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Marin C, Weiss A, Gooch JC. Updates in the Surgical Management of Benign and High-Risk Breast Lesions. Clin Breast Cancer 2024; 24:278-285. [PMID: 38171944 DOI: 10.1016/j.clbc.2023.12.008] [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: 11/01/2023] [Revised: 12/18/2023] [Accepted: 12/19/2023] [Indexed: 01/05/2024]
Abstract
Benign breast disease (BBD) is a heterogenous group of lesions often classified as nonproliferative or proliferative, with the latter group further categorized based on the presence of atypia. Although nonproliferative lesions are more common, the risk of breast cancer is elevated in women with proliferative lesions. Historically, the majority of proliferative lesions were excised due to concern for future and/or concomitant breast cancer at the site of the index lesion. However, contemporary data suggest that the risk of cancer associated with various proliferative lesions may be lower than previously thought, and management of BBD has become more nuanced. In this review, we will focus on recent updates in the management of a select group of benign and high-risk lesions.
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Affiliation(s)
- Chelsea Marin
- Department of Surgery, Division of Surgical Oncology, University of Rochester Medical Center, Rochester, NY
| | - Anna Weiss
- Department of Surgery, Division of Surgical Oncology, University of Rochester Medical Center, Rochester, NY; Wilmot Cancer Center, University of Rochester Medical Center, Rochester, NY
| | - Jessica C Gooch
- Department of Surgery, Division of Surgical Oncology, University of Rochester Medical Center, Rochester, NY; Wilmot Cancer Center, University of Rochester Medical Center, Rochester, NY.
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2
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Laws A, Leonard S, Hershey E, Stokes S, Vincuilla J, Sharma E, Milliron K, Garber JE, Merajver SD, King TA, Pilewskie ML. Upgrade Rates and Breast Cancer Development Among Germline Pathogenic Variant Carriers with High-Risk Breast Lesions. Ann Surg Oncol 2024; 31:3120-3127. [PMID: 38261128 DOI: 10.1245/s10434-024-14947-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 01/04/2024] [Indexed: 01/24/2024]
Abstract
BACKGROUND High-risk lesions (HRL) of the breast are risk factors for future breast cancer development and may be associated with a concurrent underlying malignancy when identified on needle biopsy; however, there are few data evaluating HRLs in carriers of germline pathogenic variants (PVs) in breast cancer predisposition genes. METHODS We identified patients from two institutions with germline PVs in high- and moderate-penetrance breast cancer predisposition genes and an HRL in an intact breast, including atypical ductal hyperplasia (ADH), flat epithelial atypia (FEA), and lobular neoplasia (LN). We calculated upgrade rates at surgical excision and used Kaplan-Meier methods to characterize 3-year breast cancer risk in patients without upgrade. RESULTS Of 117 lesions in 105 patients, 65 (55.6%) were ADH, 48 (41.0%) were LN, and 4 (3.4%) were FEA. Most PVs (83.8%) were in the BRCA1/2, CHEK2 and ATM genes. ADH and FEA were excised in most cases (87.1%), with upgrade rates of 11.8% (95% confidence interval [CI] 5.5-23.4%) and 0%, respectively. LN was selectively excised (53.8%); upgrade rate in the excision group was 4.8% (95% CI 0.8-22.7%), and with 20 months of median follow-up, no same-site cancers developed in the observation group. Among those not upgraded, the 3-year risk of breast cancer development was 13.1% (95% CI 6.3-26.3%), mostly estrogen receptor-positive (ER +) disease (89.5%). CONCLUSIONS Upgrade rates for HRLs in patients with PVs in breast cancer predisposition genes appear similar to non-carriers. HRLs may be associated with increased short-term ER+ breast cancer risk in PV carriers, warranting strong consideration of surgical or chemoprevention therapies in this population.
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Affiliation(s)
- Alison Laws
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Saskia Leonard
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
- John A. Burns School of Medicine, University of Hawaii, Honolulu, HI, USA
| | - Emma Hershey
- Department of Surgery, Michigan Medicine, Ann Arbor, MI, USA
| | - Samantha Stokes
- Division of Cancer Genetics and Prevention, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Julie Vincuilla
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Eshita Sharma
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Kara Milliron
- Breast and Ovarian Cancer Risk Evaluation Program, Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI, USA
| | - Judy E Garber
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Division of Cancer Genetics and Prevention, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Sofia D Merajver
- Breast and Ovarian Cancer Risk Evaluation Program, Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI, USA
| | - Tari A King
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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3
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Rubio IT, Wyld L, Marotti L, Athanasiou A, Regitnig P, Catanuto G, Schoones JW, Zambon M, Camps J, Santini D, Dietz J, Sardanelli F, Varga Z, Smidt M, Sharma N, Shaaban AM, Gilbert F. European guidelines for the diagnosis, treatment and follow-up of breast lesions with uncertain malignant potential (B3 lesions) developed jointly by EUSOMA, EUSOBI, ESP (BWG) and ESSO. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:107292. [PMID: 38061151 DOI: 10.1016/j.ejso.2023.107292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 11/17/2023] [Indexed: 01/16/2024]
Abstract
INTRODUCTION Breast lesions of uncertain malignant potential (B3) include atypical ductal and lobular hyperplasias, lobular carcinoma in situ, flat epithelial atypia, papillary lesions, radial scars and fibroepithelial lesions as well as other rare miscellaneous lesions. They are challenging to categorise histologically, requiring specialist training and multidisciplinary input. They may coexist with in situ or invasive breast cancer (BC) and increase the risk of subsequent BC development. Management should focus on adequate classification and management whilst avoiding overtreatment. The aim of these guidelines is to provide updated information regarding the diagnosis and management of B3 lesions, according to updated literature review evidence. METHODS These guidelines provide practical recommendations which can be applied in clinical practice which include recommendation grade and level of evidence. All sections were written according to an updated literature review and discussed at a consensus meeting. Critical appraisal by the expert writing committee adhered to the 23 items in the international Appraisal of Guidelines, Research and Evaluation (AGREE) tool. RESULTS Recommendations for further management after core-needle biopsy (CNB) or vacuum-assisted biopsy (VAB) diagnosis of a B3 lesion reported in this guideline, vary depending on the presence of atypia, size of lesion, sampling size, and patient preferences. After CNB or VAB, the option of vacuum-assisted excision or surgical excision should be evaluated by a multidisciplinary team and shared decision-making with the patient is crucial for personalizing further treatment. De-escalation of surgical intervention for B3 breast lesions is ongoing, and the inclusion of vacuum-assisted excision (VAE) will decrease the need for surgical intervention in further approaches. Communication with patients may be different according to histological diagnosis, presence or absence of atypia, or risk of upgrade due to discordant imaging. Written information resources to help patients understand these issues alongside with verbal communication is recommended. Lifestyle interventions have a significant impact on BC incidence so lifestyle interventions need to be suggested to women at increased BC risk as a result of a diagnosis of a B3 lesion. CONCLUSIONS These guidelines provide a state-of-the-art overview of the diagnosis, management and prognosis of B3 lesions in modern multidisciplinary breast practice.
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Affiliation(s)
- Isabel T Rubio
- Breast Surgical Oncology, Clinica Universidad de Navarra, Madrid, Spain; European Society of Breast Cancer Specialists (EUSOMA), Florence, Italy; European Society of Surgical Oncology (ESSO), Brussels, Belgium.
| | - Lynda Wyld
- Department of Oncology and Metabolism, University of Sheffield Medical School, Beech Hill Road, Sheffield, S10 2RX, UK; Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust, Doncaster, UK
| | - Lorenza Marotti
- European Society of Breast Cancer Specialists (EUSOMA), Florence, Italy
| | | | - Peter Regitnig
- Diagnostic and Research Institute of Pathology, Medical University of Graz, Graz, Austria
| | - Giuseppe Catanuto
- Humanitas-Istituto Clinico Catanese Misterbianco, Italy; Fondazione G.Re.T.A., ETS, Napoli, Italy
| | - Jan W Schoones
- Research Policy & Graduate School Advisor, Leiden University Medical Center Leiden, the Netherlands
| | - Marzia Zambon
- Europa Donna - The European Breast Cancer Coalition, Milan, Italy
| | - Julia Camps
- Breast Health Units in Ribera Salud Hospitals.Valencia, Spain
| | - Donatella Santini
- Department of Pathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy
| | - Jill Dietz
- The American Society of Breast Surgeons, Columbia, MD, USA
| | - Francesco Sardanelli
- Department of Biomedical Sciences for Health, Università Degli Studi di Milano, Milan, Italy; Unit of Radiology, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Zsuzsanna Varga
- Department of Pathology and Molecular Pathology, University Hospital Zurich, Zurich, Switzerland
| | - Marjolein Smidt
- GROW-School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, the Netherlands; Department of Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Nisha Sharma
- Breast Unit, Level 1 Chancellor Wing, St James Hospital, Beckett Street Leeds, West Yorkshire, LS9 7TF, UK
| | - Abeer M Shaaban
- Cellular Pathology, Queen Elizabeth Hospital Birmingham, Birmingham, UK; Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Fiona Gilbert
- Department of Radiology, University of Cambridge, Cambridge Biomedical Campus, UK.
