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Keating N, Cevik J, Hopkins D, Lippey J. Malignant upgrade rate and associated clinicopathologic predictors for concordant intraductal papilloma without atypia: A systematic review and meta-analysis. J Surg Oncol 2024; 129:1025-1033. [PMID: 38305061 DOI: 10.1002/jso.27592] [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: 10/17/2023] [Revised: 01/08/2024] [Accepted: 01/11/2024] [Indexed: 02/03/2024]
Abstract
Previously reported upgrade rates for benign breast intraductal papilloma (IDP) are widely variable. However, many previous studies have failed to consider radiologic-pathologic discordance of lesions. This review aims to synthesize malignant upgrade data for benign, concordant IDP at surgical excision. Thirteen studies were included in our meta-analysis. The pooled estimate for percentage underestimation of carcinoma was 1.4% (95% CI: 0.8%-2.0%). We conclude that these lesions can be safely managed by active surveillance.
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Affiliation(s)
- Niamh Keating
- Department of Breast Surgery, St Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia
| | - Jevan Cevik
- The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - David Hopkins
- The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Jocelyn Lippey
- Department of Breast Surgery, St Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia
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Corbin H, Bomeisl P, Amin AL, Marshall HN, Gilmore H, Harbhajanka A. Upgrade Rates of Intraductal Papilloma with and without Atypia Diagnosed on Core Needle Biopsy and Clinicopathologic Predictors. Hum Pathol 2022; 128:90-100. [PMID: 35863513 DOI: 10.1016/j.humpath.2022.07.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 07/11/2022] [Accepted: 07/12/2022] [Indexed: 11/04/2022]
Abstract
Surgical excision of breast intraductal papilloma (IDP) without atypia diagnosed on core needle biopsy (CNB) is controversial as the risk of upgrade to malignant lesions is not well established. This study investigates upgrade rates of benign and atypical IDP to ductal carcinoma in situ (DCIS) and invasive carcinoma (IC) and clinicopathologic predictors. We identified 556 cases of IDP diagnosed on CNB at a single institution from 2010-2020 after excluding patients with a history of breast carcinoma, ipsilateral high-risk lesion, radiologic/pathologic discordance, or less than 2 years of follow-up if no excision within one year. Of these, 97 biopsies were consistent with atypical IDP and 459 were benign IDP. Surgical excision was performed for 318 (57.2%), and the remaining 238 (42.8%) underwent active monitoring. The upgrade rate for IDP without atypia was 2/225 (0.9%; 1 DCIS and 1 IC). Of 93 surgically excised atypical IDPs, 19/93 (20.4%) upgraded (14 DCIS and 5 IC). Of 238 non-excised IDPs followed clinically (range 24-140 months, mean 60 months), there was no subsequent breast cancer diagnosed at the IDP site on follow-up. Mean age of patients was 56 yr±12.6sd without upgrade, 63 yr±10.6sd (p value=0.027) with DCIS, and 61 yr±10.8sd (p value=0.35) with IC. Atypical IDP was more likely to upgrade if biopsied by stereotactic guidance (8/19, 42.1% p=0.035). At our institution, we had an exceedingly low upgrade rate for benign IDP. Overall, patients with upgrade to DCIS were older. For atypical IDP, upgrade was seen in higher proportions of stereotactic biopsies.
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Affiliation(s)
- Haley Corbin
- Case Western Reserve University School of Medicine, 9501 Euclid Avenue, Cleveland, OH 44106, USA.
| | - Philip Bomeisl
- Department of Pathology, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106, USA
| | - Amanda L Amin
- Department of Surgery, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106, USA
| | - Holly N Marshall
- Department of Radiology, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106, USA
| | - Hannah Gilmore
- Department of Pathology, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106, USA
| | - Aparna Harbhajanka
- Department of Pathology, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106, USA
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Noritake M, Yamada A, Yamanaka S, Utsunomiya D, Inoue T. Intraductal Papilloma With Carcinoma of the Breast Described by Dedicated Breast 18F-FDG PET. Clin Nucl Med 2022; 47:557-558. [PMID: 35143457 DOI: 10.1097/rlu.0000000000004086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
ABSTRACT Intraductal papilloma (IDP) is a benign tumor of the breast. However, IDP has been reported to show high uptake of 18F-FDG using whole-body PET. We experienced IDP with low-grade ductal carcinoma in situ using dedicated breast PET, which is more sensitive than whole-body PET. The 18F-FDG uptake of the whole tumor was high, and differentiation between the carcinoma and the residual benign lesion was difficult. This is the first report of IDP detected with dedicated breast PET. Diagnosis of IDP is sometimes controversial; papilloma may show glucose uptake similar to that of low-grade carcinoma.
