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Le J, O’Keefe TJ, Khan S, Grossi SM, Choi HY, Ojeda-Fournier H, Armani A, Wallace AM, Blair SL. Distance of Biopsy-Confirmed High-Risk Breast Lesion from Concurrently Identified Breast Malignancy Associated with Risk of Carcinoma at the High-Risk Lesion Site. Cancers (Basel) 2024; 16:2268. [PMID: 38927976 PMCID: PMC11201489 DOI: 10.3390/cancers16122268] [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: 05/20/2024] [Revised: 06/10/2024] [Accepted: 06/14/2024] [Indexed: 06/28/2024] Open
Abstract
High-risk breast lesions including incidental intraductal papilloma without atypia (IPA), lobular hyperplasia (LCIS or ALH), flat epithelial atypia (FEA) and complex sclerosing lesion (CSL) are not routinely excised due to low upgrade rates to carcinoma. We aim to identify features of these lesions predictive of upgrade when identified concurrently with invasive disease. Methods: A single-center retrospective cohort study was performed for patients who underwent multi-site lumpectomies with invasive disease at one site and a high-risk lesion at another site between 2006 and 2021. A multinomial logistic regression was performed. Results: Sixty-five patients met the inclusion criteria. Four patients (6.2%) had an upgrade to in situ disease (DCIS) and one (1.5%) to invasive carcinoma. Three upgraded high-risk lesions were ipsilateral to the concurrent carcinoma and two were contralateral. In the multivariate model, a high-risk lesion within 5 cm of an ipsilateral malignancy was associated with increased risk of upgrade. The 3.8% upgrade rate for high-risk lesions located greater than 5 cm from ipsilateral malignancy or in the contralateral breast suggests that omission of excisional biopsy may be considered. Excisional biopsy of lesions within 5 cm of ipsilateral malignancy is recommended given the 25% upgrade risk in our series.
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Affiliation(s)
- Julie Le
- Division of Breast Surgery, The Comprehensive Breast Health Center, University of California San Diego, 3855 Health Sciences Dr, La Jolla, CA 92093, USA
| | - Thomas J. O’Keefe
- Department of Surgery, Jennifer Moreno Department of Veterans Affairs Medical Center, La Jolla, CA 92161, USA
| | - Sohini Khan
- Department of Surgery, University of California San Diego, 3855 Health Sciences Dr, La Jolla, CA 92093, USA
| | - Sara M. Grossi
- Division of Breast Surgery, The Comprehensive Breast Health Center, University of California San Diego, 3855 Health Sciences Dr, La Jolla, CA 92093, USA
- Department of Surgery, Jennifer Moreno Department of Veterans Affairs Medical Center, La Jolla, CA 92161, USA
| | - Hye Young Choi
- Division of Breast Imaging, University of California San Diego, 3855 Health Sciences Dr, La Jolla, CA 92093, USA
- Department of Medicine, Gyeongsang National University College of Medicine, Jinju-si 52727, Republic of Korea
| | - Haydee Ojeda-Fournier
- Division of Breast Imaging, University of California San Diego, 3855 Health Sciences Dr, La Jolla, CA 92093, USA
| | - Ava Armani
- Division of Breast Surgery, The Comprehensive Breast Health Center, University of California San Diego, 3855 Health Sciences Dr, La Jolla, CA 92093, USA
| | - Anne M. Wallace
- Division of Breast Surgery, The Comprehensive Breast Health Center, University of California San Diego, 3855 Health Sciences Dr, La Jolla, CA 92093, USA
| | - Sarah L. Blair
- Division of Breast Surgery, The Comprehensive Breast Health Center, University of California San Diego, 3855 Health Sciences Dr, La Jolla, CA 92093, USA
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Lou C, Wang W, Zhou B. Treatment Strategy for Breast Benign Intraductal Papilloma: A Meta-Analysis. J Environ Pathol Toxicol Oncol 2024; 43:39-49. [PMID: 38608144 DOI: 10.1615/jenvironpatholtoxicoloncol.2024052888] [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: 04/14/2024] Open
Abstract
Currently, the optimal treatment approach for breast benign intraductal papilloma (IDP) diagnosed via biopsy remains uncertain. There is ongoing debate regarding the feasibility of clinical follow-up and the criteria for selective surgical excision. This study aims to conduct a meta-analysis to determine the rate of upgrade from breast benign IDP and identify predictive factors associated with the conversion of benign IDP to high-risk lesions or carcinoma, which could guide healthcare practitioners in selecting the appropriate clinical treatment strategy. We conducted a comprehensive search across multiple databases (PubMed, Web Of Science, Cochrane Library, and Embase) for studies published between 2012 and 2023 that