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Limberg J, DiLalla GA. Increased risk of upstage when combinations of breast lesions of uncertain malignant potential are found on core needle biopsy-The need for surgical excision. Am J Surg 2024; 227:4-5. [PMID: 37863794 DOI: 10.1016/j.amjsurg.2023.09.042] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 09/29/2023] [Accepted: 09/30/2023] [Indexed: 10/22/2023]
Affiliation(s)
- Jessica Limberg
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Gayle A DiLalla
- Department of Surgery, Duke University Medical Center, Durham, NC, USA.
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5
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Harper LK, Carnahan MB, Bhatt AA, Simmons CL, Patel BK, Downs E, Pockaj BA, Yancey K, Eversman SE, Sharpe RE. Imaging Characteristics of and Multidisciplinary Management Considerations for Atypical Ductal Hyperplasia and Flat Epithelial Atypia: Review of Current Literature. Radiographics 2023; 43:e230016. [PMID: 37768862 DOI: 10.1148/rg.230016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/30/2023]
Abstract
High-risk lesions of the breast are frequently encountered in percutaneous biopsy specimens. While benign, these lesions have historically undergone surgical excision due to their potential to be upgraded to malignancy. However, there is emerging evidence that a tailored management approach should be considered to reduce overtreatment of these lesions. Flat epithelial atypia (FEA) and atypical ductal hyperplasia (ADH) are two of the most commonly encountered high-risk lesions. FEA has been shown to have a relatively low rate of progression to malignancy, and some guidelines are now recommending observation over routine excision in select cases. Selective observation may be reasonable in cases where the target lesion is small and completely removed at biopsy and when there are no underlying risk factors, such as a history of breast cancer or genetic mutation or concurrent ADH. ADH has the highest potential upgrade rate to malignancy of all the high-risk lesions. Most society guidelines continue to recommend surgical excision of this lesion. More recently, some literature suggests that ADH lesions that appear completely removed at biopsy, involve limited foci (less than two or three) with no necrosis or significant atypia, manifest as a small group of mammographic calcifications, or demonstrate no enhancement at MRI may be reasonable for observation. Ultimately, management of all high-risk lesions must be based on a multidisciplinary approach that considers all patient, radiologic, clinical, and histopathologic factors. ©RSNA, 2023 Quiz questions for this article are available in the supplemental material.
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Affiliation(s)
- Laura K Harper
- From the Departments of Radiology (L.K.H., M.B.C., B.K.P., K.Y., S.E.E., R.E.S.), Pathology (E.D.), and Surgery (B.A.P.), Mayo Clinic, 5777 E Mayo Blvd, Phoenix, AZ 85054; Department of Radiology, Mayo Clinic, Rochester, Minn (A.A.B.); and Department of Radiology, Phoenix Children's Hospital, Phoenix, Ariz (C.L.S.)
| | - Molly B Carnahan
- From the Departments of Radiology (L.K.H., M.B.C., B.K.P., K.Y., S.E.E., R.E.S.), Pathology (E.D.), and Surgery (B.A.P.), Mayo Clinic, 5777 E Mayo Blvd, Phoenix, AZ 85054; Department of Radiology, Mayo Clinic, Rochester, Minn (A.A.B.); and Department of Radiology, Phoenix Children's Hospital, Phoenix, Ariz (C.L.S.)
| | - Asha A Bhatt
- From the Departments of Radiology (L.K.H., M.B.C., B.K.P., K.Y., S.E.E., R.E.S.), Pathology (E.D.), and Surgery (B.A.P.), Mayo Clinic, 5777 E Mayo Blvd, Phoenix, AZ 85054; Department of Radiology, Mayo Clinic, Rochester, Minn (A.A.B.); and Department of Radiology, Phoenix Children's Hospital, Phoenix, Ariz (C.L.S.)
| | - Curtis L Simmons
- From the Departments of Radiology (L.K.H., M.B.C., B.K.P., K.Y., S.E.E., R.E.S.), Pathology (E.D.), and Surgery (B.A.P.), Mayo Clinic, 5777 E Mayo Blvd, Phoenix, AZ 85054; Department of Radiology, Mayo Clinic, Rochester, Minn (A.A.B.); and Department of Radiology, Phoenix Children's Hospital, Phoenix, Ariz (C.L.S.)
| | - Bhavika K Patel
- From the Departments of Radiology (L.K.H., M.B.C., B.K.P., K.Y., S.E.E., R.E.S.), Pathology (E.D.), and Surgery (B.A.P.), Mayo Clinic, 5777 E Mayo Blvd, Phoenix, AZ 85054; Department of Radiology, Mayo Clinic, Rochester, Minn (A.A.B.); and Department of Radiology, Phoenix Children's Hospital, Phoenix, Ariz (C.L.S.)
| | - Erinn Downs
- From the Departments of Radiology (L.K.H., M.B.C., B.K.P., K.Y., S.E.E., R.E.S.), Pathology (E.D.), and Surgery (B.A.P.), Mayo Clinic, 5777 E Mayo Blvd, Phoenix, AZ 85054; Department of Radiology, Mayo Clinic, Rochester, Minn (A.A.B.); and Department of Radiology, Phoenix Children's Hospital, Phoenix, Ariz (C.L.S.)
| | - Barbara A Pockaj
- From the Departments of Radiology (L.K.H., M.B.C., B.K.P., K.Y., S.E.E., R.E.S.), Pathology (E.D.), and Surgery (B.A.P.), Mayo Clinic, 5777 E Mayo Blvd, Phoenix, AZ 85054; Department of Radiology, Mayo Clinic, Rochester, Minn (A.A.B.); and Department of Radiology, Phoenix Children's Hospital, Phoenix, Ariz (C.L.S.)
| | - Kristina Yancey
- From the Departments of Radiology (L.K.H., M.B.C., B.K.P., K.Y., S.E.E., R.E.S.), Pathology (E.D.), and Surgery (B.A.P.), Mayo Clinic, 5777 E Mayo Blvd, Phoenix, AZ 85054; Department of Radiology, Mayo Clinic, Rochester, Minn (A.A.B.); and Department of Radiology, Phoenix Children's Hospital, Phoenix, Ariz (C.L.S.)
| | - Sarah E Eversman
- From the Departments of Radiology (L.K.H., M.B.C., B.K.P., K.Y., S.E.E., R.E.S.), Pathology (E.D.), and Surgery (B.A.P.), Mayo Clinic, 5777 E Mayo Blvd, Phoenix, AZ 85054; Department of Radiology, Mayo Clinic, Rochester, Minn (A.A.B.); and Department of Radiology, Phoenix Children's Hospital, Phoenix, Ariz (C.L.S.)
| | - Richard E Sharpe
- From the Departments of Radiology (L.K.H., M.B.C., B.K.P., K.Y., S.E.E., R.E.S.), Pathology (E.D.), and Surgery (B.A.P.), Mayo Clinic, 5777 E Mayo Blvd, Phoenix, AZ 85054; Department of Radiology, Mayo Clinic, Rochester, Minn (A.A.B.); and Department of Radiology, Phoenix Children's Hospital, Phoenix, Ariz (C.L.S.)
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Xie CL, Whitman GJ, Middleton LP, Bevers TB, Bedrosian I, Chung HL. Isolated Flat Epithelial Atypia: Upgrade Outcomes After Multidisciplinary Review-Based Management Using Excision or Imaging Surveillance. JOURNAL OF BREAST IMAGING 2023; 5:575-584. [PMID: 37744722 PMCID: PMC10516722 DOI: 10.1093/jbi/wbad049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Indexed: 09/26/2023]
Abstract
Objective To compare flat epithelial atypia (FEA) upgrade rates after excision versus surveillance and to identify variables associated with upgrade. Methods This single-institution retrospective study identified isolated FEA cases determined by percutaneous biopsy from April 2005 through July 2022 with excision or ≥2 years surveillance. All cases were recommended for excision or surveillance based on multidisciplinary discussion of clinical, imaging, and pathologic variables with emphasis on sampling adequacy and significant atypia. Truth was determined by pathology at excision or the absence of cancer on surveillance. Upgrade was defined as cancer occurring ≤2 cm from the biopsy site. Demographic, imaging, and biopsy variables were compared between those that did and did not upgrade. Results Among 112 cases of isolated FEA, imaging findings included calcifications in 81.3% (91/112), MRI lesions in 11.6% (13/112), and distortions or masses in 7.1% (8/112). Excision was recommended in 12.5% (14/112) and surveillance in 87.5% (98/112) of cases. Among those recommended for excision, 28.6% (4/14) of cases were upgraded, all to ductal carcinoma in situ. In those recommended for surveillance, 1.0% (1/98) were upgraded to invasive cancer. Overall, FEA had a 4.5% (5/112) upgrade rate, and 2.7% (3/112) also developed cancer >2 cm from the FEA. There were no significant differences in demographic, imaging, and biopsy variables between those that did and did not upgrade to cancer. Conclusion Multidisciplinary management of isolated FEA distinguishes those at higher risk of upgrade to cancer (28.6%) in whom surgery is warranted from those at low risk of upgrade (1.0%) who can be managed non-operatively.