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Affiliation(s)
| | - Akimitsu Yamada
- Gastroenterological Surgery, Graduate School of Medicine, Yokohama City University
| | - Shoji Yamanaka
- Department of Pathology, Yokohama City University Hospital, Yokohama
| | | | - Tomio Inoue
- Advanced Medical Center, Shonan Kamakura General Hospital, Kamakura, Japan
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Lueders A, Spivey T. Breast Density Lacks Influence on Upgrade Rates to High Risk Lesions and Cancer Among Proliferative Breast Lesion Excisions. Am Surg 2022; 88:2119-2123. [PMID: 35477318 DOI: 10.1177/00031348221091949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Breast density is an independent risk factor for the development of breast cancer. We assessed if upgrade rates to high-risk lesions and cancer were influenced by density when evaluating proliferative complex sclerosing lesions and intraductal papillomas. METHODS This is a retrospective single institution study. We evaluated 168 women aged 18-86 who received a core needle biopsy revealing a breast proliferative lesion of complex sclerosing lesion (CSL) or intraductal papilloma. We analyzed the upgrade rate to high-risk atypia (HRL) and cancer. Subgroup analysis based on age and breast density was performed. RESULTS The patient collective was well balanced-51% had dense breasts and 42% were under 50 years old. Half were diagnosed with papilloma based on CNB and the other half with CSL. For those proliferative lesions without atypia, the upgrade rate to cancer was 1.6%. CNB showed concomitant HRL in 23% of patients with non-dense breasts and in 22% with dense tissue. In 24 cases, the pathology was considered an upgrade by showing either a not prior noted HRL or carcinoma. Most patients with upgrade following surgical excision were over 50 years old. Dense breasts did not show a higher risk of upgrade following surgical excision (P = .975). CONCLUSION Our data did not reveal a difference between upgrade rates of proliferative lesions excised in dense and non-dense breasts. Further evaluation is warranted to establish whether density should be considered as a meaningful factor in excision vs observation of CSL and papillomas.
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Affiliation(s)
- Amelie Lueders
- General Surgery Department, 24104St Vincent Indianapolis, Indianapolis, IN, USA
| | - Tara Spivey
- Breast Surgery Department, 24104St Vincent Indianapolis, Indianapolis, IN, USA
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Cullinane C, Byrne J, Kelly L, O Sullivan M, Antony Corrigan M, Paul Redmond H. The positive predictive value of vacuum assisted biopsy (VAB) in predicting final histological diagnosis for breast lesions of uncertain malignancy (B3 lesions): A systematic review & meta-analysis. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2022; 48:1464-1474. [PMID: 35491362 DOI: 10.1016/j.ejso.2022.04.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 03/22/2022] [Accepted: 04/08/2022] [Indexed: 10/18/2022]
Abstract
INTRODUCTION High-risk or B3 breast lesions are considered lesions of uncertain malignant potential and comprise between 5 and 12% of initial biopsy results. We sought to perform a systematic review and meta-analysis of studies published within the last twenty years to determine the pooled Positive Predictive Value (PPV) of VAB in selected B3 lesions. METHODS The study report is based on the guidelines of PRISMA and Meta-Analysis of Observational Studies in Epidemiology. OUTCOMES The primary outcome of this study was to determine the PPV of VAB in determining final histological diagnosis in B3 breast lesions using pooled estimates. The secondary outcomes were to determine if needle gauge or the re-classification of Lobular Carcinoma in Situ(LCIS) introduced in 2012 influenced pooled estimates. RESULTS 78 studies incorporating 6,377 B3 lesions were included in this review, 1214 of which were upgraded to DCIS or invasive malignancy following surgical excision(19%). The pooled PPV of VAB in Atypical Ductal Hyperplasia(ADH) and Lobular Neoplasia(LN) were 0.79(CI 0.76-0.83) and 0.84(CI 0.8-0.88). VAB of Flat Epithelial Atypia(FEA), radial scar and papillary lesions with/without atypia all had a pooled PPV >90% (underestimation rates 7%, 1%, 5% and 3% respectively). Needle gauge size and the change in LCIS classification did not appear to influence underestimation rates on subgroup analysis. CONCLUSION Results from this meta-analysis suggests it is reasonable to perform VAB as definitive treatment for certain B3 lesions, specifically LN, FEA, radial scar, and papillary lesions when specific criteria are fulfilled. Surgical excision should continue as the mainstay of treatment for ADH.