evaluated upgrade rates and predictive factors of breast benign IDP diagnosed via biopsy. In addition, we included studies that reported on the clinical follow-up of patients with breast benign IDP. In total, 32 studies comprising 7371 cases of biopsy-diagnosed breast benign IDP were included. Among these cases, 720 demonstrated an upgrade to high-risk lesions or carcinoma, resulting in an upgrade rate of 6.94% [95% confidence interval (CI): 3.0-8.0%]. A subgroup of 1713 patients was clinically followed up, demonstrating an average follow-up duration of 30.95 months. Among them, 26 cases experienced an upgrade to high-risk lesions or carcinoma, yielding an upgrade rate of 1.51% (95% CI 0.00-2.00). Furthermore, we identified nine predictive factors associated with the upgrading of breast benign IDP, which included age at diagnosis, personal history of breast cancer, family history of breast cancer, multiple IDPs, lesion size ≥ 10 mm, palpable mass, calcification, and the presence of mass and asymmetry in mammographic findings. Although the conversion rate of breast benign IDP to high-risk lesions or carcinoma is relatively low, timely identification of predictive factors associated with benign IDP upgrades may help selecting the optimal clinical treatment strategy, such as surgery for patients with benign IDP presenting one or more predictive factors, while clinical follow-up for those without specific risk factors.
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Affiliation(s)
- Congkun Lou
- Comprehensive Cancer Center, Nanjing Tianyinshan Hospital, Nanjing 211100, China
| | - Wenhsin Wang
- Xiamen Keli Medical Beauty Clinic, Xiamen 361003, China
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3
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Carnahan MB, Harper L, Brown PJ, Bhatt AA, Eversman S, Sharpe RE, Patel BK. False-Positive and False-Negative Contrast-enhanced Mammograms: Pitfalls and Strategies to Improve Cancer Detection. Radiographics 2023; 43:e230100. [PMID: 38032823 DOI: 10.1148/rg.230100] [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: 12/02/2023]
Abstract
Contrast-enhanced mammography (CEM) is a relatively new breast imaging modality that uses intravenous contrast material to increase detection of breast cancer. CEM combines the structural information of conventional mammography with the functional information of tumor neovascularity. Initial studies have demonstrated that CEM and MRI perform with similar accuracies, with CEM having a slightly higher specificity (fewer false positives), although larger studies are needed. There are various reasons for false positives and false negatives at CEM. False positives at CEM can be caused by benign lesions with vascularity, including benign tumors, infection or inflammation, benign lesions in the skin, and imaging artifacts. False negatives at CEM can be attributed to incomplete or inadequate visualization of lesions, marked background parenchymal enhancement (BPE) obscuring cancer, lack of lesion contrast enhancement due to technical issues or less-vascular cancers, artifacts, and errors of lesion perception or characterization. When possible, real-time interpretation of CEM studies is ideal. If additional views are necessary, they may be obtained while contrast material is still in the breast parenchyma. Until recently, a limitation of CEM was the lack of CEM-guided biopsy capability. However, in 2020, the U.S. Food and Drug Administration cleared two devices to support CEM-guided biopsy using a stereotactic biopsy technique. The authors review various causes of false-positive and false-negative contrast-enhanced mammograms and discuss strategies to reduce these diagnostic errors to improve cancer detection while mitigating unnecessary additional imaging and procedures. ©RSNA, 2023 Quiz questions for this article are available in the supplemental material.
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Affiliation(s)
- Molly B Carnahan
- From the Department of Radiology, Mayo Clinic Arizona, 5777 E Mayo Blvd, Phoenix, AZ 85054 (M.B.C., L.H., P.J.B., S.E., R.E.S., B.K.P.); and Department of Radiology, Mayo Clinic Rochester, Rochester, Minn (A.A.B.)
| | - Laura Harper
- From the Department of Radiology, Mayo Clinic Arizona, 5777 E Mayo Blvd, Phoenix, AZ 85054 (M.B.C., L.H., P.J.B., S.E., R.E.S., B.K.P.); and Department of Radiology, Mayo Clinic Rochester, Rochester, Minn (A.A.B.)
| | - Parker J Brown
- From the Department of Radiology, Mayo Clinic Arizona, 5777 E Mayo Blvd, Phoenix, AZ 85054 (M.B.C., L.H., P.J.B., S.E., R.E.S., B.K.P.); and Department of Radiology, Mayo Clinic Rochester, Rochester, Minn (A.A.B.)