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Affiliation(s)
- Charlies L Xie
- MD Anderson Cancer Center, Department of Breast Imaging, Houston, TX, USA
| | - Gary J Whitman
- MD Anderson Cancer Center, Department of Breast Imaging, Houston, TX, USA
| | | | - Therese B Bevers
- MD Anderson Cancer Center, Department of Clinical Cancer Prevention, Houston, TX, USA
| | - Isabelle Bedrosian
- MD Anderson Cancer Center, Department of Breast Surgical Oncology, Houston, TX, USA
| | - Hannah L Chung
- MD Anderson Cancer Center, Department of Breast Imaging, Houston, TX, USA
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Strickland S, Turashvili G. Are Columnar Cell Lesions the Earliest Non-Obligate Precursor in the Low-Grade Breast Neoplasia Pathway? Curr Oncol 2022; 29:5664-5681. [PMID: 36005185 PMCID: PMC9406596 DOI: 10.3390/curroncol29080447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 08/09/2022] [Accepted: 08/09/2022] [Indexed: 11/16/2022] Open
Abstract
Columnar cell lesions (CCLs) of the breast comprise a spectrum of morphologic alterations of the terminal duct lobular unit involving variably dilated and enlarged acini lined by columnar epithelial cells. The World Health Organization currently classifies CCLs without atypia as columnar cell change (CCC) and columnar cell hyperplasia (CCH), whereas flat epithelial atypia (FEA) is a unifying term encompassing both CCC and CCH with cytologic atypia. CCLs have been increasingly recognized in stereotactic core needle biopsies (CNBs) performed for the assessment of calcifications. CCLs are believed to represent the earliest non-obligate precursor of low-grade invasive breast carcinomas as they share molecular alterations and often coexist with entities in the low-grade breast neoplasia pathway. Despite this association, however, the risk of progression of CCLs to invasive breast carcinoma appears low and may not exceed that of concurrent proliferative lesions. As the reported upgrade rates of pure CCL/FEA when identified as the most advanced high-risk lesion on CNB vary widely, the management of FEA diagnosed on CNB remains controversial. This review will include a historical overview of CCLs and will examine histologic diagnostic criteria, molecular alterations, prognosis and issues related to upgrade rates and clinical management.
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Affiliation(s)
- Sarah Strickland
- Department of Pathology and Laboratory Medicine, Faculty of Medicine, University of Ottawa, Ottawa, ON K1N 6N5, Canada
| | - Gulisa Turashvili
- Department of Pathology and Laboratory Medicine, Emory University Hospital, Emory University School of Medicine, Atlanta, GA 30322, USA
- Correspondence:
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8
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The effect of delay of excisional biopsy on upstage rate for atypical ductal hyperplasia, flat epithelial atypia, intraductal papilloma, and radial scar. Breast Cancer Res Treat 2022; 196:527-534. [PMID: 36181604 PMCID: PMC9526195 DOI: 10.1007/s10549-022-06745-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 09/11/2022] [Indexed: 01/31/2023]
Abstract
PURPOSE When Core Needle Biopsy (CNB) demonstrates Atypical Ductal Hyperplasia (ADH), Flat Epithelial Atypia (FEA), Intraductal Papilloma (IDP), or Radial Scar/Complex Sclerosing Lesion (RS), excisional biopsy (EB) is often performed to rule out underlying malignancy with upstage rates (UR) ranging between 1 and 20%. The COVID-19 pandemic led to delayed EB for many patients. We sought to evaluate whether this delay was associated with higher UR. METHODS We performed a retrospective analysis of women who underwent CNB and then EB for ADH, FEA, IDP, or RS between 2017 and 2021 using an IRB-approved repository. UR was evaluated by days between CNB and EB. RESULTS 473 patients met inclusion. 55 were upstaged to cancer (11.6%). 178 patients had pure ADH on CNB and 37 were upstaged (20.8%). 50 patients had pure FEA and 3 were upstaged (6%). 132 had pure IDP and 7 were upstaged (5.3%). 98 had pure RS and 1 was upstaged (1%). 7/15 (46.7%) had a combination of diagnoses or diagnosis with palpable mass and were upstaged. Days between CNB and EB were < 60 for 275 patients (58.1%), 60-90 for 108 (22.8%), 91-120 for 43 (9.1%), and > 120 for 47 (9.9%). There was no significant difference in UR (10.9% for < 60, 14.8% for 60-90, 7% for 90-120, and 12.8% for > 120, p = 0.54). UR for ADH was clinically increased after 60 days (27.8 vs. 17.5%), but this did not reach statistical significance (p = 0.1). CONCLUSION Surgical delay was not associated with an increased UR.
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9
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Girardi V, Guaragni M, Ruzzenenti N, Palmieri F, Fogazzi G, Cozzi A, Lucchini D, Buffoli A, Schiaffino S, Sardanelli F. B3 Lesions at Vacuum-Assisted Breast Biopsy under Ultrasound or Mammography Guidance: A Single-Center Experience on 3634 Consecutive Biopsies. Cancers (Basel) 2021; 13:5443. [PMID: 34771606 PMCID: PMC8582448 DOI: 10.3390/cancers13215443] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 10/22/2021] [Accepted: 10/26/2021] [Indexed: 11/30/2022] Open
Abstract
The rate of upgrade to cancer for breast lesions with uncertain malignant potential (B3 lesions) diagnosed at needle biopsy is highly influenced by several factors, but large series are seldom available. We retrospectively assessed the upgrade rates of a consecutive series of B3 lesions diagnosed at ultrasound- or mammography-guided vacuum-assisted biopsy (VAB) at an EUSOMA-certified Breast Unit over a 7-year timeframe. The upgrade rate was defined as the number of ductal carcinoma in situ (DCIS) or invasive cancer at pathology after excision or during follow-up divided by the total number of B3 lesions. All lesions were reviewed by one of four pathologists with a second opinion for discordant assessments of borderline cases. Excision or surveillance were defined by the multidisciplinary tumor board, with 6- and 12-month follow-up. Out of 3634 VABs (63% ultrasound-guided), 604 (17%) yielded a B3 lesion. After excision, 17/604 B3 lesions were finally upgraded to malignancy (2.8%, 95% confidence interval [CI] 1.8-4.5%), 10/17 (59%) being upgraded to DCIS and 7/17 (41%) to invasive carcinoma. No cases were upgraded during follow-up. B3a lesions showed a significantly lower upgrade rate (0.4%, 95% CI 0.1-2.1%) than B3b lesions (4.7%, 95% CI 2.9-7.5%, p = 0.001), that had a 22.0 adjusted odds ratio for upgrade (95% CI 2.1-232.3). No significant difference was found in upgrade rates according to imaging guidance or needle caliper. Surveillance-oriented management can be considered for B3a lesions, while surgical excision should be pursued for B3b lesions.
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Affiliation(s)
- Veronica Girardi
- Breast Radiology, EUSOMA-Certified Breast Unit, Istituto Clinico Sant’Anna, Via del Franzone 31, 25127 Brescia, Italy;
| | - Monica Guaragni
- Breast Pathology, EUSOMA-Certified Breast Unit, Istituto Clinico Sant’Anna, Via del Franzone 31, 25127 Brescia, Italy; (M.G.); (N.R.)
| | - Nella Ruzzenenti
- Breast Pathology, EUSOMA-Certified Breast Unit, Istituto Clinico Sant’Anna, Via del Franzone 31, 25127 Brescia, Italy; (M.G.); (N.R.)
| | - Fabrizio Palmieri
- Breast Surgery, EUSOMA-Certified Breast Unit, Istituto Clinico Sant’Anna, Via del Franzone 31, 25127 Brescia, Italy;
| | - Gianluca Fogazzi
- Breast Medical Oncology, EUSOMA-Certified Breast Unit, Istituto Clinico Sant’Anna, Via del Franzone 31, 25127 Brescia, Italy;
| | - Andrea Cozzi
- Department of Biomedical Sciences for Health, Università degli Studi di Milano, Via Mangiagalli 31, 20133 Milano, Italy;
| | - Diana Lucchini
- Breast Psycho-Oncology, EUSOMA-Certified Breast Unit, Istituto Clinico Sant’Anna, Via del Franzone 31, 25127 Brescia, Italy;
| | - Alberto Buffoli
- Radiation Oncology, EUSOMA-Certified Breast Unit, Istituto Clinico Sant’Anna, Via del Franzone 31, 25127 Brescia, Italy;
| | - Simone Schiaffino
- Unit of Radiology, IRCCS Policlinico San Donato, Via Morandi 30, 20097 San Donato Milanese, Italy;
| | - Francesco Sardanelli
- Department of Biomedical Sciences for Health, Università degli Studi di Milano, Via Mangiagalli 31, 20133 Milano, Italy;
- Unit of Radiology, IRCCS Policlinico San Donato, Via Morandi 30, 20097 San Donato Milanese, Italy;
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Nicosia L, Latronico A, Addante F, De Santis R, Bozzini AC, Montesano M, Frassoni S, Bagnardi V, Mazzarol G, Pala O, Lazzeroni M, Lissidini G, Mastropasqua MG, Cassano E. Atypical Ductal Hyperplasia after Vacuum-Assisted Breast Biopsy: Can We Reduce the Upgrade to Breast Cancer to an Acceptable Rate? Diagnostics (Basel) 2021; 11:diagnostics11061120. [PMID: 34205428 PMCID: PMC8259513 DOI: 10.3390/diagnostics11061120] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Revised: 06/16/2021] [Accepted: 06/17/2021] [Indexed: 12/02/2022] Open
Abstract
(1) Background: to evaluate which factors can reduce the upgrade rate of atypical ductal hyperplasia (ADH) to in situ or invasive carcinoma in patients who underwent vacuum-assisted breast biopsy (VABB) and subsequent surgical excision. (2) Methods: 2955 VABBs were reviewed; 141 patients with a diagnosis of ADH were selected for subsequent surgical excision. The association between patients’ characteristics and the upgrade rate to breast cancer was evaluated in both univariate and multivariate analyses. (3) Results: the upgrade rates to ductal carcinoma in situ (DCIS) and invasive carcinoma (IC) were, respectively, 29.1% and 7.8%. The pooled upgrade rate to DCIS or IC was statistically lower at univariate analysis, considering the following parameters: complete removal of the lesion (p-value < 0.001); BIRADS ≤ 4a (p-value < 0.001); size of the lesion ≤15 mm (p-value: 0.002); age of the patients <50 years (p-value: 0.035). (4) Conclusions: the overall upgrade rate of ADH to DCIS or IC is high and, as already known, surgery should be recommended. However, ADH cases should always be discussed in multidisciplinary meetings: some parameters appear to be related to a lower upgrade rate. Patients presenting these parameters could be strictly followed up to avoid overtreatment.
