were assessed with logistic regression.

RESULTS

Of the 90 patients, 81 (90%), median age 55 y, underwent surgical excision. Indications for diagnostic core needle biopsy included mammographic calcifications (48, 53.3%), mass/distortion (28, 31.1%), and non-mass enhancement (12, 13.3%). Final surgical pathology upgraded 11 of 81 patients (13.6%, 95% CI: 7.8%-22.7%) to cancer: invasive lobular (n = 7), invasive ductal (n = 1), and ductal carcinoma in situ/pleomorphic lobular carcinoma in situ (n = 3). Only 1 patient with invasive cancer was node-positive. Concurrent contralateral cancer (OR 4.41, 95% CI: 1.06-17.38, P = .04) and larger lesion size (OR 1.78 per 1 cm, 95% CI: 1.19-2.95, P = .005) predicted upgrade.

CONCLUSION

Our data suggest that, unlike atypical lobular hyperplasia, lobular carcinoma in situ identified on core needle biopsy should be surgically excised. The high proportion of upgrades to early stage invasive lobular carcinoma underscores the value of this approach.

Outcomes of classic lobular neoplasia diagnosed on breast core needle biopsy: a retrospective multi-center study

Management of classic lobular neoplasia (cLN) diagnosed on core needle biopsy (CNB) is controversial. Our aim in this study was to review cases of cLN diagnosed on CNB to determine the rate and risk factors of an upgrade to ductal carcinoma in situ (DCIS) or invasive carcinoma on excision. All breast CNBs with a diagnosis of atypical lobular hyperplasia (ALH) or classic lobular carcinoma in situ (cLCIS) from three different institutions within a single health care system between 2013 and 2018 were retrieved. Cases with any additional high-risk lesions in the same CNB or discordant radiological-pathological correlation were excluded. Information about age, personal history of prior or concurrent breast cancer (P/CBC), and radiological and histological findings were recorded. A total of 287 cLN cases underwent surgical excision. Analysis of these 287 cLN cases showed 11 (3.8%) upgrade lesions on excision. Among the 172 ALH cases, there were 3 (1.7%) upgrades, which were all invasive lobular carcinomas (ILCs). On the other hand, 8 of 115 (7%) cLCIS cases revealed upgrade on excision (2 ILC, 5 DCIS. and 1 ILC + DCIS). Statistical analysis revealed that cLN cases with P/CBC, radiological asymmetry, or architectural distortion had a statistically significant higher upgrade rate on excision. Our findings revealed a low upgrade rate (3.8%) on the excision of classic lobular neoplasia diagnosed on breast core needle biopsy. Clinicoradiological surveillance can be appropriate when lobular neoplasia is identified on core biopsy with pathological radiological concordance in patients without a history of breast cancer, with the caveat that radiological asymmetry and architectural distortion are associated with a significant increase in an upgrade on excision.

Problematic issues in breast core needle biopsies

Image-directed core needle biopsies of the breast are routinely used in current clinical practice for the initial assessment of non-palpable breast lesions. This article provides an update on several important issues regarding evaluation of breast core needle biopsies.

Triaging Atypical Lobular Hyperplasia and Lobular Carcinoma In Situ on Percutaneous Core Biopsy to Surgery or Observation: Assiduous Radiologic-Pathologic Correlation Works, Quantitating Extent of Disease Does Not

Context.—

The management of lobular neoplasia (LN) found on core biopsy is controversial and ranges from obligatory surgical excision to clinical/imaging observation.

Objective.—

To determine if in cases of core needle biopsy yielding LN, quantification of normal and diseased terminal ductal lobular units (TDLUs) can predict which cases require surgical excision and which can be safely followed. A secondary goal is to assess whether the concordance or discordance of core biopsy results, determined by rigorous radiologic-pathologic correlation, can predict for upgrade to malignancy at excision.

Design.—

In this retrospective study, 79 specimens from 78 women who underwent image-guided core needle biopsies between 2005 and 2012 yielding LN were evaluated for total number of TDLUs and total number and percentage of TDLUs involved by LN. Additionally, radiologic-pathologic correlation was performed to assess concordance or discordance. All were correlated with the results of surgical excisional biopsy or imaging/clinical follow-up.