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Abbassi-Rahbar S, Sack S, Larson KE, Wagner JL, Kilgore LJ, Balanoff CR, Winblad OD, Amin AL. Multidisciplinary Review of Intraductal Papilloma of the Breast can Identify Patients who may Omit Surgical Excision. Ann Surg Oncol 2021; 28:5768-5774. [PMID: 34338925 DOI: 10.1245/s10434-021-10520-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 07/16/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND The purpose of this study was to define contemporary management recommendations regarding who would benefit from surgical excision of intraductal papilloma (IDP). METHODS A prospective database from a single institution identified patients with IDP on percutaneous biopsy from February 2015 to September 2020. Categorical patient demographic, biopsy, and pathologic variables were analyzed using Fisher's exact test and continuous demographic and imaging variables using the Mann-Whitney U test. RESULTS IDP was present in 416 biopsies, at a median age of 56 years. The median size was 0.9 cm, and the majority had greater than 50% of the target excised by biopsy. Surgical excision was performed for 124 of 416 biopsies (29.8%). Upgrade to malignancy was identified in 14 (11.3%): 8 to ductal carcinoma in situ (DCIS) and 6 to invasive cancer. Upgrade was significantly associated with concurrent ipsilateral breast cancer (p = 0.027), larger imaging size (p = 0.045), <50% excised with biopsy (p = 0.02), and atypia involving IDP (p = 0.045). Age, clinical presentation, and concurrent contralateral cancer were not significantly associated with upgrade. Lowest upgrade risk (0%) was in pure IDP ≤1 cm with >50% removed by biopsy. Of 401 biopsies that either did not upgrade or undergo excision, 7 (1.7%) developed subsequent breast cancer over a median follow-up of 23.5 months (interquartile range [IQR] 11,41), none at IDP site. CONCLUSIONS After multidisciplinary review, the management of IDP can be stratified into low- and high-risk for upgrade groups using key criteria. Low-risk group may omit surgical excision, because those patients have 0% risk of upgrade over the limited short-term follow-up.
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Affiliation(s)
| | - Stephen Sack
- University of Kansas Medical Center, Kansas City, KS, USA
| | - Kelsey E Larson
- Department of Surgery, The University of Kansas Health System, Kansas City, KS, USA
| | - Jamie L Wagner
- Department of Surgery, The University of Kansas Health System, Kansas City, KS, USA
| | - Lyndsey J Kilgore
- Department of Surgery, The University of Kansas Health System, Kansas City, KS, USA
| | - Christa R Balanoff
- Department of Surgery, The University of Kansas Health System, Kansas City, KS, USA
| | - Onalisa D Winblad
- Department of Radiology, The University of Kansas Health System, Kansas City, KS, USA
| | - Amanda L Amin
- Department of Surgery, The University of Kansas Health System, Kansas City, KS, USA.