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Affiliation(s)
- Luca Nicosia
- Department of Breast Radiology, IEO European Institute of Oncology, IRCCS, 20141 Milan, Italy; (L.N.); (A.L.); (A.C.B.); (M.M.); (E.C.)
| | - Antuono Latronico
- Department of Breast Radiology, IEO European Institute of Oncology, IRCCS, 20141 Milan, Italy; (L.N.); (A.L.); (A.C.B.); (M.M.); (E.C.)
| | - Francesca Addante
- Department of Emergency and Organ Transplantation, Section of Anatomic Pathology, School of Medicine, University “Aldo Moro”, 70124 Bari, Italy;
| | - Rossella De Santis
- Postgraduate School in Radiology, University of Milan, 20122 Milan, Italy;
| | - Anna Carla Bozzini
- Department of Breast Radiology, IEO European Institute of Oncology, IRCCS, 20141 Milan, Italy; (L.N.); (A.L.); (A.C.B.); (M.M.); (E.C.)
| | - Marta Montesano
- Department of Breast Radiology, IEO European Institute of Oncology, IRCCS, 20141 Milan, Italy; (L.N.); (A.L.); (A.C.B.); (M.M.); (E.C.)
| | - Samuele Frassoni
- Department of Statistics and Quantitative Methods, University of Milan-Bicocca, 20126 Milan, Italy; (S.F.); (V.B.)
| | - Vincenzo Bagnardi
- Department of Statistics and Quantitative Methods, University of Milan-Bicocca, 20126 Milan, Italy; (S.F.); (V.B.)
| | - Giovanni Mazzarol
- Division of Pathology and Laboratory Medicine, IEO European Institute of Oncology, IRCCS, 20141 Milan, Italy; (G.M.); (O.P.)
| | - Oriana Pala
- Division of Pathology and Laboratory Medicine, IEO European Institute of Oncology, IRCCS, 20141 Milan, Italy; (G.M.); (O.P.)
| | - Matteo Lazzeroni
- Division of Cancer Prevention and Genetics, IEO European Institute of Oncology IRCCS, 20141 Milan, Italy;
| | - Germana Lissidini
- Division of Breast Surgery, IEO European Institute of Oncology, IRCCS, 20141 Milan, Italy;
| | - Mauro Giuseppe Mastropasqua
- Department of Emergency and Organ Transplantation, Section of Anatomic Pathology, School of Medicine, University “Aldo Moro”, 70124 Bari, Italy;
- Correspondence: ; Tel.: +39-0805594414
| | - Enrico Cassano
- Department of Breast Radiology, IEO European Institute of Oncology, IRCCS, 20141 Milan, Italy; (L.N.); (A.L.); (A.C.B.); (M.M.); (E.C.)
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11
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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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12
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The impact of vacuum-assisted excision in the management of indeterminate B3 lesions in the NHS Breast Screening Programme in England. Clin Radiol 2021; 76:470.e23-470.e29. [PMID: 33814122 DOI: 10.1016/j.crad.2021.01.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 01/26/2021] [Indexed: 11/21/2022]
Abstract
AIM To assess the impact of vacuum-assisted excision (VAE) on the management of B3 lesions in the England NHS Breast Screening Programme following an update of national guidance. A secondary aim was to investigate the histological features of malignancies resulting from upgrade of B3 lesions by either VAE or surgery. MATERIALS AND METHODS The study population was all women recalled for assessment after breast screening who had a wide-bore needle biopsy with a B3 result over the period 01/04/2018 to 31/03/2019. Data were extracted from the National Breast Screening Service (NBSS) computer system at unit level. Women with a B3 result were split into those with and without atypia. The upgrade rates and histological features of malignancies in the different groups were analysed. RESULTS In total, 2,234,514 women attended for screening between 1/4/218 and 31/3/2019, 84,559 women were referred to assessment, and of those 40,037 women had a core biopsy resulting in 3,355 were B3 lesions (8.38%). Within these, 556 cancers were diagnosed, giving an upgrade rate of 16.57% (556/3,355). The upgrade for B3 lesions with atypia was significantly higher than for B3 lesions without atypia (29.1% versus 13.3%, p<0.001). CONCLUSION The introduction of the new B3 guidelines has resulted in 73.8% of B3 lesions with atypia and 65.1% of B3 lesions with no atypia having VAE rather than surgery. The data highlights the importance of managing these indeterminate lesions appropriately with an overall upgrade rate of 16.57%.
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13
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Wahab RA, Lee SJ, Mulligan ME, Zhang B, Mahoney MC. Upgrade Rate of Pure Flat Epithelial Atypia Diagnosed at Core Needle Biopsy: A Systematic Review and Meta-Analysis. Radiol Imaging Cancer 2021; 3:e200116. [PMID: 33778758 DOI: 10.1148/rycan.2021200116] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 11/11/2020] [Accepted: 11/19/2020] [Indexed: 11/11/2022]
Abstract
Purpose To perform a systematic review and meta-analysis to calculate the pooled upgrade rate of pure flat epithelial atypia (FEA) diagnosed at core needle biopsy (CNB). Materials and Methods A PubMed and Embase database search was performed in December 2019. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. Study quality and publication bias were assessed. The upgrade rate of pure FEA to cancer, invasive carcinoma, and ductal carcinoma in situ (DCIS), as well as the co-occurrence rate of atypical ductal hyperplasia (ADH), with 95% CIs were calculated. A random effect model was used to integrate the proportions and their corresponding 95% CI. Study heterogeneity was calculated using τ2 and I 2 . Results A total of 2482 cases of pure FEA across 42 studies (mean age range, 46-59 years) met inclusion criteria to be analyzed. Significant study heterogeneity was identified (τ2 = 0.001, I 2 = 67%). The pooled upgrade rates reported for pure FEA were 5% (95% CI: 3%, 6%) for breast cancer, 1% (95% CI: 0%, 2%) for invasive carcinoma, and 2% (95% CI: 1%, 3%) for DCIS. When more than 90% of calcifications were removed at CNB, the pooled upgrade rate was 0% (95% CI: 0%, 2%). The pooled co-occurrence rate of ADH at surgical excision was 17% (95% CI: 12%, 21%). Study quality was medium to high with a risk of publication bias (P < .01). Conclusion Pure FEA diagnosed at CNB should be surgically excised due to the pooled upgrade rate of 5% for breast cancer. If more than 90% of the targeted calcifications are removed by CNB for pure FEA, close imaging follow-up is recommended.Keywords: Biopsy/Needle Aspiration, Breast, MammographySupplemental material is available for this article.© RSNA, 2021.
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Affiliation(s)
- Rifat A Wahab
- Department of Radiology, University of Cincinnati Medical Center, 234 Goodman St, ML 0761, Cincinnati, OH 45267-0761 (R.A.W., S.J.L., M.E.M., M.C.M.); and Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio (B.Z.)
| | - Su-Ju Lee
- Department of Radiology, University of Cincinnati Medical Center, 234 Goodman St, ML 0761, Cincinnati, OH 45267-0761 (R.A.W., S.J.L., M.E.M., M.C.M.); and Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio (B.Z.)
| | - Margaret E Mulligan
- Department of Radiology, University of Cincinnati Medical Center, 234 Goodman St, ML 0761, Cincinnati, OH 45267-0761 (R.A.W., S.J.L., M.E.M., M.C.M.); and Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio (B.Z.)
| | - Bin Zhang
- Department of Radiology, University of Cincinnati Medical Center, 234 Goodman St, ML 0761, Cincinnati, OH 45267-0761 (R.A.W., S.J.L., M.E.M., M.C.M.); and Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio (B.Z.)
| | - Mary C Mahoney
- Department of Radiology, University of Cincinnati Medical Center, 234 Goodman St, ML 0761, Cincinnati, OH 45267-0761 (R.A.W., S.J.L., M.E.M., M.C.M.); and Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio (B.Z.)
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14
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Flat epithelial atypia: What the radiologist needs to know in 2021. Clin Imaging 2021; 75:150-156. [PMID: 33592394 DOI: 10.1016/j.clinimag.2021.01.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Revised: 01/10/2021] [Accepted: 01/28/2021] [Indexed: 11/22/2022]
Abstract
The World Health Organization defines flat epithelial atypia (FEA), as a "presumably neoplastic intraductal alteration characterized by the replacement of native epithelial cells by a single layer or three to five layers of mildly atypical cells.". In this article, we will review FEA and compare its characteristics and differences with other atypical high-risk breast lesions. In addition, the imaging appearance of FEA will be described. Finally, we will discuss current outcomes and provide an update on its management based on the last recommendations.