Results.—

There were 5 upgrades to malignancy. There was no association between upgrade to malignancy and any of the 3 TDLU variables evaluated, including total TDLUs in the specimen (P = .42), total abnormal TDLUs (P = .56), and percent of TDLUs that are abnormal (P = .07). Kendall rank correlation demonstrated a correlation between discordance and upgrade to cancer at surgery that was statistically significant (τb = −0.394, P &lt; .001).

Conclusions.—

Quantifying total TDLU and those involved by LN on core biopsy will not aid in triaging patients to surgery or observation. Assiduous radiologic-pathologic correlation to determine lesion concordance/discordance can predict those patients who would benefit from surgical excision.

Suspicious amorphous microcalcifications detected on full-field digital mammography: correlation with histopathology

Objective

To evaluate suspicious amorphous calcifications diagnosed on full-field digital mammography (FFDM) and establish correlations with histopathology findings.

Materials and Methods

This was a retrospective study of 78 suspicious amorphous calcifications (all classified as BI-RADS^® 4) detected on FFDM. Vacuum-assisted breast biopsy (VABB) was performed. The histopathological classification of VABB core samples was as follows: pB2 (benign); pB3 (uncertain malignant potential); pB4 (suspicion of malignancy); and pB5 (malignant). Treatment was recommended for pB5 lesions. To rule out malignancy, surgical excision was recommended for pB3 and pB4 lesions. Patients not submitted to surgery were followed for at least 6 months.

Results

Among the 78 amorphous calcifications evaluated, the histopathological analysis indicated that 8 (10.3%) were malignant/suspicious (6 classified as pB5 and 2 classified as pB4) and 36 (46.2%) were benign (classified as pB2). The remaining 34 lesions (43.6%) were classified as pB3: 33.3% were precursor lesions (atypical ductal hyperplasia, lobular neoplasia, or flat epithelial atypia) and 10.3% were high-risk lesions. For the pB3 lesions, the underestimation rate was zero.

Conclusion

The diagnosis of precursor lesions (excluding atypical ductal hyperplasia, which can be pB4 depending on the severity and extent of the lesion) should not necessarily be considered indicative of underestimation of malignancy. Suspicious amorphous calcifications correlated more often with precursor lesions than with malignant lesions, at a ratio of 3:1.

Observation versus excision of lobular neoplasia on core needle biopsy of the breast

PURPOSE

Controversy surrounds management of lobular neoplasia (LN), [atypical lobular hyperplasia (ALH) or lobular carcinoma in situ (LCIS)], diagnosed on core needle biopsy (CNB). Retrospective series of pure ALH and LCIS reported "upgrade" rate to DCIS or invasive cancer in 0-40%. Few reports document radiologic/pathologic correlation to exclude cases of discordance that are the likely source of most upgrades, and there is minimal data on outcomes with follow-up imaging and clinical surveillance.

METHODS

Cases of LN alone on CNB (2001-2014) were reviewed. CNB yielding LN with other pathologic findings for which surgery was indicated were excluded. All patients had either surgical excision or clinical follow-up with breast imaging. All cases included were subject to radiologic-pathologic correlation after biopsy.

RESULTS

178 cases were identified out of 62213 (0.3%). 115 (65%) patients underwent surgery, and 54 (30%) patients had surveillance for > 12 months (mean = 55 months). Of the patients who underwent surgical excision, 13/115 (11%) were malignant. Eight of these 13 found malignancy at excision when CNB results were considered discordant (5 DCIS, and 3 invasive lobular carcinoma), with the remainder, 5/115 (4%), having a true pathologic upgrade: 3 DCIS, and 2 microinvasive lobular carcinoma. Among 54 patients not having excision, 12/54 (22%) underwent subsequent CNB with only 1 carcinoma found at the initial biopsy site.

CONCLUSIONS

Surgical excision of LN yields a low upgrade rate when careful consideration is given to radiologic/pathologic correlation to exclude cases of discordance. Observation with interval breast imaging is a reasonable alternative for most cases.

