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Fraker JL, Clune CG, Sahni SK, Yaganti A, Vegunta S. Prevalence, Impact, and Diagnostic Challenges of Benign Breast Disease: A Narrative Review. Int J Womens Health 2023; 15:765-778. [PMID: 37223067 PMCID: PMC10202205 DOI: 10.2147/ijwh.s351095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 05/05/2023] [Indexed: 05/25/2023] Open
Abstract
Benign breast diseases, which are commonly seen in clinical practice, have various clinical presentations and implications, as well as management strategies. This article describes common benign breast lesions, presentations of these lesions, and typical radiographic and histologic findings. Also included in this review are the most recent data and guideline-based recommendations for the management of benign breast diseases at diagnosis, including surgical referral, medical management, and ongoing surveillance.
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Affiliation(s)
- Jessica L Fraker
- Division of Women’s Health Internal Medicine, Mayo Clinic, Scottsdale, AZ, USA
| | - Caroline G Clune
- Center for Breast Care, Mayo Clinic Health System — Southwest Wisconsin Region, La Crosse, WI, USA
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Sabrina K Sahni
- Jacoby Center for Breast Health, Mayo Clinic, Jacksonville, FL, USA
| | - Avani Yaganti
- Southern Illinois University School of Medicine, Springfield, IL, USA
| | - Suneela Vegunta
- Division of Women’s Health Internal Medicine, Mayo Clinic, Scottsdale, AZ, USA
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2
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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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3
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Ferre R, Kuzmiak CM. Upgrade rate of percutaneously diagnosed pure flat epithelial atypia: systematic review and meta-analysis of 1,924 lesions. J Osteopath Med 2022; 122:253-262. [PMID: 35150124 DOI: 10.1515/jom-2021-0206] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Accepted: 12/14/2021] [Indexed: 12/29/2022]
Abstract
CONTEXT Management remains controversial due to the risk of upgrade for malignancy from flat epithelial atypia (FEA). Data about the frequency and malignancy upgrade rates are scant. Namely, observational follow-up is advised by many studies in cases of pure FEA on core biopsy and in the absence of an additional surgical excision. For cases of pure FEA, the American College of Surgeons no longer recommends surgical excision but rather recommends observation with clinical and imaging follow-up. OBJECTIVES The aim of this study is to perform a systematic review and meta-analysis to calculate the pooled upgrade of pure FEA following core needle biopsies. METHODS A search of MEDLINE and Embase databases were conducted in December 2020. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. A fixed- or random-effects model was utilized. Heterogeneity among studies was estimated by utilizing the I2 statistic and considered high if the I2 was greater than 50%. The random-effects model with the DerSimonian and Laird method was utilized to calculate the pooled upgrade rate and its 95% confidence interval. RESULTS A total of 1924 pure FEA were analyzed among 59 included studies. The overall pooled upgrade rate to malignancy was 8.8%. The pooled upgrade rate for mammography only was 8.9%. The pooled upgrade rate for ultrasound was 14%. The pooled upgrade rate for mammography and ultrasound combined was 8.8%. The pooled upgrade rate for MRI-only cases was 27.3%. CONCLUSIONS Although the guidelines for the management of pure FEA are variable, our data support that pure FEA diagnosed at core needle biopsy should undergo surgical excision since the upgrade rate >2%.