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15
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Abstract
High-risk breast lesions (HRLs) are a group of heterogeneous lesions that can be associated with a synchronous or adjacent breast cancer and that confer an elevated lifetime risk of breast cancer. Management of HRLs after core needle biopsy may include close imaging and clinical follow-up or excisional biopsy to evaluate for cancer. This article reviews histologic features and clinical presentation of each of the HRLs, current evidence with regard to management, and guidelines from the American Society of Breast Surgeons and National Comprehensive Cancer Network. In addition, imaging surveillance and risk-reduction strategies for women with HRLs are discussed.
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16
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McMahon MA, Haigh I, Chen Y, Millican-Slater RA, Sharma N. Role of vacuum assisted excision in minimising overtreatment of ductal atypias. Eur J Radiol 2020; 131:109258. [PMID: 32919262 DOI: 10.1016/j.ejrad.2020.109258] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 08/23/2020] [Accepted: 08/25/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE B3 lesions are indeterminate lesions of uncertain malignant potential. They include lesions with and without epithelial atypia. Those with atypia include atypical intraductal epithelial proliferation (AIDEP)/atypical ductal hyperplasia (ADH) and flat epithelial atypia (FEA). They are traditionally managed with surgery. Vacuum assisted excision (VAE) allows larger samples to be obtained using a vacuum assisted biopsy (VAB) device, which equates to a surgical biopsy. We propose that VAE and mammographic surveillance is a safe alternative to surgery in managing the ductal atypias; (AIDEP/ADH and FEA). METHOD Retrospective analysis of prospectively collected data on B3 lesions (April 2009 - March 2016) from consecutive breast screening patients diagnosed with AIDEP/ADH or FEA on initial diagnostic core biopsy. Mammographic abnormality, breast density, size, management pathway and upgrade to cancer and types of cancer were also collected during the treatment pathway and 5 year surveillance period (April 2009 - April 2019). RESULTS 273 cases of ductal atypia were identified. 187/273 (68.5 %) cases were managed with VAE only as no upgrade to malignancy and then 5 year mammographic surveillance. 34/273 (12.5 %) cases had a VAE diagnosing malignancy. 24/273 (8.8 %) cases had a VAE and then a surgical biopsy due to radiological or pathological concern, 8/24 upgraded to malignancy. 22/273 (8%) cases had a surgical diagnostic biopsy, 9/22 (41 %) cases were upgraded to malignancy. In total 51/273 (19 %) cases were diagnosed with cancer on the new pathway (13 invasive (all ER positive and Her2 negative) and 38 non-invasive, (34 ductal carcinoma in situ (DCIS) and 4 cases of lobular carcinoma in situ (LCIS)). While 17/273 (6.2 %) cases developed malignancy (12 invasive (all HER2 negative) and 4 DCIS and 1 LCIS) during the 5 year surveillance period. CONCLUSIONS VAE is a safe alternative to surgery in managing ductal atypias. 187/273 (68.5 %) women avoided surgery. While 34/51 cancers (66.7 %) were diagnosed preoperatively using VAE, allowing the women to have a single therapeutic procedure.
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Affiliation(s)
- M A McMahon
- Department of Breast Radiology, Leeds Teaching Hospitals NHS Trust, United Kingdom
| | - I Haigh
- Department of Breast Radiology, Leeds Teaching Hospitals NHS Trust, United Kingdom
| | - Y Chen
- Division of Cancer and Stem Cell, School of Medicine at University of Nottingham, United Kingdom
| | | | - N Sharma
- Department of Breast Radiology, Leeds Teaching Hospitals NHS Trust, United Kingdom.
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17
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Lyburn ID, Pinder SE. Screening detects a myriad of breast disease - refining practice will increase effectiveness and reduce harm. Br J Radiol 2020; 93:20200135. [PMID: 32816520 DOI: 10.1259/bjr.20200135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
For many individuals, the term 'cancer' equates to a disease that if untreated will progress, spread from the area initially affected and ultimately cause death. 'Breast cancer', however, is a diverse of range of pathological entities, incorporating indolent to fast-growing and aggressive lesions, with varying histological patterns, clinical presentations, treatment responses and outcomes. Screening for malignancy is based on the assumption that cancer has a gradual, orderly progression and that detecting lesions earlier in their natural history, and intervening, will reduce mortality. The natural history of epithelial atypia, ductal carcinoma in situ and even invasive breast cancer is poorly understood, but widely variable. We believe that population breast screening methodology needs to change to focus on diagnosis of lesions of greatest clinical relevance.
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Affiliation(s)
- Iain D Lyburn
- Cheltenham Imaging Centre, Cobalt Medical Charity, Cheltenham, United Kingdom
| | - Sarah E Pinder
- School of Cancer & Pharmaceutical Sciences, King's College, London, United Kingdom
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18
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Gordon PB, Branch E. Upgrade Rate of Flat Epithelial Atypia Diagnosed at Stereotactic Core Needle Biopsy of Microcalcifications: Is Excisional Biopsy Indicated? JOURNAL OF BREAST IMAGING 2020; 2:336-342. [PMID: 38424960 DOI: 10.1093/jbi/wbaa037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Indexed: 03/02/2024]
Abstract
OBJECTIVE Whether the optimal management of pure flat epithelial atypia (FEA) found on core needle biopsy (CNB) specimens is surgical excision or imaging follow-up remains controversial. This study aimed to determine the upgrade rate to ductal carcinoma in situ (DCIS), invasive carcinoma or a high-risk lesion (atypical ductal hyperplasia, atypical lobular hyperplasia, or lobular carcinoma in situ), and it explored the relationship between a family history of breast cancer and the risk of upgrade. METHODS Cases with pure FEA found on stereotactic CNB of microcalcifications between March 2011 to December 2017 were followed by excisional biopsy or periodic imaging. The proportion of cases upgraded to a high-risk lesion and the odds of upgrade as related to a family history of breast cancer were determined with 95% confidence intervals (CIs). RESULTS We identified 622 cases of pure FEA; 101 (16.2%) underwent surgical excision and 269 (43.2%) had imaging follow-up of ≥ 24 months. There were no upgrades to DCIS or invasive cancer in any of these 370 individuals (0%), and 4.6% (17/370; 95% CI: 2.9%-7.2%) were upgraded to a high-risk lesion. There was a nonstatistically significant trend between family history and upgrade to high-risk lesion (odds ratio 1.72 [95% CI: 0.65%-4.57%]). CONCLUSION In our study, the upgrade rate of pure FEA to malignancy was 0%. We suggest that regular imaging follow-up is an appropriate alternative to surgery. Because of potential differences in biopsy techniques and pathologist interpretation of the primary biopsy, individual institutions should audit their own results prior to altering their management of FEA.
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Affiliation(s)
- Paula B Gordon
- BC Women's Hospital and Health Care Centre, Sadie Diamond Breast Program, Vancouver, BC, Canada
| | - Emma Branch
- BC Women's Health Research Institute, Vancouver, BC, Canada
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19
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Flat Epithelial Atypia in Breast Core Needle Biopsies With Radiologic-Pathologic Concordance: Is Excision Necessary? Am J Surg Pathol 2020; 44:182-190. [PMID: 31609784 DOI: 10.1097/pas.0000000000001385] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Flat epithelial atypia (FEA) is an alteration of terminal duct lobular units by a proliferation of ductal epithelium with low-grade atypia. No consensus exists on whether the diagnosis of FEA in core needle biopsy (CNB) requires excision (EXC). We retrospectively identified all in-house CNBs obtained between January 2012 and July 2018 with FEA. We reviewed all CNB slides and assessed radiologic-pathologic concordance. An upgrade was defined as invasive carcinoma (IC) and/or ductal carcinoma in situ in the EXC. The EXC slides of all upgraded cases were rereviewed. Out of ∼15,700 consecutive CNBs in the study period, 106 CNBs from 106 patients yielded FEA alone or with classic lobular neoplasia (LN). We excluded 52 CNBs (40 patients with prior/concurrent carcinoma and 12 without EXC). After rereview, we reclassified 14 cases (2 marked nuclear atypia, 10 focal atypical ductal hyperplasia, 2 benign). The final FEA study cohort consisted of 40 CNBs from 40 women. The CNB targeted mammographic calcifications in 36 (90%) cases, magnetic resonance imaging nonmass enhancement in 3 (8%), and 1 (2%) sonographic mass. All CNBs were deemed radiologic-pathologic concordant. FEA was present alone in 34 CNBs and with LN in 6. EXC yielded 2 low-grade IC, each spanning <2 mm, identified in tissue sections without biopsy site changes. The remaining 38 cases had no upgrade. Classic LN did not affect the upgrade. The upgrade rate of FEA was 5%; both minute, low-grade "incidental" IC. We conclude that nonsurgical management may be considered in patients without prior/concurrent carcinoma and radiologic-pathologic concordant CNB diagnosis of FEA.