| | - Asha A Bhatt
- From the Department of Radiology, Mayo Clinic Arizona, 5777 E Mayo Blvd, Phoenix, AZ 85054 (M.B.C., L.H., P.J.B., S.E., R.E.S., B.K.P.); and Department of Radiology, Mayo Clinic Rochester, Rochester, Minn (A.A.B.)
| | - Sarah Eversman
- From the Department of Radiology, Mayo Clinic Arizona, 5777 E Mayo Blvd, Phoenix, AZ 85054 (M.B.C., L.H., P.J.B., S.E., R.E.S., B.K.P.); and Department of Radiology, Mayo Clinic Rochester, Rochester, Minn (A.A.B.)
| | - Richard E Sharpe
- From the Department of Radiology, Mayo Clinic Arizona, 5777 E Mayo Blvd, Phoenix, AZ 85054 (M.B.C., L.H., P.J.B., S.E., R.E.S., B.K.P.); and Department of Radiology, Mayo Clinic Rochester, Rochester, Minn (A.A.B.)
| | - Bhavika K Patel
- From the Department of Radiology, Mayo Clinic Arizona, 5777 E Mayo Blvd, Phoenix, AZ 85054 (M.B.C., L.H., P.J.B., S.E., R.E.S., B.K.P.); and Department of Radiology, Mayo Clinic Rochester, Rochester, Minn (A.A.B.)
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Elfgen C, Leo C, Kubik-Huch RA, Muenst S, Schmidt N, Quinn C, McNally S, van Diest PJ, Mann RM, Bago-Horvath Z, Bernathova M, Regitnig P, Fuchsjäger M, Schwegler-Guggemos D, Maranta M, Zehbe S, Tausch C, Güth U, Fallenberg EM, Schrading S, Kothari A, Sonnenschein M, Kampmann G, Kulka J, Tille JC, Körner M, Decker T, Lax SF, Daniaux M, Bjelic-Radisic V, Kacerovsky-Strobl S, Condorelli R, Gnant M, Varga Z. Third International Consensus Conference on lesions of uncertain malignant potential in the breast (B3 lesions). Virchows Arch 2023:10.1007/s00428-023-03566-x. [PMID: 37330436 DOI: 10.1007/s00428-023-03566-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 05/01/2023] [Accepted: 05/17/2023] [Indexed: 06/19/2023]
Abstract
The heterogeneous group of B3 lesions in the breast harbors lesions with different malignant potential and progression risk. As several studies about B3 lesions have been published since the last Consensus in 2018, the 3rd International Consensus Conference discussed the six most relevant B3 lesions (atypical ductal hyperplasia (ADH), flat epithelial atypia (FEA), classical lobular neoplasia (LN), radial scar (RS), papillary lesions (PL) without atypia, and phyllodes tumors (PT)) and made recommendations for diagnostic and therapeutic approaches. Following a presentation of current data of each B3 lesion, the international and interdisciplinary panel of 33 specialists and key opinion leaders voted on the recommendations for further management after core-needle biopsy (CNB) and vacuum-assisted biopsy (VAB). In case of B3 lesion diagnosis on CNB, OE was recommended in ADH and PT, whereas in the other B3 lesions, vacuum-assisted excision was considered an equivalent alternative to OE. In ADH, most panelists (76%) recommended an open excision (OE) after diagnosis on VAB, whereas observation after a complete VAB-removal on imaging was accepted by 34%. In LN, the majority of the panel (90%) preferred observation following complete VAB-removal. Results were similar in RS (82%), PL (100%), and FEA (100%). In benign PT, a slim majority (55%) also recommended an observation after a complete VAB-removal. VAB with subsequent active surveillance can replace an open surgical intervention for most B3 lesions (RS, FEA, PL, PT, and LN). Compared to previous recommendations, there is an increasing trend to a de-escalating strategy in classical LN. Due to the higher risk of upgrade into malignancy, OE remains the preferred approach after the diagnosis of ADH.
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Affiliation(s)
- Constanze Elfgen
- Breast-Center Zurich, Zurich, Switzerland.