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Affiliation(s)
- Romuald Ferre
- Centre hospital de la Sarre, 679 Route 111, La Sarre, QC J9Z 2Y9, Canada
- Department of Radiology, Hopital du Grand Portage, Riviere du Loup, QC, Canada
| | - Cherie M Kuzmiak
- Department of Radiology, UNC School of Medicine, Chapel Hill, NC, USA
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4
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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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5
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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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6
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Lucioni M, Rossi C, Lomoro P, Ballati F, Fanizza M, Ferrari A, Garcia-Etienne CA, Boveri E, Meloni G, Sommaruga MG, Ferraris E, Lasagna A, Bonzano E, Paulli M, Sgarella A, Di Giulio G. Positive predictive value for malignancy of uncertain malignant potential (B3) breast lesions diagnosed on vacuum-assisted biopsy (VAB): is surgical excision still recommended? Eur Radiol 2020; 31:920-927. [PMID: 32816199 DOI: 10.1007/s00330-020-07161-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 06/20/2020] [Accepted: 08/06/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE Breast lesions classified as of "uncertain malignant potential" represent a heterogeneous group of abnormalities with an increased risk of associated malignancy. Clinical management of B3 lesions diagnosed on vacuum-assisted breast biopsy (VABB) is still challenging: surgical excision is no longer the only available treatment and VABB may be sufficient for therapeutic excision. The aim of the present study is to evaluate the positive predictive value (PPV) for malignancy in B3 lesions that underwent surgical excision, identifying possible upgrading predictive factors and characterizing the malignant lesions eventually diagnosed. These results are compared with a subset of patients with B3 lesions who underwent follow-up. METHODS A total of 1250 VABBs were performed between January 2006 and December 2017 at our center. In total, 150 B3 cases were diagnosed and 68 of them underwent surgical excision. VABB findings were correlated with excision histology. A PPV for malignancy for each B3 subtype was derived. RESULTS The overall PPV rate was 28%, with the highest upgrade rate for atypical ductal hyperplasia (41%), followed by classical lobular neoplasia (29%) and flat epithelial atypia (11%). Only two cases of carcinoma were detected in the follow-up cohort, both associated with atypical ductal hyperplasia at VABB. CONCLUSION Open surgery is recommended in case of atypical ductal hyperplasia while, for other B3 lesions, excision with VABB only may be an acceptable alternative if radio-pathological correlation is assessed, if all microcalcifications have been removed by VABB, and if the lesion lacks high-risk cytological features. KEY POINTS • Surgical treatment is strongly recommended in case of ADH, while the upgrade rate in case of pure FEA, especially following complete microcalcification removal by VABB, may be sufficiently low to advice surveillance as a management strategy. • The use of 11-G- or 8-G-needle VABB, resulting in possible complete diagnostic excision of the lesion, can be an acceptable alternative in case of RS, considering open surgery only for selected high-risk patients. • LN management is more controversial: surgical excision may be recommended following classical LN diagnosis on breast biopsy if an additional B3 lesion is concurrently detected while in the presence of isolated LN with adequate radiological-pathological correlation follow-up alone could be an acceptable option.
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Affiliation(s)
- Marco Lucioni
- Anatomic Pathology Section, Department of Human Pathology, University of Pavia, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Chiara Rossi
- Anatomic Pathology Section, Department of Human Pathology, University of Pavia, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Pascal Lomoro
- Breast Imaging Department, Valduce Hospital, Via Dante Alighieri 11, 22100, Como, Italy.
| | - Francesco Ballati
- Breast Imaging Department, University of Pavia, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Marianna Fanizza
- Breast Imaging Department, University of Pavia, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Alberta Ferrari
- Breast Surgery Department, Fondazione IRCCS Policlinico San Matteo, Università degli Studi di Pavia, Pavia, Italy
| | - Carlos A Garcia-Etienne
- Breast Surgery Department, Fondazione IRCCS Policlinico San Matteo, Università degli Studi di Pavia, Pavia, Italy
| | - Emanuela Boveri
- Anatomic Pathology Section, Department of Human Pathology, University of Pavia, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Giulia Meloni
- Breast Imaging Department, University of Pavia, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Maria Grazia Sommaruga