Paradigm Shifts in Breast Care Delivery: Impact of Imaging in a Multidisciplinary Environment

OBJECTIVE

The practice of breast imaging in a collaborative multidisciplinary environment adds significant value to outcomes in women's health care. In this article, we describe multidisciplinary considerations in breast cancer screening and early detection, the impact of imaging and histopathologic findings in the diagnostic evaluation and management of breast abnormalities, and the contribution of imaging to surgical and radiation therapy planning for the breast cancer patient.

CONCLUSION

The multidisciplinary delivery of breast care for women that incorporates screening, diagnosis of borderline and high-risk lesions, and management of the breast cancer patient adds considerable value to outcomes in health care.

Lobular neoplasia diagnosed on breast Core biopsy: frequency of carcinoma on excision and implications for management

The appropriate follow-up and treatment for patients with a core biopsy diagnosis of lobular neoplasia (atypical lobular hyperplasia or lobular carcinoma in situ) remains controversial. Several studies have attempted to address this issue, with recommendations ranging from close clinical follow-up or surveillance to mandatory surgical excision in all cases. We report the findings at our institution, where virtually every core needle biopsy diagnosis of lobular neoplasia results in follow-up excision. The goal of the study was to identify potential predictors of upgrade to a more significant lesion. We identified 76 patients over a 15-year period with a core biopsy diagnosis of pure lobular neoplasia and no other high-risk lesions. Subsequent surgical excision identified 10 cases (13%) that were upgraded to carcinoma. Upgrade diagnoses included invasive ductal carcinoma (n=1), invasive lobular carcinoma (n=4), ductal carcinoma in situ (n=3), and pleomorphic lobular carcinoma in situ (n=2). All 10 upgraded cases had imaging findings suspicious for malignancy including irregular masses, asymmetric densities, or pleomorphic calcifications. Of the 10 upgraded cases, 7 were diagnosed as lobular carcinoma in situ on core biopsy. The data support a role for radiologic-pathologic correlation in the evaluation of suspicious breast lesions and suggest that the extent of lobular neoplasia in core biopsy specimens may be an indicator of the likelihood of upgrade to carcinoma.

Core Breast Biopsies Showing Lobular Carcinoma In Situ Should Be Excised and Surveillance Is Reasonable for Atypical Lobular Hyperplasia

OBJECTIVE

The purpose of this article is to determine the upgrade rate to ductal carcinoma in situ (DCIS) or invasive carcinoma at excision at the same site after percutaneous breast biopsy findings of atypical lobular hyperplasia (ALH) or lobular carcinoma in situ (LCIS) using current imaging and strict pathologic criteria.

MATERIALS AND METHODS

From January 2006 through September 2013, 32,960 breast core biopsies were performed; 1084 (3.3%) core biopsies found ALH or classic LCIS. For 447 lesions in 433 women, this was the only high-risk lesion at that site, with no ipsilateral malignancy, and results of excision were available.

RESULTS

Among the 447 lesions, 22 (4.9%) were malignant at excision, including 10 invasive carcinomas (two grade 2 and eight grade 1; all node negative) and 12 DCIS. The upgrade rate of LCIS was 9.3% (10/108; 95% CI, 5.1-16.2%) and that of ALH was 3.5% (12/339; 95% CI, 2.0-6.1%; p = 0.02). After excluding five cases with radiologic-pathologic discordance and reclassifying one core from ALH to LCIS at review, the upgrade rate for LCIS remained higher (8.4%; 9/107; 95% CI, 4.5-15.2%) than that for ALH (2.4%; 8/335; 95% CI, 1.2-4.6%; p = 0.01).

CONCLUSION

Excision is recommended for LCIS on core biopsy because of its 8.4-9.3% upgrade rate. Excluding discordant cases, patients with other high-risk lesions or concurrent malignancy, the risk of upgrade of ALH was 2.4%. Surveillance at 6, 12, and 24 months can be performed in lieu of excision because a short delay in diagnosis of the few malignancies is not expected to cause harm.