- University of Witten-Herdecke, Witten, Germany.
| | - Cornelia Leo
- Breast Center, Kantonsspital Baden, Baden, Switzerland
| | | | - Simone Muenst
- Institute of Medical Genetics and Pathology, University Hospital Basel, Basel, Switzerland
| | - Noemi Schmidt
- Department of Radiology, University Hospital Basel, Basel, Switzerland
| | - Cecily Quinn
- Irish National Breast Screening Program & Department of Histopathology, St. Vincent's University Hospital Dublin and School of Medicine, University College Dublin, Dublin, Ireland
| | - Sorcha McNally
- Radiology Department, St. Vincent University Hospital, Dublin, Ireland
| | - Paul J van Diest
- Department of Pathology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Ritse M Mann
- Department of Radiology, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Radiology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | | | - Maria Bernathova
- Department of Radiology and Nuclear Medicine, Medical University Vienna, Vienna, Austria
| | - Peter Regitnig
- Diagnostic and Research Institute of Pathology, Medical University Graz, Graz, Austria
| | - Michael Fuchsjäger
- Division of General Radiology, Department of Radiology, Medical University Graz, Graz, Austria
| | | | - Martina Maranta
- Department of Gynecology, County Hospital Chur, Chur, Switzerland
| | - Sabine Zehbe
- Radiology Section, Breast Center Stephanshorn, St. Gallen, Switzerland
| | | | - Uwe Güth
- Breast-Center Zurich, Zurich, Switzerland
| | - Eva Maria Fallenberg
- Department of Diagnostic and Interventional Radiology, School of Medicine & Klinikum Rechts der Isar, Technical University of Munich (TUM), Munich, Germany
| | - Simone Schrading
- Department of Radiology, County Hospital Lucerne, Lucerne, Switzerland
| | - Ashutosh Kothari
- Breast Surgery Unit, Guy's and St Thomas's NHS Foundation Trust, London, UK
| | | | - Gert Kampmann
- Centro di Radiologia e Senologia Luganese, Lugano, Switzerland
| | - Janina Kulka
- Department of Pathology, Forensic and Insurance Medicine, Semmelweis University Budapest, Budapest, Hungary
| | | | | | - Thomas Decker
- Breast Pathology, Reference Centers Mammography Münster, University Hospital Münster, Münster, Germany
| | - Sigurd F Lax
- Department of Pathology, Hospital Graz II, Graz, and School of Medicine, Johannes Kepler University Linz, Linz, Austria
| | - Martin Daniaux
- BrustGesundheitZentrum Tirol, University Hospital Innsbruck, Innsbruck, Austria
| | - Vesna Bjelic-Radisic
- University of Witten-Herdecke, Witten, Germany
- Breast Unit, Helios University Hospital, University Witten/Herdecke, Witten, Germany
| | | | | | - Michael Gnant
- Comprehensive Cancer Center, Medical University Vienna, Vienna, Austria
| | - Zsuzsanna Varga
- Department of Pathology and Molecular Pathology, University Hospital Zürich, Zürich, Switzerland
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5
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Warwar S, Kulkarni S. Selective surgical excision of high-risk lesions. Surgery 2023:S0039-6060(23)00117-4. [PMID: 37059651 DOI: 10.1016/j.surg.2023.02.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 02/17/2023] [Accepted: 02/23/2023] [Indexed: 04/16/2023]
Abstract
Intraductal papilloma, flat epithelial atypia, radial scar, atypical lobular hyperplasia, and lobular carcinoma in situ have historically been referred to as high-risk lesions and managed with routine surgical excision after diagnosis on core needle biopsy. The misnomer high-risk stems from high rates of upgrade to malignancy reported in historic literature. However, recent studies have found much lower upgrade rates, <2%, than previously thought. These findings are explained by advances in imaging technology, larger-bore biopsy needles, and emphasis on radiology-pathology concordance. Concordant lesions have a low upgrade risk and can be managed with radiographic and clinical surveillance instead of surgical excision. Surgical de-escalation is feasible for many of these lesions with careful multidisciplinary review and a detailed risk-benefit discussion with patients.
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Affiliation(s)
- Samantha Warwar
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Swati Kulkarni
- Division of Breast Surgery, Department of Surgery, Robert H. Lurie Comprehensive Cancer Center, Feinberg School of Medicine, Northwestern University, Chicago, IL.