- Breast Imaging Department, University of Pavia, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Elisa Ferraris
- Medical Oncology, Fondazione IRCCS Policlinico San Matteo and, Università degli Studi, Pavia, Italy
| | - Angioletta Lasagna
- Medical Oncology, Fondazione IRCCS Policlinico San Matteo and, Università degli Studi, Pavia, Italy
| | - Elisabetta Bonzano
- University of Pavia and Department of Radiation Oncology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Marco Paulli
- Anatomic Pathology Section, Department of Human Pathology, University of Pavia, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Adele Sgarella
- Breast Surgery Department, Fondazione IRCCS Policlinico San Matteo, Università degli Studi di Pavia, Pavia, Italy
| | - Giuseppe Di Giulio
- Breast Imaging Department, University of Pavia, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
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7
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Mariscotti G, Durando M, Ruggirello I, Belli P, Caumo F, Nori J, Zuiani C, Tagliafico A, Bicchierai G, Romanucci G, Londero V, Campanino PP, Bussone R, Castellano I, Mule' A, Caneva A, Bianchi S, Di Loreto C, Bergamasco L, Calabrese M, Fonio P, Houssami N. Lesions of uncertain malignant potential of the breast (B3) on vacuum-assisted biopsy for microcalcifications: Predictors of malignancy. Eur J Radiol 2020; 130:109194. [PMID: 32795765 DOI: 10.1016/j.ejrad.2020.109194] [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: 03/14/2020] [Revised: 07/04/2020] [Accepted: 07/21/2020] [Indexed: 12/31/2022]
Abstract
PURPOSE To investigate clinical, radiologic and pathologic features of B3 lesions diagnosed on VABB targeting microcalcifications, for identifying predictors of malignancy. METHOD This retrospective multi-centre study included consecutive VABBs performed over a 10-year period on suspicious microcalcifications not associated with other radiological signs diagnosed as B3 on histology from VABB, with outcomes ascertained by surgical excision. Clinical, demographic, radiological and histological (B3 subcategory) data were collected. For statistical analysis (univariate and binary logistic regression), the primary outcome variable was the upgrade rate to malignancy after surgery. Predictors of upgrade to malignancy were identified from clinical, demographic, radiological and pathological variables (including B3 subcategory). RESULTS Amongst 447 VABBs, there were 57(12.7 %) upgrades to malignancy at surgical histology (36 DCIS and 21 invasive cancer). At univariate analysis, variables significantly associated with increased risk of upgrade to malignancy were age>55 years (p = 0.01), lesion size>10 mm (p < 0.0001), BI-RADS 4b-c and 5 (p = 0.0001), and fine pleomorphic morphology (p = 0.002) of microcalcifications. Binary logistic regression confirmed as significant independent risk factors age, lesion size and BI-RADS category (p = 0.02, 0.02 and 0.0006 respectively). Amongst subcategories of B3 lesions, lobular neoplasia was significantly(p = 0.04) associated with upgrade, confirmed as an independent risk factor [p = 0.03, OR = 2.3(1.1-4.7)]. Flat epithelial atypia was significantly(p = 0.004) associated with reduced odds of upgrade, but binary logistic regression showed only borderline association [p = 0.052, OR = 0.4(0.2-1.01)]. CONCLUSIONS Across B3 lesions diagnosed on histology from VABB of suspicious microcalcifications, older age, size>10 mm, BI-RADS category≥ 4b on imaging, and lobular neoplasia were risk factors for upgrade to malignancy. This information can be used to discuss patients' tailored management options.
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Affiliation(s)
- Giovanna Mariscotti
- Radiology Institute, University of Turin, Department of Diagnostic Imaging and Radiotherapy, A. O. U. Citta della Salute e della Scienza di Torino - Presidio Ospedaliero Molinette, Via Genova 3, 10126, Torino, Italy.
| | - Manuela Durando
- Radiology Institute, University of Turin, Department of Diagnostic Imaging and Radiotherapy, A. O. U. Citta della Salute e della Scienza di Torino - Presidio Ospedaliero Molinette, Via Genova 3, 10126, Torino, Italy.
| | - Irene Ruggirello
- Radiology Institute, University of Turin, Department of Diagnostic Imaging and Radiotherapy, A. O. U. Citta della Salute e della Scienza di Torino - Presidio Ospedaliero Molinette, Via Genova 3, 10126, Torino, Italy.
| | - Paolo Belli
- Department of Radiological, Radiotherapic and Hematological Sciences, Fondazione Policlinico A. Gemelli IRCCS - Universita' Cattolica Sacro Cuore, Largo Agostino Gemelli 8, 00168, Rome, Italy.
| | - Francesca Caumo
- Radiology Department, Veneto Institute of Oncology IOV - IRCCS, Padua, Italy.
| | - Jacopo Nori
- Diagnostic Senology Unit, Azienda Ospedaliero-Universitaria Careggi, Largo G. A. Brambilla 3, 50134, Florence, Italy.
| | - Chiara Zuiani
- Institute of Radiology, Department of Medicine, University of Udine, University Hospital S. Maria della Misericordia, P.le S. Maria della Misericordia, 15, 33100, Udine, Italy.