The radiological features, diagnosis and management of screen-detected lobular neoplasia of the breast: Findings from the Sloane Project

OBJECTIVES

To investigate the radiological features, diagnosis and management of screen-detected lobular neoplasia (LN) of the breast.

MATERIALS AND METHODS

392 women with pure LN alone were identified within the prospective UK cohort study of screen-detected non-invasive breast neoplasia (the Sloane Project). Demography, radiological features and diagnostic and therapeutic procedures were analysed.

RESULTS

Non-pleomorphic LN (369/392) was most frequently diagnosed among women aged 50-54 and in 53.5% was at the first screen. It occurred most commonly on the left (58.0%; p = 0.003), in the upper outer quadrant and confined to one site (single quadrant or retroareolar region). No bilateral cases were found. The predominant radiological feature was microcalcification (most commonly granular) which increased in frequency with increasing breast density. Casting microcalcification as a predominant feature had a significantly higher lesion size compared to granular and punctate patterns (p = 0.034). 326/369 (88.3%) women underwent surgery, including 17 who underwent >1 operation, six who had mastectomy and six who had axillary surgery. Two patients had radiotherapy and 15 had endocrine treatment. Pleomorphic lobular carcinoma in situ (23/392) presented as granular microcalcification in 12; four women had mastectomy and six had radiotherapy.

CONCLUSION

Screen-detected LN occurs in relatively young women and is predominantly non-pleomorphic and unilateral. It is typically associated with granular or punctate microcalcification in the left upper outer quadrant. Management, including surgical resection, is highly variable and requires evidence-based guideline development.

Management of atypical lobular hyperplasia, atypical ductal hyperplasia, and lobular carcinoma in situ

Atypical hyperplasia and lobular carcinoma in situ are rare proliferative breast lesions, growing inside ducts and terminal ducto-lobular units. They represent a marker of increased risk for breast cancer and a non-obligate precursor of malignancy. Evidence available on diagnosis and management is scarce. They are frequently found incidentally associated with other lesions, but can be visible through mammography, ultrasound or magnetic resonance. Due to the risk of underestimation, surgical excision is often performed. The analysis of imaging and histopathological characteristics could help identifying low-risk cases, for which surgery is not necessary. Chemopreventive agents can be used for risk reduction. Careful imaging follow up is mandatory; the role of breast MRI as screening modality is under discussion.

Atypical lobular hyperplasia and lobular carcinoma in situ at core needle biopsy of the breast: An incidental finding or are there characteristic imaging findings?

BACKGROUND

Atypical lobular hyperplasia and classic-type lobular carcinoma in situ, collectively known as lobular neoplasia, are classically described as incidental findings found on breast core-needle biopsy without distinguishing imaging characteristics.

OBJECTIVE

The purpose of this study was to investigate concordant imaging findings of lobular neoplasia identified at core-needle biopsy after careful radiologic-pathologic correlation.

METHODS

The pathology database was searched from October 1, 2006 to October 1, 2013 for breast biopsies yielding lobular neoplasia not associated with a coexistent malignancy or other high risk lesion in the biopsy specimen.

RESULTS

Of the 482 biopsies performed containing lobular neoplasia, 65 cases had lobular neoplasia as the highest risk lesion at core-needle biopsy. Of the 65 total cases in which lobular neoplasia was the highest risk lesion, 18 (28%) cases had concordant imaging correlates. 13 of 18 (72%) cases presented as calcifications on mammography and 5 of 18 (28%) presented on magnetic resonance imaging as a focus (n = 2) or non-mass enhancement (n = 3).

CONCLUSION

With careful radiologic-pathologic correlation, mammographically detected calcifications and foci or non-mass enhancement on magnetic resonance imaging can be considered concordant imaging findings of lobular neoplasia after breast core-needle biopsy.