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6
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Clinicopathological and Imaging Features of Breast Papillary Lesions and Their Association with Pathologic Nipple Discharge. Diagnostics (Basel) 2023; 13:diagnostics13050878. [PMID: 36900021 PMCID: PMC10000596 DOI: 10.3390/diagnostics13050878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 02/22/2023] [Accepted: 02/23/2023] [Indexed: 03/03/2023] Open
Abstract
No studies have evaluated whether any clinicopathological or imaging characteristics of breast papillary lesions are associated with pathological nipple discharge (PND). We analyzed 301 surgically confirmed papillary breast lesions diagnosed between January 2012 and June 2022. We evaluated clinical (age of patient, size of lesion, pathologic nipple discharge, palpability, personal/family history of breast cancer or papillary lesion, location, multiplicity, and bilaterality) and imaging characteristics (Breast Imaging Reporting and Data System (BI-RADS), sonographic, and mammographic findings) and compared malignant versus non-malignant lesions and papillary lesions with versus without PND. The malignant group was significantly older than the non-malignant group (p < 0.001). Those in the malignant group were more palpable and larger (p < 0.001). Family history of cancer and peripheral location in the malignant group were more frequent than in the non-malignant group (p = 0.022 and p < 0.001). The malignant group showed higher BI-RADS, irregular shape, complex cystic and solid echo pattern, posterior enhancement on ultrasound (US), fatty breasts, visibility, and mass type on mammography (p < 0.001, 0.003, 0.009, <0.001, <0.001, <0.001, and 0.01, respectively). On multivariate logistic regression analysis, peripheral location, palpability, and age of ≥50 years were factors significantly associated with malignancy (OR: 4.125, 3.556, and 3.390, respectively; p = 0.004, 0.034, and 0.011, respectively). Central location, intraductal nature, hyper/isoechoic pattern, and ductal change were more frequent in the PND group (p = 0.003, p < 0.001, p < 0.001, and p < 0.001, respectively). Ductal change was significantly associated with PND on multivariate analysis (OR, 5.083; p = 0.029). Our findings will help clinicians examine patients with PND and breast papillary lesions more effectively.
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Varga Z, Sinn P, Lebeau A. [B3 lesions of the breast: histological, clinical, and epidemiological aspects : Update]. PATHOLOGIE (HEIDELBERG, GERMANY) 2023; 44:5-16. [PMID: 36635403 PMCID: PMC9877091 DOI: 10.1007/s00292-022-01180-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 12/22/2022] [Indexed: 01/14/2023]
Abstract
B3 lesions of the breast are a heterogeneous group of lesions with uncertain malignant potential encompassing a broad spectrum of histologically distinct alterations that often pose challenging decisions if diagnosed on the preoperative core or vacuum biopsies. B3 lesions are mostly detected due to mammographic calcifications or mass lesions and, in most cases, encompass a spectrum of atypical lesions such as atypical ductal hyperplasia, classic lobular neoplasia, flat epithelial atypia, papillomas, fibroepithelial tumors, and rarely other lesions such as mucocele-like lesions, atypical apocrine lesions, and rare stromal proliferations. The use of immunohistochemical stains (estrogen receptors, basal cytokeratin, myoepithelial markers, and stromal marker panel) is useful in the differentiation of these lesions and allowing proper classification. Regarding clinical management of B3 lesions, the radiological-pathological correlation of the given entity plays the most important key element for the proper next diagnostic and therapeutic step.
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Affiliation(s)
- Zsuzsanna Varga
- Institut für Pathologie und Molekularpathologie, Universitätsspital Zürich, Schmelzbergstr. 12, 8091 Zürich, Schweiz
| | - Peter Sinn
- Pathologisches Institut, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - Annette Lebeau
- Institut für Pathologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland ,Gemeinschaftspraxis für Pathologie, Lübeck, Deutschland
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Ziółkowski P, Woźniak M, Mansour A, An Y, Weber GF. Breast cancer risk in papilloma patients: Osteopontin splice variants indicate prognosis. Breast Cancer Res 2022; 24:64. [PMID: 36175970 PMCID: PMC9520814 DOI: 10.1186/s13058-022-01561-9] [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: 04/22/2022] [Accepted: 09/23/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Papillomas of the breast pose challenges for treatment decisions as their risk for transformation to breast cancer is low but not negligible. To spare low-risk patients the burden of substantial treatment side effects, prognostic indicators are needed for cancerous progression. The secreted metastasis mediator Osteopontin (OPN) is a marker for breast cancer aggressiveness, and its variants are prognosticators for transformation in diverse premalignant breast lesions. Here, we test whether the presence of OPN-c or OPN-exon-4 in papillomatous lesions may reflect progression risk. METHODS By immunohistochemistry, we analyze OPN-c and OPN-exon-4 in papillomas from 114 women as well as correlations between staining and progression. In departure from prior spliced OPN biomarker publications, we utilize novel monoclonal antibodies. RESULTS Fewer than 5% of OPN-c pathology score 0-1 (intensity) versus almost 18% of score 2-3 experienced cancer in follow-up. Nine of 12 women, who progressed, had pathology scores of 2-3 for OPN-c intensity at the time of initial diagnosis, and none had a score of 0. When developing a combined risk score from intensity plus percent positivity for OPN-c, the progression risk for patients with low score was 3.2%, for intermediate score was 5.7%, and for high score was 18.8%. Papillomas in patients, who were later diagnosed with cancer in the contralateral breast, displayed stronger staining positivity than non-progressors. CONCLUSION OPN splice variant immunohistochemistry on biopsies of breast papillomas will allow counseling of the patients on their risk to develop breast cancer at a later time.