| | - Alberto Tagliafico
- Department of Health Sciences (DISSAL), University of Genoa, Genova, Italy; Department of Radiology, IRCCS San Martino Hospital, 16132, Genova, Italy.
| | - Giulia Bicchierai
- Diagnostic Senology Unit, Azienda Ospedaliero-Universitaria Careggi, Largo G. A. Brambilla 3, 50134, Florence, Italy.
| | - Giovanna Romanucci
- UOSD Breast Unit ULSS9, Ospedale di Marzana, Piazzale Lambranzi, 1, 37034 Verona, Italy.
| | - Viviana Londero
- Institute of Radiology, Department of Medicine, University of Udine, University Hospital S. Maria della Misericordia, P.le S. Maria della Misericordia, 15, 33100, Udine, Italy.
| | - Pier Paolo Campanino
- Breast Imaging Service, Ospedale Koelliker, C.so Galileo Ferraris 256, 10100, Torino, Italy.
| | - Riccardo Bussone
- Breast Surgery, Presidio Sanitario Ospedale Cottolengo, Via S. Giuseppe Benedetto Cottolengo, 9, 10152, Torino, Italy.
| | | | - Antonino Mule'
- Department of Histopathology and Cytodiagnosis, Fondazione Policlinico A. Gemelli IRCCS -Universita' Cattolica Sacro Cuore, Largo Agostino Gemelli 8, 00168, Rome, Italy.
| | | | - Simonetta Bianchi
- Division of Pathological Anatomy, Department of medical and surgical critical care, University of Florence, Florence, Italy.
| | - Carla Di Loreto
- Anatomic Pathology Institute, Department of Medicine (DAME), University of Udine, Udine, Italy.
| | - Laura Bergamasco
- Department of Surgical Sciences, University of Torino, A. O. U. Citta della Salute e della Scienza di Torino - Presidio Ospedaliero Molinette, C.so Bramante 88, 10126, Torino, Italy.
| | - Massimo Calabrese
- Diagnostic Senology, IRCCS - Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, Italy.
| | - Paolo Fonio
- Radiology Institute, University of Turin, Department of Diagnostic Imaging and Radiotherapy, A. O. U. Citta della Salute e della Scienza di Torino - Presidio Ospedaliero Molinette, Via Genova 3, 10126, Torino, Italy.
| | - Nehmat Houssami
- Screening and Test Evaluation Program, School of Public Health, Sydney Medical School, University of Sydney, Sydney 2006, NSW, Australia.
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Liu C, Dingee CK, Warburton R, Pao JS, Kuusk U, Bazzarelli A, Sidhu R, McKevitt EC. Pure flat epithelial atypia identified on core needle biopsy does not require excision. Eur J Surg Oncol 2020; 46:235-239. [DOI: 10.1016/j.ejso.2019.10.029] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Revised: 09/09/2019] [Accepted: 10/23/2019] [Indexed: 11/30/2022] Open
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9
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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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10
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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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11
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All pure flat atypical atypia lesions of the breast diagnosed using percutaneous vacuum-assisted breast biopsy do not need surgical excision. Breast 2018; 40:4-9. [DOI: 10.1016/j.breast.2018.03.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2017] [Revised: 03/18/2018] [Accepted: 03/26/2018] [Indexed: 11/18/2022] Open
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12
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Flat epithelial atypia in directional vacuum-assisted biopsy of breast microcalcifications: surgical excision may not be necessary. Mod Pathol 2018; 31:1097-1106. [PMID: 29467479 DOI: 10.1038/s41379-018-0035-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2017] [Revised: 01/05/2018] [Accepted: 01/07/2018] [Indexed: 11/09/2022]
Abstract
The aim of this study was to analyze the clinicopathological features of patients with flat epithelial atypia, diagnosed in directional vacuum-assisted biopsy targeting microcalcifications, to identify upgrade rate to in situ ductal or invasive breast carcinoma, and determine factors predicting carcinoma in the subsequent excision. We retrospectively evaluated the histological, clinical, and mammographic features of 69 cases from 65 women, with directional vacuum-assisted biopsy-diagnosed flat epithelial atypia with or without atypical ductal hyperplasia or atypical lobular hyperplasia, which underwent subsequent surgical excision. The extent and percentage of microcalcifications sampled by directional vacuum-assisted biopsy were evaluated by mammography. All biopsy and surgical excision slides were reviewed. The age of the women ranged from 40 to 85 years (mean 57 years). All patients presented with mammographically detected microcalcifications only, except in one case that