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Zhang X, Liu W, Hai T, Li F. Upgrade Rate and Predictive Factors for Breast Benign Intraductal Papilloma Diagnosed at Biopsy: A Meta-Analysis. Ann Surg Oncol 2021; 28:8643-8650. [PMID: 34331160 DOI: 10.1245/s10434-021-10188-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 04/29/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Current standard management for intraductal papilloma (IDP) diagnosed at biopsy indicates complete surgical resection, but there are increasing controversies over whether and when routine excision is indeed necessary. OBJECTIVE The aim of this study was to determine the carcinoma upgrade rate and identify the associated predictive factors for IDP diagnosed at biopsy by meta-analysis. METHODS We searched the PubMed and EMBASE databases for studies published from 2009 to 2020 that investigated the upgrade rate and predictive factors of IDP diagnosed at biopsy. RESULTS A total of 7016 IDP cases diagnosed at biopsy and histologically examined after surgical excision were pooled from 44 original studies. The pooled prevalence of IDP in breast biopsy findings was 4.6% [95% confidence interval (CI) 4.4-4.7%] and the majority of IDP tumors were benign. The pooled upgrade rates to carcinoma for benign IDP and atypical IDP were 5.0% (95% CI 4.4-5.5%) and 36.0% (95% CI 32.7-39.2%), respectively. In addition, we identified 10 predictive upgrade factors for benign IDP, including Breast Imaging Reporting and Data System (BI-RADS) 5, BI-RADS 4C, mass and calcification in the mammographic finding, bloody nipple discharge, imaging-histological discordance, peripheral IDP, palpable mass, BI-RADS 4B, microcalcification, and lesion size ≥ 1 cm. The upgrade rates associated with these predictive factors ranged from 7.3 to 31.1%. CONCLUSION Surgical excision appears a reasonable recommendation for atypical IDP. Patients with benign IDP exhibiting one or more predictive factors might benefit from surgical excision, while patients with asymptomatic benign IDP without these predictive factors can be managed by imaging surveillance.
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Affiliation(s)
- Xiaoli Zhang
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Wenqing Liu
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Tao Hai
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Fei Li
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing, China.
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Catanzariti F, Avendano D, Cicero G, Garza-Montemayor M, Sofia C, Venanzi Rullo E, Ascenti G, Pinker-Domenig K, Marino MA. High-risk lesions of the breast: concurrent diagnostic tools and management recommendations. Insights Imaging 2021; 12:63. [PMID: 34037876 PMCID: PMC8155169 DOI: 10.1186/s13244-021-01005-6] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 05/04/2021] [Indexed: 12/14/2022] Open
Abstract
Breast lesions with uncertain malignant behavior, also known as high-risk or B3 lesions, are composed of a variety of pathologies with differing risks of associated malignancy. While open excision was previously preferred to manage all high-risk lesions, tailored management has been increasingly favored to reduce overtreatment and spare patients from unnecessary anxiety or high healthcare costs associated with surgical excision. The purpose of this work is to provide the reader with an accurate overview focused on the main high-risk lesions of the breast: atypical intraductal epithelial proliferation (atypical ductal hyperplasia), lobular neoplasia (including the subcategories lobular carcinoma in situ and atypical lobular hyperplasia), flat epithelial atypia, radial scar and papillary lesions, and phyllodes tumor. Beyond merely presenting the radiological aspects of these lesions and the recent literature, information about their potential upgrade rates is discussed in order to provide a useful guide for appropriate clinical management while avoiding the risks of unnecessary surgical intervention (overtreatment).
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Affiliation(s)
- Francesca Catanzariti
- Department of Biomedical Sciences and Morphologic and Functional Imaging, University of Messina, Messina, Italy
| | - Daly Avendano
- Department of Breast Imaging, Breast Cancer Center TecSalud, ITESM Monterrey, Nuevo Leon, Mexico
| | - Giuseppe Cicero
- Department of Biomedical Sciences and Morphologic and Functional Imaging, University of Messina, Messina, Italy
| | | | - Carmelo Sofia
- Department of Biomedical Sciences and Morphologic and Functional Imaging, University of Messina, Messina, Italy
| | - Emmanuele Venanzi Rullo
- Unit of Infectious Diseases, Department of Clinical and Experimental Medicine, University of Messina, 98124, Messina, Italy
| | - Giorgio Ascenti
- Department of Biomedical Sciences and Morphologic and Functional Imaging, University of Messina, Messina, Italy
| | - Katja Pinker-Domenig
- Department of Radiology, Breast Imaging Service, Memorial Sloan Kettering Cancer Center, Suite 705, 300 E 66th Street, New York, NY, 10065, USA. .,Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria.