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20
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Vanna R, Morasso C, Marcinnò B, Piccotti F, Torti E, Altamura D, Albasini S, Agozzino M, Villani L, Sorrentino L, Bunk O, Leporati F, Giannini C, Corsi F. Raman Spectroscopy Reveals That Biochemical Composition of Breast Microcalcifications Correlates with Histopathologic Features. Cancer Res 2020; 80:1762-1772. [PMID: 32094303 DOI: 10.1158/0008-5472.can-19-3204] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Revised: 12/28/2019] [Accepted: 02/21/2020] [Indexed: 11/16/2022]
Abstract
Breast microcalcifications are a common mammographic finding. Microcalcifications are considered suspicious signs of breast cancer and a breast biopsy is required, however, cancer is diagnosed in only a few patients. Reducing unnecessary biopsies and rapid characterization of breast microcalcifications are unmet clinical needs. In this study, 473 microcalcifications detected on breast biopsy specimens from 56 patients were characterized entirely by Raman mapping and confirmed by X-ray scattering. Microcalcifications from malignant samples were generally more homogeneous, more crystalline, and characterized by a less substituted crystal lattice compared with benign samples. There were significant differences in Raman features corresponding to the phosphate and carbonate bands between the benign and malignant groups. In addition to the heterogeneous composition, the presence of whitlockite specifically emerged as marker of benignity in benign microcalcifications. The whole Raman signature of each microcalcification was then used to build a classification model that distinguishes microcalcifications according to their overall biochemical composition. After validation, microcalcifications found in benign and malignant samples were correctly recognized with 93.5% sensitivity and 80.6% specificity. Finally, microcalcifications identified in malignant biopsies, but located outside the lesion, reported malignant features in 65% of in situ and 98% of invasive cancer cases, respectively, suggesting that the local microenvironment influences microcalcification features. This study confirms that the composition and structural features of microcalcifications correlate with breast pathology and indicates new diagnostic potentialities based on microcalcifications assessment. SIGNIFICANCE: Raman spectroscopy could be a quick and accurate diagnostic tool to precisely characterize and distinguish benign from malignant breast microcalcifications detected on mammography.
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Affiliation(s)
- Renzo Vanna
- Nanomedicine and Molecular Imaging Lab, Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy
| | - Carlo Morasso
- Nanomedicine and Molecular Imaging Lab, Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy
| | - Beatrice Marcinnò
- Custom Computing and Processing Systems Laboratory, Department of Electrical, Computer and Biomedical Engineering, University of Pavia, Pavia, Italy
| | - Francesca Piccotti
- Nanomedicine and Molecular Imaging Lab, Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy
| | - Emanuele Torti
- Custom Computing and Processing Systems Laboratory, Department of Electrical, Computer and Biomedical Engineering, University of Pavia, Pavia, Italy
| | - Davide Altamura
- Institute of Crystallography, National Research Council, Bari, Italy
| | - Sara Albasini
- Nanomedicine and Molecular Imaging Lab, Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy
| | - Manuela Agozzino
- Pathology Unit, Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy
| | - Laura Villani
- Pathology Unit, Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy
| | - Luca Sorrentino
- Department of Biomedical and Clinical Sciences "Luigi Sacco", University of Milan, Milan, Italy
| | - Oliver Bunk
- Paul Scherrer Institut, Villigen, Switzerland
| | - Francesco Leporati
- Custom Computing and Processing Systems Laboratory, Department of Electrical, Computer and Biomedical Engineering, University of Pavia, Pavia, Italy
| | - Cinzia Giannini
- Institute of Crystallography, National Research Council, Bari, Italy
| | - Fabio Corsi
- Department of Biomedical and Clinical Sciences "Luigi Sacco", University of Milan, Milan, Italy. .,Breast Unit, Department of Surgery, Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy
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21
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Logullo AF, Nimir C. Columnar cell lesions of the breast: a practical review for the pathologist. SURGICAL AND EXPERIMENTAL PATHOLOGY 2019. [DOI: 10.1186/s42047-018-0027-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Columnar cell lesions (CCLs) of the breast are characterized by the substitution of regular layer of cuboid epithelial by columnar cells covering the terminal duct lobular units (TDLUs). It also comprises a spectrum of lesions characterized by enlarged TDLUs with variably dilated acini lined by columnar epithelial cells, ranging from one or two layers of benign epithelium to stratified epithelium with atypia. With the increasing use of mammography screening scans in the last 30 years, columnar cell lesions (CCLs) have been diagnosed more frequently, often associated with microcalcifications and abnormal calcifications, requiring breast biopsies. This literature review presents the historical development of this entity description, with many terminologies, the CCLs categories, differential diagnoses, immunohistochemical profile and genetic alterations, reproducibility and clinical implications. In addition it discusses the significance of flat epithelial atypia (FEA), a CCL with low-grade cytological atypia.
Practical considerations
FEA are a frequent finding in breast biopsies and should be a warning sign for other possible entities within the lesion area. Since CCLs are an increasingly recognized entity in the diagnostic spectrum of breast proliferative lesions, proper training or tutorials are advisable for general pathologists in order to teach them how to identify CCLs with confidence. Intraductal proliferations with architectural complexities such as cribriform patterns, rigid cellular bridges, and true micropapillary pattern should not fall into the FEA category and are best classified as atypical ductal hyperplasia (ADH) or ductal carcinoma in situ (DCIS).
Conclusions
Among CCLs, FEA actually receives more attention due to atypia involved. FEA has been considered a non-obligate pre-neoplastic lesion and progression of these lesions to invasive cancer has been reported as increasingly low (2–7%). Therefore, controversy to the management of those lesions still remains and further intervention is restricted to cases with other premalignant lesions (ADH, DCIS) or in radiologic-pathologic disagreement.
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22
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Srour MK, Donovan C, Chung A, Harit A, Dadmanesh F, Giuliano AE, Amersi F. Flat epithelial atypia on core needle biopsy does not always mandate excisional biopsy. Breast J 2019; 26:679-684. [DOI: 10.1111/tbj.13507] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 07/16/2019] [Accepted: 07/16/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Marissa K. Srour
- Department of Surgery Cedars‐Sinai Medical Center Los Angeles California
| | - Cory Donovan
- Department of Surgery Cedars‐Sinai Medical Center Los Angeles California
| | - Alice Chung
- Department of Surgery Cedars‐Sinai Medical Center Los Angeles California
| | - Attiya Harit
- Department of Surgery Cedars‐Sinai Medical Center Los Angeles California
| | - Farnaz Dadmanesh
- Department of Pathology Cedars‐Sinai Medical Center Los Angeles California
| | | | - Farin Amersi
- Department of Surgery Cedars‐Sinai Medical Center Los Angeles California
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23
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Winer LK, Hinrichs BH, Lu S, Hanseman D, Huang Y, Reyna C, Lewis J, Shaughnessy EA. Flat epithelial atypia and the risk of sampling error: Determining the value of excision after image-guided core-needle biopsy. Am J Surg 2019; 218:730-736. [PMID: 31399195 DOI: 10.1016/j.amjsurg.2019.07.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Revised: 04/26/2019] [Accepted: 07/16/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND We determined the sampling error rate of flat epithelial atypia (FEA) and evaluated current guidelines recommending excisional biopsy. METHODS A retrospective review of consecutive excisional biopsies after image-guided core-needle biopsy identified patients with isolated FEA diagnosed between 2014 and 2018. Clinical and pathologic parameters were evaluated. RESULTS Twenty-five women with 27 biopsies were included. Based on pathologic review of original core specimens, 44.4% (N = 12) were accurately diagnosed as FEA. Upon excision, lesions were upgraded to ductal carcinoma in situ (N = 2) or invasive ductal carcinoma (N = 1) in 11.1% of cases. Older age, black race, hormone replacement, and calcifications in the image-guided biopsy specimen were associated with the presence of high-risk or malignant lesions in the excisional biopsy (all p ≤ 0.05). CONCLUSIONS In this study, FEA was frequently overcalled. However, lesions suspicious for FEA warrant excision due to their association with malignancy or high-risk lesions, which may necessitate further surgical management and/or risk-reducing strategies.
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Affiliation(s)
- Leah K Winer
- Division of Surgical Oncology, Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way (ML 0558), Cincinnati, OH, 45267, USA
| | - Benjamin H Hinrichs
- Department of Pathology, University of Cincinnati College of Medicine, 234 Goodman Street, Suite 110, Cincinnati, OH, 45219, USA
| | - Sisi Lu
- Division of Surgical Oncology, Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way (ML 0558), Cincinnati, OH, 45267, USA
| | - Dennis Hanseman
- Division of Surgical Oncology, Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way (ML 0558), Cincinnati, OH, 45267, USA
| | - Yuan Huang
- Department of Pathology, University of Cincinnati College of Medicine, 234 Goodman Street, Suite 110, Cincinnati, OH, 45219, USA
| | - Chantal Reyna
- Division of Surgical Oncology, Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way (ML 0558), Cincinnati, OH, 45267, USA
| | - Jaime Lewis
- Division of Surgical Oncology, Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way (ML 0558), Cincinnati, OH, 45267, USA
| | - Elizabeth A Shaughnessy
- Division of Surgical Oncology, Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way (ML 0558), Cincinnati, OH, 45267, USA.