had associated architectural distortion. Extent of calcifications ranged from <1 cm (n = 47), 1-3 cm (n = 15) to > 3 cm (n = 6), and no measurement (n = 1). A mean of 11 cores (range 6-25) was obtained from each lesion. Post-biopsy mammogram revealed >90% removal of calcifications in 81% of cases. Pure flat epithelial atypia represented nearly two-thirds of directional vacuum-assisted biopsy specimens (n = 43, 62%), while flat epithelial atypia coexisted with atypical ductal hyperplasia (18 cases, 26%), or atypical lobular hyperplasia (8 cases, 12%). Upon excision, none of the cases were upgraded to in situ ductal or invasive breast cancer. In one case, however, an incidental, tubular carcinoma (4 mm) was found away from biopsy site. Excluding this case, the upgrade rate was 0%. Our study adds to the growing evidence that diagnosis of flat epithelial atypia on directional vacuum-assisted biopsy for microcalcifications as the only imaging finding is not associated with a significant upgrade to carcinoma on excision, and therefore, excision may not be necessary. Additionally, excision may not be necessary for flat epithelial atypia with atypical ductal hyperplasia limited to ≤2 terminal duct-lobular units, if at least 90% of calcifications have been removed on biopsy.
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Abstract
Benign and atypical lesions associated with breast cancer risk are often encountered in core needle biopsies (CNBs) of the breast. For these lesions, the rate of "upgrade" to carcinoma in excision specimens varies widely in the literature. Many CNB studies are limited by a lack of radiological-pathological correlation, consistent criteria for excision, and clinical follow-up for patients who forego excision. This article highlights contemporary diagnostic criteria and outcome data that would support an evidence-based approach to the management of these nonmalignant lesions of the breast diagnosed on CNB.
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Affiliation(s)
- Benjamin C Calhoun
- Department of Pathology and Laboratory Medicine, University of North Carolina, Women's and Children's Hospitals, 3rd Floor, Room 30212, 101 Manning Drive, Chapel Hill, NC 27514, USA.
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Racz JM, Carter JM, Degnim AC. Challenging Atypical Breast Lesions Including Flat Epithelial Atypia, Radial Scar, and Intraductal Papilloma. Ann Surg Oncol 2017; 24:2842-2847. [DOI: 10.1245/s10434-017-5980-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Indexed: 11/18/2022]
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Samples LS, Rendi MH, Frederick PD, Allison KH, Nelson HD, Morgan TR, Weaver DL, Elmore JG. Surgical implications and variability in the use of the flat epithelial atypia diagnosis on breast biopsy specimens. Breast 2017; 34:34-43. [PMID: 28475933 DOI: 10.1016/j.breast.2017.04.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Revised: 03/31/2017] [Accepted: 04/06/2017] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVES Flat epithelial atypia (FEA) is a relatively new diagnostic term with uncertain clinical significance for surgical management. Any implied risk of invasive breast cancer associated with FEA is contingent upon diagnostic reproducibility, yet little is known regarding its use. MATERIALS AND METHODS Pathologists in the Breast Pathology Study interpreted one of four 60-case test sets, one slide per case, constructed from 240 breast biopsy specimens. An electronic data form with standardized diagnostic categories was used; participants were instructed to indicate all diagnoses present. We assessed participants' use of FEA as a diagnostic term within: 1) each test set; 2) 72 cases classified by reference as benign without FEA; and 3) six cases classified by reference as FEA. 115 pathologists participated, providing 6900 total independent assessments. RESULTS Notation of FEA ranged from 0% to 35% of the cases interpreted, with most pathologists noting FEA on 4 or more test cases. At least one participant noted FEA in 34 of the 72 benign non-FEA cases. For the 6 reference FEA cases, participant agreement with the case reference FEA diagnosis ranged from 17% to 52%; diagnoses noted by participating pathologists for these FEA cases included columnar cell hyperplasia, usual ductal hyperplasia, atypical lobular hyperplasia, and atypical ductal hyperplasia. CONCLUSIONS We observed wide variation in the diagnosis of FEA among U.S. pathologists. This suggests that perceptions of diagnostic criteria and any implied risk associated with FEA may also vary. Surgical excision following a core biopsy diagnosis of FEA should be reconsidered and studied further.