| | - Maria Adele Marino
- Department of Biomedical Sciences and Morphologic and Functional Imaging, University of Messina, Messina, Italy
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Tek C, Öztekin PS, Celepli P, Uçar F, Koşar PN. Using the Superb Microvascular Imaging Method in the Distinction of Intraductal Papilloma and Duct Ectasia With Secretion. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2021; 40:269-277. [PMID: 32681668 DOI: 10.1002/jum.15396] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 05/26/2020] [Accepted: 06/01/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVES To investigate the diagnostic value of a Superb Microvascular Imaging (SMI; Toshiba Medical Systems, Tokyo, Japan) Doppler examination for distinguishing intraductal papilloma (IDP) from duct ectasia with secretion in lesions smaller than 1 cm compared to color Doppler imaging (CDI) and power Doppler imaging (PDI). METHODS Fifty-nine lesions were evaluated by grayscale ultrasound, CDI, PDI, and SMI. Biopsied tissue samples were analyzed. Ultrasound evaluations and Doppler examinations were performed with a Toshiba Aplio 500 device. The lesions were divided into 2 groups, secretion and IDP, according to the pathologic results. Color Doppler imaging, PDI, and SMI data were compared statistically to investigate their diagnostic values. RESULTS Of the 59 lesions, 22 were secretion, and 37 were IDP. The mean diameters ± SDs were 4.7 ± 0.6 mm in the secretion group and 4.9 ± 0.8 mm in the IDP group (P = .315). There was no significant difference in grayscale ultrasound features such as shape or margin between the groups (P > .05). No significant difference was found between the groups in CDI or PDI characteristics (P > .999; P = .702, respectively). The color SMI evaluation results showed no vascularity in 18 (81.8%) lesions in the secretion group. Vascularity was detected in 32 patients (86.5%) in the IDP group. In the receiver operating characteristic analysis, the areas under the curve were calculated as 0.842 (95% confidence interval [CI], 0.728-0.925) for SMI, 0.522 (95% CI, 0.388-0.654) for PDI, and 0.518 (95% CI, 0.384-0.650) for CDI. CONCLUSIONS Superb Microvascular Imaging is more accurate and has more diagnostic ability than CDI or PDI in distinguishing small IDPs from duct ectasia with secretion because of its ability to visualize slow flow speeds of vascular structures.
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Affiliation(s)
- Cihat Tek
- Department of Radiology, Ankara Training and Research Hospital, Ankara, Turkey
| | - Pelin Seher Öztekin
- Department of Radiology, Ankara Training and Research Hospital, Ankara, Turkey
| | - Pınar Celepli
- Department of Pathology, Ankara Training and Research Hospital, Ankara, Turkey
| | - Funda Uçar
- Department of Radiology, Ankara Training and Research Hospital, Ankara, Turkey
| | - Pınar Nercis Koşar
- Department of Radiology, Ankara Training and Research Hospital, Ankara, Turkey
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High-Risk Lesions Detected by MRI-Guided Core Biopsy: Upgrade Rates at Surgical Excision and Implications for Management. AJR Am J Roentgenol 2021; 216:622-632. [PMID: 33439046 DOI: 10.2214/ajr.20.23040] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
OBJECTIVE. The purpose of our study was to evaluate the upgrade rates of high-risk lesions (HRLs) diagnosed by MRI-guided core biopsy and to assess which clinical and imaging characteristics are predictive of upgrade to malignancy. MATERIALS AND METHODS. A retrospective review was performed of all women who presented to an academic breast radiology center for MRI-guided biopsy between January 1, 2015, and November 30, 2018. Histopathologic results from each biopsy were extracted. HRLs-that is, atypical ductal hyperplasia (ADH), lobular carcinoma in situ (LCIS), atypical lobular hyperplasia (ALH), radial scar, papilloma, flat epithelial atypia (FEA), benign vascular lesion (BVL), and mucocelelike lesion-were included for analysis. Clinical history, imaging characteristics, surgical outcome, and follow-up data were recorded. Radiologic-pathologic correlation was performed. RESULTS. Of 810 MRI-guided biopsies, 189 cases (23.3%) met the inclusion criteria for HRLs. Of the 189 HRLs, 30 cases were excluded for the following reasons: 15 cases were lost to follow-up, six cases were in patients who received neoadjuvant chemotherapy after biopsy, two lesions that were not excised had less than 2 years of imaging follow-up, and seven lesions had radiologic-pathologic discordance at retrospective review. Of the 159 HRLs in our study cohort, 13 (8.2%) were upgraded to carcinoma. Surgical upgrade rates were high for ADH (22.5%, 9/40) and FEA (33.3%, 1/3); moderate for LCIS (6.3%, 3/48); and low for ALH (0.0%, 0/11), radial scar (0.0%, 0/28), papilloma (0.0%, 0/26), and BVL (0.0%, 0/3). Of the upgraded lesions, 69.2% (9/13) were upgraded to ductal carcinoma in situ (DCIS) or well-differentiated carcinoma. ADH lesions were significantly more likely to be upgraded than non-ADH lesions (p = .005). CONCLUSION. ADH diagnosed by MRI-guided core biopsy warrants surgical excision. The other HRLs, however, may be candidates for imaging follow-up rather than excision, especially after meticulous radiologic-pathologic correlation.