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Affiliation(s)
- Piotr Ziółkowski
- Department of Pathology, Wroclaw Medical University, Wroclaw, Poland.
| | - Marta Woźniak
- Department of Pathology, Wroclaw Medical University, Wroclaw, Poland
| | - Ahmad Mansour
- Department of Pathology, University of Cincinnati, Cincinnati, OH, USA
| | - Yu An
- Division of Biostatistics and Bioinformatics, Department of Environmental and Public Health Sciences, Cincinnati, OH, USA
| | - Georg F Weber
- College of Pharmacy, University of Cincinnati, 3225 Eden Avenue, Cincinnati, OH, 45267-0004, USA.
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Panigrahi B, Fernandes K, Mullen LA, Oluyemi E, Myers KS, Philip M, Carlo PD, Ambinder EB. Solitary Dilated Ducts Revisited: Malignancy Rate and Implications for Management. Acad Radiol 2022; 30:807-813. [PMID: 36115737 DOI: 10.1016/j.acra.2022.08.018] [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: 06/27/2022] [Revised: 08/07/2022] [Accepted: 08/12/2022] [Indexed: 11/25/2022]
Abstract
RATIONALE AND OBJECTIVES A solitary dilated duct (SDD) is a single asymmetrically dilated breast duct with diameter more than 2 mm. The Breast Imaging Reporting and Data System (BI-RADS) fifth edition recommends additional imaging and biopsy for SDDs without demonstrated benign etiology, however management of this rare entity remains controversial. This study describes practice patterns, malignancy rate, and features associated with high-risk/malignant SDDs to better stratify patients requiring biopsy versus follow-up. MATERIALS AND METHODS This IRB-approved retrospective study identified mammographic, sonographic and MRI exams utilizing the term "solitary dilated duct" at a multisite academic institution between 1/1/2010 and 12/31/2020. Clinical and imaging features, BI-RADS assessments, and outcomes were analyzed. Univariate and multivariate analyses identified predictors of high-risk/malignant histology. RESULTS SDDs identified in 49 women (mean age 56.1 years) were assessed as BI-RADS 4/5 (31/49, 63%), BI-RADS 3 (9/49, 18%), or BI-RADS 2 (9/49, 18%). Most sampled lesions were benign (16/31, 52%) and the remaining were high-risk (15/31, 48%, all papillary lesions). The only papilloma with atypia on core biopsy upgraded to grade 2 DCIS on excision (malignancy rate 1/49, 2%). All anechoic SDDs were benign (n=13), and all benign SDDs lacked internal vascularity. SDDs with associated masses were associated with malignant/high-risk outcomes on multivariate analysis (p < .001). CONCLUSION The BI-RADS fifth edition recommends biopsy for SDDs without demonstrated benign etiology. In our 11-year study period, practice patterns were variable with a low malignancy rate of 2%. Our findings suggest that anechoic SDDs may be followed, and SDDs with associated masses or internal vascularity require biopsy.
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Affiliation(s)
- Babita Panigrahi
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Medicine, 601 N. Caroline St, Baltimore, 21287, Maryland.