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Affiliation(s)
- Laura S Samples
- Department of Medicine, University of Washington School of Medicine, 325 Ninth Ave, Box 359780, Seattle, WA 98104, USA
| | - Mara H Rendi
- Department of Pathology, University of Washington School of Medicine, 1959 NE Pacific St., Box 356100, Seattle, WA, USA
| | - Paul D Frederick
- Department of Medicine, University of Washington School of Medicine, 325 Ninth Ave, Box 359780, Seattle, WA 98104, USA
| | - Kimberly H Allison
- Department of Pathology, Stanford University School of Medicine, 300 Pasteur Drive, Lane 235, Stanford, CA 94305, USA
| | - Heidi D Nelson
- Providence Cancer Center, Providence Health and Services Oregon, and Departments of Medical Informatics and Clinical Epidemiology and Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Mail Code FM, Portland, OR 97239, USA
| | - Thomas R Morgan
- Department of Medicine, University of Washington School of Medicine, 325 Ninth Ave, Box 359780, Seattle, WA 98104, USA
| | - Donald L Weaver
- Department of Pathology and University of Vermont Cancer Center, University of Vermont, Given Courtyard, 89 Beaumont Ave, Burlington, VT 05405, USA
| | - Joann G Elmore
- Department of Medicine, University of Washington School of Medicine, 325 Ninth Ave, Box 359780, Seattle, WA 98104, USA.
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Upgrade rates of high-risk breast lesions diagnosed on core needle biopsy: a single-institution experience and literature review. Mod Pathol 2016; 29:1471-1484. [PMID: 27538687 DOI: 10.1038/modpathol.2016.127] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2016] [Revised: 05/31/2016] [Accepted: 06/02/2016] [Indexed: 11/08/2022]
Abstract
Optimal management of high-risk breast lesions detected by mammogram yielding atypical ductal hyperplasia, flat epithelial atypia, atypical lobular hyperplasia, lobular carcinoma in situ, and radial scar without atypia on core needle biopsy is controversial. This is a single-institution retrospective review of 5750 core needle biopsy cases seen over 14.5 years, including 249 (4.3%), 72 (1.3%), 50 (0.9%), 37 (0.6%), and 54 (0.9%) cases of atypical ductal hyperplasia, flat epithelial atypia, atypical lobular hyperplasia, lobular carcinoma in situ, and radial scar without atypia, respectively. Patient age, radiologic characteristics, needle gauge, and excision diagnoses were recorded. Of 462 high-risk cases analyzed, 333 (72%) underwent excision. Upgrade rate to ductal carcinoma in situ, pleomorphic carcinoma in situ, or invasive mammary carcinoma was 18% for atypical ductal hyperplasia, 11% for flat epithelial atypia, 9% for atypical lobular hyperplasia, 28% for lobular carcinoma in situ, and 16% for radial scar. Carcinoma diagnosed on excision was more likely to be in situ than invasive, and if invasive, more likely to be low grade than high grade. Overall, cases that were benign (vs high risk or carcinoma) on excision were less likely to have residual calcifications after biopsy (17% vs 27%, P=0.013), and more likely to have a smaller mass size (<1 cm) (82% vs 50%, P=0.001). On subgroup analysis, atypical ductal hyperplasia cases that were benign (vs high risk or carcinoma) on excision were more likely to have smaller mass size (<1 cm) (P=0.025). Lobular neoplasia diagnosed incidentally (vs targeted) on core needle biopsy was less likely to upgrade on excision (5% vs 39%, P=0.002). A comprehensive literature review was performed, identifying 116 studies reporting high-risk lesion upgrade rates, and our upgrade rates were similar to those of more recent larger studies. Careful radiological-pathological correlation is needed to identify high-risk lesion subgroups that may not need excision.