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Lin LH, Ozerdem U, Cotzia P, Lee J, Chun J, Schnabel F, Darvishian F. Upgrade rate of intraductal papilloma diagnosed on core needle biopsy in a single institution. Hum Pathol 2020; 110:43-49. [PMID: 33159966 DOI: 10.1016/j.humpath.2020.10.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 10/28/2020] [Accepted: 10/30/2020] [Indexed: 11/17/2022]
Abstract
The management of intraductal papilloma (IDP) diagnosed on core needle biopsy (CNB) is controversial due to the variable upgrade rates to breast carcinoma (BC) on subsequent surgical excision reported in the literature. The purpose of our study was to investigate the upgrade rate of IDP diagnosed on CNB to BC in subsequent surgical excision and the impact of clinical, pathologic, and radiologic variables. This is a retrospective cohort of all women who had a diagnosis of IDP on a CNB between 2005 and 2018 in a tertiary academic center with subsequent surgical excision. Upgrade was defined as ductal carcinoma in situ (DCIS) and invasive carcinoma on surgical excision. Statistical analyses included Pearson's chi-square, Wilcoxon rank-sum, and logistic regression. A total of 216 women with IDP in a CNB were included. Nineteen patients (8.8%) upgraded to BC in the overall cohort, including 14 DCIS and 5 invasive carcinomas. An upgrade rate of 27% was found in atypical IDP (14 of 51 cases), while only 3% of pure IDP upgraded to BC (5 of 165 cases). Older age (>53 years) at the time of biopsy (odds ratio [OR] = 1.05, 95% confidence interval [CI] = 1.01-1.09, p = 0.027) and concomitant atypical ductal hyperplasia (ADH) (OR = 9.69, 95% CI = 3.37-27.81, p < 0.0001) were significantly associated with upgrade. Our results support surgical excision of IDP on CNB when associated with ADH or diagnosed in women aged older than 53 years. The low surgical upgrade rate of 3% for pure IDP on CNB in younger women should be part of the management discussion.
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Affiliation(s)
- Lawrence Hsu Lin
- New York University Langone Health, Department of Pathology, New York, NY, 10016, United States
| | - Ugur Ozerdem
- New York University Langone Health, Department of Pathology, New York, NY, 10016, United States
| | - Paolo Cotzia
- New York University Langone Health, Department of Pathology, New York, NY, 10016, United States
| | - Jiyon Lee
- New York University Langone Health, Department of Radiology, NYU Perlmutter Cancer Center, New York, NY, 10016, United States
| | - Jennifer Chun
- New York University Langone Health, Department of Surgery, Division of Breast Surgical Oncology, NYU Perlmutter Cancer Center, New York, NY, 10016, United States
| | - Freya Schnabel
- New York University Langone Health, Department of Surgery, Division of Breast Surgical Oncology, NYU Perlmutter Cancer Center, New York, NY, 10016, United States
| | - Farbod Darvishian
- New York University Langone Health, Department of Pathology, New York, NY, 10016, United States.