| | - Kevin Fernandes
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Medicine, 601 N. Caroline St, Baltimore, 21287, Maryland
| | - Lisa A Mullen
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Medicine, 601 N. Caroline St, Baltimore, 21287, Maryland
| | - Eniola Oluyemi
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Medicine, 601 N. Caroline St, Baltimore, 21287, Maryland
| | - Kelly S Myers
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Medicine, 601 N. Caroline St, Baltimore, 21287, Maryland
| | - Mary Philip
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Medicine, 601 N. Caroline St, Baltimore, 21287, Maryland
| | - Philip Di Carlo
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Medicine, 601 N. Caroline St, Baltimore, 21287, Maryland
| | - Emily B Ambinder
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Medicine, 601 N. Caroline St, Baltimore, 21287, Maryland; Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins Medicine, Baltimore, Maryland
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10
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Chung HL, Bevers TB, Legha RS, Speer ME, Tso HH, Sun J, Leung JW. Nipple Discharge Imaging Evaluation with Mammography, Ultrasound, Galactography, and MRI. Acad Radiol 2022; 30:783-797. [PMID: 35760711 DOI: 10.1016/j.acra.2022.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 05/20/2022] [Accepted: 05/22/2022] [Indexed: 11/26/2022]
Abstract
RATIONALE AND OBJECTIVE To determine the diagnostic yield of various imaging tests used to evaluate nipple discharge. MATERIALS AND METHODS A single institution, IRB-approved, retrospective study was performed of 320 consecutive patients presenting with nipple discharge. Imaging and pathology were reviewed to determine the yield for malignancy, atypical high-risk lesions (HRLs), and intraductal papillomas (IDPs). RESULTS Of the 320 patients, pathology or follow up confirmed 40 breast malignancies (40/320, 12.5%),14 atypical HRLs (14/320, 4.4%), 71 IDPs (71/320, 22.2%), 48 other benign pathologies (48/320,15.0%), and 147 unknown but benign cases (147/320, 45.9%). Physiologic discharge characteristics were observed in a minority of malignant cases: nonspontaneous (4/40, 10.0%); neither bloody nor clear (4/40, 10.0%); bilateral (3/40, 7.5%). Malignancy was associated with older age (p < 0.001) and bloody discharge (odds ratio 6.5, p < 0.0001). The combination of digital mammography and ultrasound had a 93% sensitivity and a 98% NPV, while contrast enhanced MRI (CE-MRI) had a 100% sensitivity and a 100% NPV for malignancy. Only three galactography examinations were performed among the malignant cohort, with minimal contribution (1 of 3) to the diagnostic evaluation. In this case, galactography findings helped determine imaging-pathology discordance, prompting a recommendation for surgical excision and subsequently a malignant diagnosis. CONCLUSION The combination of mammography and ultrasonography detected 93% of breast malignancies associated with nipple discharge and had a 98% NPV for malignancy. The value of CE-MRI is its ability to detect the remaining malignancies, not detected on mammography or ultrasound, and its ability to obviate the need for surgical duct excision.
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Jatana S, Zahra S, Miron AD, Antonacci G, Di Lena É, Thériault M, Meterissian S. A retrospective study evaluating outcomes of surgical excision versus radiologic follow-up of benign breast papillomas without atypia. Am J Surg 2022; 224:932-937. [PMID: 35513913 DOI: 10.1016/j.amjsurg.2022.04.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 03/09/2022] [Accepted: 04/22/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND There is uncertainty whether benign breast papillomas without atypia (BP) can be followed by imaging or require surgical resection. METHODS A single-center, retrospective cohort study of patients diagnosed with BP (2011-2021) to determine the upgrade rate on surgery, and factors associated with surgical intervention and upgrade. RESULTS 139 BPs were included. 27(19.4%) had upfront surgery; 112(80.6%) had imaging follow-up. The upfront surgery group had higher rates of pre-excision nipple inversion (n = 2(8.3%)vs.n = 0(0%),p = 0.003). In the imaging group, the median follow-up was 3.8years, and 9 had subsequent resection. Upgrade rate was 5.8%(8/139). Of all BPs undergoing surgery (n = 36), patients ≥60years (75.0%vs.25.0%,p = 0.049) or with family history of breast cancer (87.5%vs.48.1%,p = 0.048) were more likely to have upgrade. CONCLUSIONS Despite a low number of events, this study supports radiologic follow-up of BP except in patients ≥60 years or with family history of breast cancer, adding to the growing body of evidence supporting watchful waiting of BPs.
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Affiliation(s)
- Sukhdeep Jatana
- Faculty of Medicine, McGill University, Montreal. 3605 Rue de la Montagne Décarie, Montreal, Quebec, H3G 2M1, Canada
| | - Saly Zahra
- Department of Diagnostic Radiology, McGill University University Health Centre, 1001 Boulevard Décarie, Montreal, Quebec, H4A 3J1, Canada
| | - Alexander-Darius Miron
- Cedars Breast Clinic, McGill University Health Centre, 1001 Boulevard Décarie, Montreal, Quebec, H4A 3J1, Canada
| | - Georgianna Antonacci
- Cedars Breast Clinic, McGill University Health Centre, 1001 Boulevard Décarie, Montreal, Quebec, H4A 3J1, Canada
| | - Élise Di Lena
- Division of General Surgery, Department of Surgery, McGill University Health Centre, 1001 Boulevard Décarie, Montreal, Quebec, H4A 3J1, Canada
| | - Mélanie Thériault
- Department of Diagnostic Radiology, McGill University University Health Centre, 1001 Boulevard Décarie, Montreal, Quebec, H4A 3J1, Canada
| | - Sarkis Meterissian
- Faculty of Medicine, McGill University, Montreal. 3605 Rue de la Montagne Décarie, Montreal, Quebec, H3G 2M1, Canada; Cedars Breast Clinic, McGill University Health Centre, 1001 Boulevard Décarie, Montreal, Quebec, H4A 3J1, Canada; Division of General Surgery, Department of Surgery, McGill University Health Centre, 1001 Boulevard Décarie, Montreal, Quebec, H4A 3J1, Canada.