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Calhoun BC, Collins LC. Recommendations for excision following core needle biopsy of the breast: a contemporary evaluation of the literature. Histopathology 2015; 68:138-51. [DOI: 10.1111/his.12852] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Affiliation(s)
| | - Laura C Collins
- Department of Pathology; Beth Israel Deaconess Medical Center and Harvard Medical School; Boston MA USA
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Magnetic Resonance Imaging-Guided Core Needle Breast Biopsies Resulting in High-Risk Histopathologic Findings: Upstage Frequency and Lesion Characteristics. Clin Breast Cancer 2015; 15:234-9. [DOI: 10.1016/j.clbc.2014.12.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Revised: 12/05/2014] [Accepted: 12/16/2014] [Indexed: 11/20/2022]
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Management of flat epithelial atypia on breast core biopsy may be individualized based on correlation with imaging studies. Mod Pathol 2015; 28:670-6. [PMID: 25412845 DOI: 10.1038/modpathol.2014.159] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2014] [Revised: 10/15/2014] [Accepted: 10/16/2014] [Indexed: 11/08/2022]
Abstract
Flat epithelial atypia of the breast commonly co-exists with atypical ductal hyperplasia, lobular neoplasia, and indolent forms of invasive carcinomas such as tubular carcinoma. Most patients with pure flat epithelial atypia on core biopsy undergo surgical excision to evaluate for carcinoma in the adjacent breast tissue. Studies to date have reported varying upgrade rates with most recommending follow-up excision. These studies have often lacked detailed radiographic correlation, central review by breast pathologists and information regarding the biology of the carcinomas identified upon excision. In this study, we report the frequency of upgrade to invasive carcinoma or ductal carcinoma in situ in excision specimens following a diagnosis of pure flat epithelial atypia on core biopsy. Radiographic correlation is performed for each case and grade/receptor status of detected carcinomas is reported. Seventy-three (73) core biopsies containing pure flat epithelial atypia were identified from our files, meeting inclusion criteria for the study. In the subsequent excision biopsies, five (7%) cases contained invasive carcinoma or ductal carcinoma in situ and seventeen (23%) contained atypical ductal hyperplasia or lobular neoplasia. All of the ductal carcinoma in situ cases with estrogen receptor results were estrogen receptor positive and intermediate grade. The invasive tumors were small (pT1a) hormone receptor-positive, HER2-negative, low-grade invasive ductal or tubular carcinomas with negative sentinel lymph-node biopsies. No upgrades were identified in the 14 patients who had all of their calcifications removed by the stereotactic core biopsy. Our rate of upgrade to carcinoma, once cases with discordant imaging are excluded, is at the lower end of the range reported in the literature. Given the low upgrade rate and indolent nature of the carcinomas associated with flat epithelial atypia, case management may be individualized based on clinical and radiographic findings. Excision may not be necessary for patients without remaining calcifications following core biopsy.
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Morrow M, Schnitt SJ, Norton L. Current management of lesions associated with an increased risk of breast cancer. Nat Rev Clin Oncol 2015; 12:227-38. [PMID: 25622978 DOI: 10.1038/nrclinonc.2015.8] [Citation(s) in RCA: 79] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
High-risk breast lesions, which comprise benign lesions and in situ carcinomas (lobular carcinoma in situ and ductal carcinoma in situ), are clinically, morphologically, and biologically heterogeneous and are associated with an increased risk of invasive breast cancer development, albeit to varying degrees. Recognition and proactive management of such lesions can help to prevent progression to invasive disease, and might, therefore, reduce breast cancer incidence, morbidity, and mortality. However, this opportunity comes with the possibility of overdiagnosis and overtreatment, necessitating risk-based intervention. Notably, despite the progress in defining the molecular changes associated with carcinogenesis, alterations identifying the individuals with high-risk lesions that will progress to invasive carcinoma remain to be identified. Thus, until reproducible clinicopathological or molecular features predicting an individual's risk of breast cancer are found, management strategies must be defined by population-level risks as determined by models such as the Gail or IBIS models, as well as patient attitudes toward the risks and benefits of interventions. Herein, we review the contemporary approaches to diagnosis and management of high-risk breast lesions. Progress in this area will ultimately be dependent on the ability to individualize risk prediction through better definition of the key drivers in the carcinogenic process.
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Affiliation(s)
- Monica Morrow
- Breast Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Stuart J Schnitt
- Department of Pathology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA 02215, USA
| | - Larry Norton
- Breast Cancer Medicine Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
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