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12
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Polat DS, Knippa EE, Ganti R, Seiler SJ, Goudreau SH. Benign breast papillomas without atypia diagnosed with core needle biopsy: Outcome of surgical excision and imaging follow-up. Eur J Radiol 2020; 131:109237. [PMID: 32905954 DOI: 10.1016/j.ejrad.2020.109237] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 08/05/2020] [Accepted: 08/16/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE To evaluate the surgical upgrade rate to malignancy and high-risk lesions in cases of papilloma without atypia diagnosed with imaging-guided percutaneous core needle biopsy (CNB) and to determine whether any lesion imaging features, biopsy techniques, and pathological factors can predict lesion upgrade to help guide clinical management. MATERIALS AND METHODS Benign papillomas without atypia (n = 399) diagnosed with CNB were retrospectively reviewed. The surgical upgrade rate to malignancy or high-risk lesion (atypical ductal hyperplasia, atypical lobular hyperplasia, lobular carcinoma in-situ, flat epithelial atypia and atypical papilloma) was determined. Detection modality (i.e. mammography, ultrasonography (US), magnetic resonance imaging (MRI)), lesion type and size, biopsy-guidance modality (US, stereotactic, MRI), biopsy needle size (<14 G vs ≥14 G), use of vacuum assistance, and presenting symptoms were statistically analyzed. The reference standard for evaluation of upgrade was either excision or at least 24 months of imaging follow-up. Chi Square test and Fisher exact tests were performed for categorical variables, and the Mann-Whitney-U test was used for continuous variables. RESULTS Ultrasound was the predominant biopsy modality (78.4 %, p < 0.001). Of the 399 benign papilloma lesions in 329 women, 239 (59.9 %) were excised and 93 others were followed for at least 24 months (total of 332). Of these 332 lesions, 7 (2.1 %) were upgraded to ductal carcinoma in-situ and 41 (12.3 %) to high-risk lesions at excision. Larger lesion size (≥15 mm, p = 0.009), smaller biopsy needle size (≥14 G, p = 0.027), and use of spring-loaded biopsy device (p = 0.012) were significantly associated with upgrade to atypia. Only lesion size (≥15 mm, p = 0.02) was associated with upgrade to cancer. CONCLUSION Upgrade to malignancy of biopsy-proven benign papillomas without atypia at the time of surgery was sufficiently low (2.1 %) to support non-operative management. Surgery may be performed for selected cases- those with larger lesion size and those whose biopsies were performed with smaller spring-loaded biopsy needles.
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Affiliation(s)
- Dogan S Polat
- Department of Diagnostic Radiology, University of Texas Southwestern Medical Center, Dallas, TX, United States.
| | - Emily E Knippa
- Department of Diagnostic Radiology, University of Texas Southwestern Medical Center, Dallas, TX, United States.
| | - Ramapriya Ganti
- Department of Radiology and Medical Imaging, University of Virginia, United States.
| | - Stephen J Seiler
- Department of Diagnostic Radiology, University of Texas Southwestern Medical Center, Dallas, TX, United States.
| | - Sally H Goudreau
- Department of Diagnostic Radiology, University of Texas Southwestern Medical Center, Dallas, TX, United States.
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13
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MacColl C, Salehi A, Parpia S, Hodgson N, Ramonas M, Williams P. Benign breast papillary lesions diagnosed on core biopsy: upgrade rate and risk factors associated with malignancy on surgical excision. Virchows Arch 2019; 475:701-707. [PMID: 31372738 DOI: 10.1007/s00428-019-02626-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 06/24/2019] [Accepted: 07/15/2019] [Indexed: 11/27/2022]
Abstract
Evaluation of radiologically detected breast lesions is a common task in surgical pathology. Some benign lesions on biopsy are associated with an upgrade to in situ or invasive carcinoma on excision. The non-atypical breast papilloma has published upgrade rates of 0 to 29%. Traditionally, papillomas have been managed surgically, but the wide range of upgrade rates has raised uncertainty about the need for routine surgical excision. This study aims to identify risk factors associated with upgrade and determine the upgrade rate of non-atypical papillomas at our institution. In a retrospective review of pathology reports, we identified 266 patients with a diagnosis of benign papilloma on breast core biopsy. One hundred eighty-two patients underwent surgical resection. The final surgical pathology reports of all patients were reviewed and divided into one of two groups-benign or malignant. Twenty-one patients had a final diagnosis of in situ or invasive carcinoma, resulting in an upgrade rate of 12%. Radiologically detected lesions with calcifications were at higher risk for upgrade (OR = 4.45, 95% CI 1.08-18.27) than lesions without calcifications. Additionally, advanced patient age (OR = 1.07, 95% CI 1.03-1.13) and lesion size greater than 0.5 cm (OR = 2.59, 95% CI 0.38-17.48) was associated with upgrade to malignancy. Routine surgical excision of all papillomas is not recommended. Younger patients without high-risk features may benefit from clinical and radiologic follow-up alone. Accurate risk stratification will spare low-risk women unnecessary surgery.