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24
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Luiten JD, Voogd AC, Tjan-Heijnen VC, Wesseling J, Luiten EJ, Duijm LE. Utility of diagnostic breast excision biopsies during two decades of screening mammography. Breast 2019; 46:157-162. [DOI: 10.1016/j.breast.2019.05.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 05/28/2019] [Accepted: 05/31/2019] [Indexed: 01/19/2023] Open
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25
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Luiten JD, Korte B, Voogd AC, Vreuls W, Luiten EJT, Strobbe LJ, Rutten MJCM, Plaisier ML, Lohle PN, Hooijen MJH, Tjan-Heijnen VCG, Duijm LEM. Trends in frequency and outcome of high-risk breast lesions at core needle biopsy in women recalled at biennial screening mammography, a multiinstitutional study. Int J Cancer 2019; 145:2720-2727. [PMID: 31001821 PMCID: PMC6766874 DOI: 10.1002/ijc.32353] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 03/21/2019] [Accepted: 04/11/2019] [Indexed: 11/18/2022]
Abstract
Between January 1, 2011, and December 31, 2016, we studied the incidence, management and outcome of high‐risk breast lesions in a consecutive series of 376,519 screens of women who received biennial screening mammography. During the 6‐year period covered by the study, the proportion of women who underwent core needle biopsy (CNB) after recall remained fairly stable, ranging from 39.2% to 48.1% (mean: 44.2%, 5,212/11,783), whereas the proportion of high‐risk lesions at CNB (i.e., flat epithelial atypia, atypical ductal hyperplasia, lobular carcinoma in situ and papillary lesions) gradually increased from 3.2% (25/775) in 2011 to 9.5% (86/901) in 2016 (p < 0.001). The mean proportion of high‐risk lesions at CNB that were subsequently treated with diagnostic surgical excision was 51.4% (169/329) and varied between 41.0% and 64.3% through the years, but the excision rate for high‐risk lesions per 1,000 screens and per 100 recalls increased from 0.25 (2011) to 0.70 (2016; p < 0.001) and from 0.81 (2011) to 2.50 (2016; p < 0.001), respectively. The proportion of all diagnostic surgical excisions showing in situ or invasive breast cancer was 29.0% (49/169) and varied from 22.2% (8/36) in 2014 to 38.5% (5/13) in 2011. In conclusion, the proportion of high‐risk lesions at CNB tripled in a 6‐year period, with a concomitant increased excision rate for these lesions. As the proportion of surgical excisions showing in situ or invasive breast cancer did not increase, a rising number of screened women underwent invasive surgical excision with benign outcome. What's new? Screening mammography aims to catch breast cancer early to reduce associated morbidity and mortality. Women with suspect findings at mammography frequently are recalled for further testing with core needle biopsy (CNB). In this investigation, the proportion of high‐risk lesions detected at CNB was found to have tripled among women in the Netherlands who underwent mammographic screening between 2011 and 2016. This increase was accompanied by an increase in lesion excision rates. Of excised lesions, little more than 14% proved to be malignant at two‐year follow‐up. The remainder of lesions exhibited benign pathology, suggesting that many women underwent potentially unnecessary surgery.
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Affiliation(s)
- Jacky D Luiten
- Department of Surgery, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands.,School for Oncology and Developmental Biology, Faculty of Health Medicine and Life Sciences, Research Institute GROW, Maastricht University, Maastricht, The Netherlands
| | - Bram Korte
- Department of Radiology, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - Adri C Voogd
- Department of Epidemiology, Faculty of Health Medicine and Life Sciences, Research Institute GROW, Maastricht University, Maastricht, The Netherlands.,Department of Research, Netherlands Comprehensive Cancer Organization, Utrecht, The Netherlands
| | - Willem Vreuls
- Department of Pathology, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Ernest J T Luiten
- Department of Surgical Oncology, Amphia Hospital, Breda, The Netherlands
| | - Luc J Strobbe
- Department of Surgical Oncology, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | | | - Menno L Plaisier
- Department of Radiology, Maxima Medical Centre, Veldhoven, The Netherlands
| | - Paul N Lohle
- Department of Radiology, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
| | | | - Vivianne C G Tjan-Heijnen
- School for Oncology and Developmental Biology, Faculty of Health Medicine and Life Sciences, Research Institute GROW, Maastricht University, Maastricht, The Netherlands.,Department of Internal Medicine, Division of Medical Oncology, GROW, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Lucien E M Duijm
- Department of Radiology, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands.,Dutch Expert Centre for Screening, Nijmegen, The Netherlands
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26
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Kim SJ, Kim WG. Sonographic Features of Flat Epithelial Atypia Manifesting as a Non-Mass-Like Lesion: A Case Report. AMERICAN JOURNAL OF CASE REPORTS 2019; 20:340-344. [PMID: 30872562 PMCID: PMC6429983 DOI: 10.12659/ajcr.914178] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Patient: Female, 47 Final Diagnosis: Flat epithelial atypia of the breast Symptoms: — Medication: — Clinical Procedure: — Specialty: Radiology
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Affiliation(s)
- Suk Jung Kim
- Department of Radiology, Haeundae Paik Hospital, Inje University College of Medicine, Busan, South Korea
| | - Woo Gyeong Kim
- Department of Pathology, Haeundae Paik Hospital, Inje University College of Medicine, Busan, South Korea
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27
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Christou A, Koutoulidis V, Koulocheri D, Panourgias E, Nonni A, Zografos CG, Zografos GC. Role of one-pass breast lesion excision system in complete excision of high-risk breast lesions with atypia expressed as clusters of microcalcifications. Eur Radiol 2019; 29:3149-3158. [PMID: 30617496 DOI: 10.1007/s00330-018-5925-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 10/30/2018] [Accepted: 11/28/2018] [Indexed: 10/27/2022]
Abstract
PURPOSE To assess the role of the breast lesion excision system (BLES) in complete removal of clusters of microcalcifications found on mammogram proved histologically to be high-risk lesions with cell atypia. METHODS AND MATERIALS Three hundred ninety-four consecutive women (mean age 58.5 years, range 39-78 years) with 400 clusters of suspicious microcalcifications underwent stereotactic biopsy using the intact BLES device between January 2014 and January 2016. All cases proved histologically to be high-risk lesions were subsequently assessed for complete removal. The underestimation rate was also assessed. RESULTS Thirty-eight out of 400 (9.5%) lesions were high-risk lesions with atypia with mean size 7.63 mm (st. dev. = 4.03 mm) which was within the size that the BLES needle can excise (20 mm). Four (10.5%) papillomas with atypia, 14 (36.8%) cases with flat epithelial atypia (FEA), 10 (26.3%) cases with lobular intraepithelial neoplasia (LIN-LIN 1, LIN 2), 8 (21.2%) with atypical ductal hyperplasia (ADH) and 2 (5.3%) cases with mucocele-like lesions (MLL) with atypia were found. Twenty-nine out of 38 lesions had subsequent surgery. Complete excision was achieved in 23/29 lesions (79.3%). No underestimation was found. Two-year mammographic stability was found in all lesions. Non-parametric statistical analysis showed no other significant predictive factor for complete excision apart from the distance of the lesions from the specimen margins (p = 0.031 Mann-Whitney test). CONCLUSION One-pass BLES intact biopsy technique is a safe method of complete removal of high-risk atypical lesions with high accuracy rates for certain histologies and could be potentially used as an alternative excision method to diagnostic surgery in selected cases. KEY POINTS • Breast lesion excision system (BLES) is an image-guided biopsy technique that uses radiofrequency to remove an intact piece of tissue including the target breast neoplasm. • Breast lesion excision system (BLES) under stereotactic guidance is able to accurately biopsy high-risk breast lesions expressed mammographically as clusters of suspicious microcalcifications. • BLES under stereotactic guidance is an accurate technique for en bloc excision of selected cases of small clusters of suspicious microcalcifications proved to be high-risk lesions with histopathologically disease-free margins of excision.
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Affiliation(s)
| | - Vassilis Koutoulidis
- 1st Department of Radiology Areteion Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitra Koulocheri
- Department of Radiology, Breast Unit Hippokration Hospital, Athens, Greece
| | - Evangelia Panourgias
- 1st Department of Radiology, School of Medicine, National and Kapodistrian University of Athens Areteion Hospital, Athens, Greece
| | - Afrodite Nonni
- 1st Department of Pathology, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | | | - George C Zografos
- Hippokration Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
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28
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Rageth CJ, O'Flynn EAM, Pinker K, Kubik-Huch RA, Mundinger A, Decker T, Tausch C, Dammann F, Baltzer PA, Fallenberg EM, Foschini MP, Dellas S, Knauer M, Malhaire C, Sonnenschein M, Boos A, Morris E, Varga Z. Second International Consensus Conference on lesions of uncertain malignant potential in the breast (B3 lesions). Breast Cancer Res Treat 2018; 174:279-296. [PMID: 30506111 PMCID: PMC6538569 DOI: 10.1007/s10549-018-05071-1] [Citation(s) in RCA: 148] [Impact Index Per Article: 24.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Accepted: 11/23/2018] [Indexed: 11/24/2022]
Abstract
Purpose The second International Consensus Conference on B3 lesions was held in Zurich, Switzerland, in March 2018, organized by the International Breast Ultrasound School to re-evaluate the consensus recommendations. Methods This study (1) evaluated how management recommendations of the first Zurich Consensus Conference of 2016 on B3 lesions had influenced daily practice and (2) reviewed current literature towards recommendations to biopsy. Results In 2018, the consensus recommendations for management of B3 lesions remained almost unchanged: For flat epithelial atypia (FEA), classical lobular neoplasia (LN), papillary lesions (PL) and radial scars (RS) diagnosed on core-needle biopsy (CNB) or vacuum-assisted biopsy (VAB), excision by VAB in preference to open surgery, and for atypical ductal hyperplasia (ADH) and phyllodes tumors (PT) diagnosed at VAB or CNB, first-line open surgical excision (OE) with follow-up surveillance imaging for 5 years. Analyzing the Database of the Swiss Minimally Invasive Breast Biopsies (MIBB) with more than 30,000 procedures recorded, there was a significant increase in recommending more frequent surveillance of LN [65% in 2018 vs. 51% in 2016 (p = 0.004)], FEA (72% in 2018 vs. 62% in 2016 (p = 0.005)), and PL [(76% in 2018 vs. 70% in 2016 (p = 0.04)] diagnosed on VAB. A trend to more frequent surveillance was also noted also for RS [77% in 2018 vs. 67% in 2016 (p = 0.07)]. Conclusions Minimally invasive management of B3 lesions (except ADH and PT) with VAB continues to be appropriate as an alternative to first-line OE in most cases, but with more frequent surveillance, especially for LN.