Incidence of Adjacent Synchronous Invasive Carcinoma and/or Ductal Carcinoma In-situ in Patients with Lobular Neoplasia on Core Biopsy: Results from a Prospective Multi-Institutional Registry (TBCRC 020)

BACKGROUND

Lobular neoplasia (LN) represents a spectrum of atypical proliferative lesions, including atypical lobular hyperplasia and lobular carcinoma-in-situ. The need for excision for LN found on core biopsy (CB) is controversial. We conducted a prospective multi-institutional trial (TBCRC 20) to determine the rate of upgrade to cancer after excision for pure LN on CB.

METHODS

Patients with a CB diagnosis of pure LN were prospectively identified and consented to excision. Cases with discordant imaging and those with additional lesions requiring excision were excluded. Upgrade rates to cancer were quantified on the basis of local and central pathology review. Confidence intervals and sample size were based on exact binomial calculations.

RESULTS

A total of 77 of 79 registered patients underwent excision (median age 51 years, range 27-82 years). Two cases (3%; 95% confidence interval 0.3-9) were upgraded to cancer (one tubular carcinoma, one ductal carcinoma-in-situ) at excision per local pathology. Central pathology review of 76 cases confirmed pure LN in the CB in all but two cases. In one case, the tubular carcinoma identified at excision was also found in the CB specimen, and in the other, LN was not identified, yielding an upgrade rate of one case (1%; 95% CI 0.01-7) by central pathology review.

CONCLUSIONS

In this prospective study of 77 patients with pure LN on CB, the upgrade rate was 3% by local pathology and 1% by central pathology review, demonstrating that routine excision is not indicated for patients with pure LN on CB and concordant imaging findings.

Is Excisional Biopsy and Chemoprevention Warranted in Patients with Atypical Lobular Hyperplasia on Core Biopsy?

The management of atypical lobular hyperplasia (ALH) on core biopsy remains controversial. The upstaging rates after surgical excision vary. We reviewed our upgrade rates and use of chemoprevention for ALH. Patients were identified through our pathology database for ALH from 2006 to 2013. Patients were included in the study that had a diagnosis only of ALH on core needle biopsy. Tumor and patient characteristics and final pathology were analyzed. ALH was identified in 56 patients since 2006. Sixteen patients met the inclusion criteria. All the patients underwent surgical excision. Final pathology of the excised specimens confirmed ALH in 62 per cent (n = 11). Two cases contained lobular carcinoma in situ. The upgrade rate on excisional biopsy was 18.75 per cent (n = 3) to invasive cancer. Chemopreventative treatment was taken by 44 per cent of the patients. After a mean follow-up of three years, none of the patients who received chemoprevention developed breast cancer. One patient who refused tamoxifen developed breast cancer. This is one of the few studies to examine the current treatment of ALH. We noted a significant upstaging rate after excision. We recommend women to undergo surgical excision. Patients should also consider chemoprevention to reduce their risk for developing breast cancer.

Imaging-histologic discordance at percutaneous biopsy of the lung

RATIONALE AND OBJECTIVES

The purpose of this study was to quantify the degree of imaging-histologic discordance in a cohort of patients undergoing computed tomography (CT)-guided lung biopsy for focal lung disease.

MATERIALS AND METHODS

A retrospective review was performed of 186 patients who underwent percutaneous lung biopsy of a parenchymal lesion at our institution between January and December 2009. Diagnostic radiology reports of CT or positron emission tomography-CTs performed before biopsy were used to classify the lesion as malignant or benign by five readers. Pathology reports of the biopsied lesions were classified by three readers. Inter-reader agreement and imaging-histologic concordance were quantified using kappa statistics. Discordant benign cases were then revisited to determine downstream effects.

RESULTS

Inter-reader agreement on report content was substantial or almost perfect with kappas >0.783. Kappas for concordance were as follows: malignant (0.448), primary lung cancer (0.517), metastatic disease to lung (0.449), benign (0.510), and overall agreement (0.381). Of the twelve discordant benign cases that were revisited, four were found to be false negatives, resulting in a delay in diagnosis.

CONCLUSIONS

Our study of imaging-histologic discordance in percutaneous biopsy of lung lesions supports the need for imaging report standardization and improved integration and communication between the fields of radiology and pathology.