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Affiliation(s)
- Christine MacColl
- Department of Pathology and Molecular Medicine, McMaster University Medical Center, 1200 Main Street West, Hamilton, ON, L8N 3Z5, Canada.
- Department of Pathology and Molecular Medicine, Juravinski Hospital - Hamilton Health Sciences, 711 Concession St, Hamilton, ON, L8V 1C3, Canada.
| | - Amir Salehi
- Department of Pathology and Molecular Medicine, Juravinski Hospital - Hamilton Health Sciences, 711 Concession St, Hamilton, ON, L8V 1C3, Canada
| | - Sameer Parpia
- Department of Oncology, McMaster University, 711 Concession St, Hamilton, ON, L8V 1C3, Canada
| | - Nicole Hodgson
- Department of Surgery, Juravinski Hospital - Hamilton Health Sciences, 711 Concession St, Hamilton, ON, L8V 1C3, Canada
| | - Milita Ramonas
- Department of Radiology, Juravinski Hospital - Hamilton Health Sciences, 711 Concession St, Hamilton, ON, L8V 1C3, Canada
| | - Phillip Williams
- Department of Pathology and Molecular Medicine, Juravinski Hospital - Hamilton Health Sciences, 711 Concession St, Hamilton, ON, L8V 1C3, Canada
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14
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Paepke S, Metz S, Brea Salvago A, Ohlinger R. Benign Breast Tumours - Diagnosis and Management. Breast Care (Basel) 2018; 13:403-412. [PMID: 30800034 DOI: 10.1159/000495919] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
With improvements in breast imaging, mammography, ultrasound and minimally invasive interventions, the detection of early breast cancer, non-invasive cancers, lesions of uncertain malignant potential, and benign lesions has increased. However, with the improved diagnostic capabilities comes a substantial risk of false-positive benign lesions and vice versa false-negative malignant lesions. A statement is provided on the manifestation, imaging, and diagnostic verification of isolated benign breast tumours that have a frequent manifestation, in addition to general therapy management recommendations. Histological evaluation of benign breast tumours is the most reliable diagnostic method. According to the S3 guideline and information gained from analysis of the literature, preference is to be given to core biopsy for each type of tumour as the preferred diagnostic method. An indication for open biopsy is also to be established should the tumour increase in size in the follow-up interval, after recurring discrepancies in the vacuum biopsy results, or at the request of the patient. As an alternative, minimally invasive procedures such as therapeutic vacuum biopsy, cryoablation or high-intensity focused ultrasound are also becoming possible alternatives in definitive surgical management. The newer minimally invasive methods show an adequate degree of accuracy and hardly any restrictions in terms of post-interventional cosmetics so that current requirements of extensive breast imaging can be thoroughly met.
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Affiliation(s)
- Stefan Paepke
- Department of Obstetrics and Gynecology, Technical University of Munich, Munich, Germany.,Roman Herzog Comprehensive Cancer Center, Munich, Germany.,Comprehensive Cancer Center München, Munich, Germany
| | - Stephan Metz
- Department of Radiology, Technical University of Munich, Munich, Germany
| | - Anika Brea Salvago
- Department of Gynecology and Obstetrics, Ernst-Moritz-Arndt University Greifswald, Greifswald, Germany
| | - Ralf Ohlinger
- Department of Gynecology and Obstetrics, Ernst-Moritz-Arndt University Greifswald, Greifswald, Germany
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