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Affiliation(s)
- Christoph J Rageth
- Département de Gynécologie et d'Obstétrique, Centre du sein, Hôpitaux Universitaires de Genève, Bd de la Cluse 30, 1211, Geneva 14, Switzerland. .,, Ringlikerstrasse 53, 8142, Uitikon Waldegg, Switzerland.
| | - Elizabeth A M O'Flynn
- The Rose Centre, St George's University Hospitals NHS Foundation Trust, Perimeter Road, London, SW17 0QT, UK
| | - Katja Pinker
- Breast Imaging Service, Department of Radiology, Memorial Sloan Kettering Cancer Center, 300 E 66th St, New York, NY, 10065, USA
| | - Rahel A Kubik-Huch
- Department of Medical Services, Institute of Radiology, Kantonsspital Baden, im Ergel, 5404, Baden, Switzerland
| | - Alexander Mundinger
- Zentrum Radiologie der Niels-Stensen-Kliniken; Marienhospital Osnabrück, Bischofsstraße 1, 49074, Osnabrück, Germany
| | - Thomas Decker
- Institut für Pathologie am Dietrich-Bonhoeffer-Klinikum, Salvador-Allende-Straße 30, 17036, Neubrandenburg, Germany
| | - Christoph Tausch
- Brust-Zentrum Zürich, Seefeldstr. 214, 8008, Zurich, Switzerland
| | - Florian Dammann
- Interventional and Pediatric Radiology, Department of Diagnostic, Inselspital, University Hospital Bern, Freiburgstrasse 10, 3010, Bern, Switzerland
| | - Pascal A Baltzer
- Department of Biomedical Imaging and Image-guided Therapy, Allgemeines Krankenhaus, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Eva Maria Fallenberg
- Department of Radiology, University Hospital, Ludwig Maximilian University Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Maria P Foschini
- Department of Biomedical and Neuromotor Sciences, Unit of Anatomic Pathology at Bellaria Hospital, University of Bologna, Via Altura 3, 40139, Bologna, Italy
| | - Sophie Dellas
- Clinic of Radiology and Nuclear Medicine, University Hospital Basel, University of Basel, Petersgraben 4, 4031, Basel, Switzerland
| | - Michael Knauer
- Breast Center St. Gallen, Cantonal Hospital St. Gallen, Rorschacher Str. 95, 9007, St. Gallen, Switzerland
| | - Caroline Malhaire
- Imaging Department, Institut Curie, PSL Research University, Paris, France
| | - Martin Sonnenschein
- Division of Radiology, Breast Center Bern (Brustzentrum Bern), Klinik Engeried, Lindenhofgruppe AG, Riedweg 15, 3012, Bern, Switzerland
| | - Andreas Boos
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, Rämistr. 100, 8091, Zurich, Switzerland
| | - Elisabeth Morris
- Breast Imaging Service, Department of Radiology, Memorial Sloan Kettering Cancer Center, 300 E 66th St, New York, NY, 10065, USA
| | - Zsuzsanna Varga
- Institute of Pathology and Molecular Pathology, University Hospital Zurich, Switzerland Schmelzbergstrasse 12., 8091, Zurich, Switzerland
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29
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Gulla S, Lancaster R, De Los Santos J. High-Risk Breast Lesions and Current Management. Semin Roentgenol 2018; 53:252-260. [DOI: 10.1053/j.ro.2018.08.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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30
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Abstract
PURPOSE OF REVIEW The aim of this review is to summarize recently published literature addressing atypical ductal hyperplasia (ADH), lobular neoplasia (atypical lobular hyperplasia [ALH] and classic lobular carcinoma in situ [C-LCIS]), non-classic lobular carcinoma in situ (NC-LCIS), papillary lesions, and flat epithelial atypia (FEA). RECENT FINDINGS While ADH, ALN, and C-LCIS are well-established markers of an increased risk of future breast cancers, the risk implications are less clear for papillary lesions and FEA. NC-LCIS is the least well-characterized lesion, with scant published literature on its natural history and surgical management when encountered on needle biopsy. Recent data suggest that lobular neoplasia on core biopsy of a BI-RADS ≤ 4 concordant lesion does not require an excision, while ADH, atypical papillomas, and NC-LCIS should be excised. Evidence on FEA and papillomas without atypia suggests a low risk of upgrade on excision, and prospective studies on the upgrade of these lesions are ongoing.
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Affiliation(s)
- Faina Nakhlis
- Department of Surgery, Brigham and Women's Hospital, 75 Francis St., Boston, MA, 02115, USA. .,Surgical Oncology, Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, 450 Brookline Ave., Boston, MA, 02115, USA.
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31
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Lipman M, Chambers A, Umphrey HR. Current Management of High-Risk Breast Lesions. CURRENT RADIOLOGY REPORTS 2018. [DOI: 10.1007/s40134-018-0268-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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32
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Latronico A, Nicosia L, Faggian A, Abbate F, Penco S, Bozzini A, Cannataci C, Mazzarol G, Cassano E. Atypical ductal hyperplasia: Our experience in the management and long term clinical follow-up in 71 patients. Breast 2017; 37:1-5. [PMID: 29032282 DOI: 10.1016/j.breast.2017.10.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Revised: 10/06/2017] [Accepted: 10/06/2017] [Indexed: 12/27/2022] Open
Abstract
INTRODUCTION Atypical ductal hyperplasia (ADH) is a high-risk benign lesion found in approximately 1-10% of breast biopsies and associated with a variable incidence of carcinoma after surgical excision. The main goal of our study is to present our experience in the management and long-term follow-up of 71 patients with ADH diagnosed on breast biopsy. MATERIALS AND METHODS Results of 3808 breast biopsy specimens from 1 January 2000 to 31 December 2005 were analyzed to identify all biopsies which resulted in a diagnosis of ADH. The histopathological results of the 45 patients who underwent surgery were analyzed. Long-term follow-up for the remaining patients was carried out. RESULTS 45 of 71 (63.4%) patients with histological diagnosis of ADH on breast biopsy underwent surgery. Definitive histological results revealed invasive carcinoma in 7 cases (15.6%), high grade Ductal Carcinoma in situ (DCIS) in 10 (22.2%) patients, Lobular Carcinoma in situ (LCIS) in 4 cases (8.9%) and benign findings in 24 cases (53.3%). 12 of 71 (16.9%) patients underwent only long term follow-up; one (8,3%) of these developed invasive breast carcinoma after 6 years. CONCLUSION Atypical ductal hyperplasia diagnosed on breast biopsy is associated with a relatively high incidence of invasive carcinoma and high grade ductal carcinoma in situ at the time of surgical excision. Certain radiological and cytological criteria can be used to help determine which patients should forgo surgery and be followed up with good results. Long term follow-up is always crucial for patients who have not undergone surgery.
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MESH Headings
- Adult
- Aged
- Biopsy
- Breast/pathology
- Breast Neoplasms/diagnosis
- Breast Neoplasms/pathology
- Breast Neoplasms/surgery
- Carcinoma, Ductal, Breast/pathology
- Carcinoma, Ductal, Breast/surgery
- Carcinoma, Intraductal, Noninfiltrating/diagnosis
- Carcinoma, Intraductal, Noninfiltrating/pathology
- Carcinoma, Intraductal, Noninfiltrating/surgery
- Carcinoma, Lobular/pathology
- Carcinoma, Lobular/surgery
- Female
- Follow-Up Studies
- Humans
- Middle Aged
- Neoplasm Grading
- Time Factors
- Watchful Waiting
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Affiliation(s)
- Antuono Latronico
- European Institute of Oncology, Breast Imaging Unit, Via G. Ripamonti, 435, 20141, Milano, Italy
| | - Luca Nicosia
- Postgraduate School of Radiology, Università degli Studi di Milano, Milan, Via Festa del Perdono 7, Milan, Italy.
| | - Angela Faggian
- Department of Radiology, Private Hospital "Villa dei Fiori", Acerra, Naples, Italy
| | - Francesca Abbate
- European Institute of Oncology, Breast Imaging Unit, Via G. Ripamonti, 435, 20141, Milano, Italy
| | - Silvia Penco
- European Institute of Oncology, Breast Imaging Unit, Via G. Ripamonti, 435, 20141, Milano, Italy
| | - Anna Bozzini
- European Institute of Oncology, Breast Imaging Unit, Via G. Ripamonti, 435, 20141, Milano, Italy
| | - Christine Cannataci
- Medical Imaging Department, Mater Dei Hospital, Triq Dun Karm, Msida, MSD 2090, Malta
| | - Giovanni Mazzarol
- European Institute of Oncology, Pathology Department, Via G. Ripamonti, 435, 20141, Milano, Italy
| | - Enrico Cassano
- European Institute of Oncology, Breast Imaging Unit, Via G. Ripamonti, 435, 20141, Milano, Italy
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