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Jee Y, Bakht A, Burner JM, Coldren DL, Howard-McNatt M, Chiba A. Intraductal Papilloma on Breast Biopsy: Upstaging Rate and Implications for Practice Guidelines. Am Surg 2022; 88:1467-1470. [PMID: 35420506 DOI: 10.1177/00031348221082276] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND The recommendation for management of intraductal papilloma has not been clearly established and its surgical excision criteria remain controversial. This study determines the institutional malignancy upstage rate of benign intraductal papillomas and identifies risk factors for upstage. METHODS Retrospective review was conducted on female patients who were diagnosed with intraductal papillomas without atypia on core needle biopsy at Atrium Health Wake Forest Baptist Hospital between 1/2012 and 6/2021. Patients were excluded if there was a concomitant malignancy or atypia or deemed to be discordant with imaging. Features associated with upstage on imaging and histopathology were obtained from the electronic medical record. RESULTS This study included 245 intraductal papillomas without atypia in 231 women (mean age, 59.1 ± 12.3 [SD] years). Approximately 31% (76/245) of the papillomas were excised, whereas 69% (169/245) of the papillomas underwent surveillance. Of the patients who underwent excisional biopsy, upstage rate for DCIS was 1.3% (1/76) and 5.3% (4/76) for atypia. All of the papillomas upstaged to DCIS or atypia had lesion size ≥10 mm on imaging. Out of the 139 intraductal papillomas that underwent radiologic surveillance, two (1.4%) developed malignancy and three (2.2%) developed atypia. DISCUSSION The risk of upstaging of intraductal papilloma without atypia to malignancy remains extremely low. Therefore, routine surgical excision may not be necessary. While the papillomas upstaged to either malignancy or atypia have size abnormality ≥10 mm, other potential selective excision criteria should be explored to further decrease the risk of an upstage.
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Affiliation(s)
- Yoonsun Jee
- Atrium Health Wake Forest Baptist, Winston Salem, NC, USA
| | - Azad Bakht
- Atrium Health Wake Forest Baptist, Winston Salem, NC, USA
| | | | | | | | - Akiko Chiba
- Atrium Health Wake Forest Baptist, Winston Salem, NC, USA
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Ross DS, D'Alfonso TM. Papillary Neoplasms of the Breast: Diagnostic Features and Molecular Insights. Surg Pathol Clin 2022; 15:133-146. [PMID: 35236629 DOI: 10.1016/j.path.2021.11.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Papillary neoplasms of the breast are a heterogeneous group of tumors characterized by fibrovascular cores lined by epithelium, with or without myoepithelial cells. Papillary neoplasms include benign, atypical, and malignant tumors that show varying histopathologic features and clinical outcomes. Appropriate pathologic classification is crucial to guide clinical treatment. Classification of papillary neoplasms is largely based on morphology, with immunohistochemistry playing an ancillary role to establish diagnoses. Recent molecular studies have provided insight into the genomics of these lesions. This review summarizes the histologic, immunohistochemical, and molecular features of papillary neoplasms of the breast that are important for diagnosis and treatment.
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Affiliation(s)
- Dara S Ross
- Memorial Sloan Kettering Cancer Center, 1275 York Avenue, S-624, New York, NY 10065, USA
| | - Timothy M D'Alfonso
- Memorial Sloan Kettering Cancer Center, 1275 York Avenue, A-504, New York, NY 10065, USA.
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Editor's Notebook: December 2021. AJR Am J Roentgenol 2021; 217:1261-1262. [PMID: 34797170 DOI: 10.2214/ajr.21.26768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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The Global Reading Room: Managing a Benign Papilloma. AJR Am J Roentgenol 2021; 218:758-759. [PMID: 34406057 DOI: 10.2214/ajr.21.26684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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