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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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Everidge SA, Sun J, Teshome M, Tamirisa N, Sun S, Adesoye T, Nia E, Bevers T, Bedrosian I, Patel M, Singh P. Lobular Neoplasia Diagnosed by MRI-Guided Breast Biopsy: Identifying Upgrade Rate to Malignancy and Outcomes of Clinical and Surgical Management. Ann Surg Oncol 2024; 31:2224-2230. [PMID: 38117388 DOI: 10.1245/s10434-023-14764-x] [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: 07/27/2023] [Accepted: 11/27/2023] [Indexed: 12/21/2023]
Abstract
OBJECTIVE The aim of this study was to determine surgical and clinical outcomes of lobular neoplasia (LN) diagnosed by magnetic resonance imaging (MRI) biopsy, including upgrade to malignancy, and to assess for characteristics associated with upgrade. METHOD A single-institution retrospective study, between 2013 and 2022, of patients with histopathological findings of LN via MRI-guided biopsy was performed using an institutional database and review of the electronic medical records. Decision for excision or surveillance was made by a multidisciplinary team per institutional practice. Patient demographics and imaging characteristics were summarized using descriptive analyses. Upgrade was defined as upgrade to cancer on surgical pathology for patients treated with excision or the development of cancer at the biopsy site during surveillance. The Wilcoxon rank-sum test and Fisher's exact test were used to compare features of the upgraded cohort with the remainder of the group. RESULTS Ninety-four MRI biopsies diagnosing LN were included. Median age was 57 years (range 37-78 years). Forty-six lesions underwent excision while 48 lesions were surveilled. The upgrade rate was 7.4% (7/94). Upgrades in the excised cohort consisted of pleomorphic lobular carcinoma in situ (LCIS; n = 1), ductal carcinoma in situ (DCIS; n = 3) and invasive lobular carcinoma (ILC; n = 2), while one interval development of DCIS was observed at the site of biopsy in the surveillance cohort. No MRI or patient variables were associated with upgrade. CONCLUSIONS In this contemporary cohort of MRI-detected LNs, the upgrade rate was low. Omission of surgery for MRI-detected LNs in carefully selected patients may be considered in a shared decision-making capacity between the patient and the treatment team. Larger cohorts are needed to determine factors predictive of upgrade risk.
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Affiliation(s)
- Shlermine A Everidge
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jia Sun
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mediget Teshome
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Nina Tamirisa
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Susie Sun
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Taiwo Adesoye
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Emily Nia
- Department of Breast Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Therese Bevers
- Department of Clinical Cancer Prevention, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Isabelle Bedrosian
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Miral Patel
- Department of Breast Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Puneet Singh
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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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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Miceli R, Mercado CL, Hernandez O, Chhor C. Active Surveillance for Atypical Ductal Hyperplasia and Ductal Carcinoma In Situ. JOURNAL OF BREAST IMAGING 2023; 5:396-415. [PMID: 38416903 DOI: 10.1093/jbi/wbad026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Indexed: 03/01/2024]
Abstract
Atypical ductal hyperplasia (ADH) and ductal carcinoma in situ (DCIS) are relatively common breast lesions on the same spectrum of disease. Atypical ductal hyperblasia is a nonmalignant, high-risk lesion, and DCIS is a noninvasive malignancy. While a benefit of screening mammography is early cancer detection, it also leads to increased biopsy diagnosis of noninvasive lesions. Previously, treatment guidelines for both entities included surgical excision because of the risk of upgrade to invasive cancer after surgery and risk of progression to invasive cancer for DCIS. However, this universal management approach is not optimal for all patients because most lesions are not upgraded after surgery. Furthermore, some DCIS lesions do not progress to clinically significant invasive cancer. Overtreatment of high-risk lesions and DCIS is considered a burden on patients and clinicians and is a strain on the health care system. Extensive research has identified many potential histologic, clinical, and imaging factors that may predict ADH and DCIS upgrade and thereby help clinicians select which patients should undergo surgery and which may be appropriate for active surveillance (AS) with imaging. Additionally, multiple clinical trials are currently underway to evaluate whether AS for DCIS is feasible for a select group of patients. Recent advances in MRI, artificial intelligence, and molecular markers may also have an important role to play in stratifying patients and delineating best management guidelines. This review article discusses the available evidence regarding the feasibility and limitations of AS for ADH and DCIS, as well as recent advances in patient risk stratification.
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Affiliation(s)
- Rachel Miceli
- NYU Langone Health, Department of Radiology, New York, NY, USA
| | | | | | - Chloe Chhor
- NYU Langone Health, Department of Radiology, New York, NY, USA
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Harbhajanka A, Gilmore HL, Calhoun BC. High-risk and selected benign breast lesions diagnosed on core needle biopsy: Evidence for and against immediate surgical excision. Mod Pathol 2022; 35:1500-1508. [PMID: 35654997 DOI: 10.1038/s41379-022-01092-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 04/18/2022] [Accepted: 04/18/2022] [Indexed: 11/09/2022]
Abstract
The vast majority of image-detected breast abnormalities are diagnosed by percutaneous core needle biopsy (CNB) in contemporary practice. For frankly malignant lesions diagnosed by CNB, the standard practice of excision and multimodality therapy have been well-defined. However, for high-risk and selected benign lesions diagnosed by CNB, there is less consensus on optimal patient management and the need for immediate surgical excision. Here we outline the arguments for and against the practice of routine surgical excision of commonly encountered high-risk and selected benign breast lesions diagnosed by CNB. The entities reviewed include atypical ductal hyperplasia, atypical lobular hyperplasia, lobular carcinoma in situ, intraductal papillomas, and radial scars. The data in the peer-reviewed literature confirm the benefits of a patient-centered, multidisciplinary approach that moves away from the reflexive "yes" or "no" for routine excision for a given pathologic diagnosis.
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Affiliation(s)
- Aparna Harbhajanka
- Department of Pathology, Case Western University School of Medicine, Cleveland, OH, 44106, USA
| | - Hannah L Gilmore
- Department of Pathology, Case Western University School of Medicine, Cleveland, OH, 44106, USA
| | - Benjamin C Calhoun
- Department of Pathology and Laboratory Medicine, The University of North Carolina School of Medicine, Chapel Hill, NC, 27599, USA.
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Preneoplastic Low-Risk Mammary Ductal Lesions (Atypical Ductal Hyperplasia and Ductal Carcinoma In Situ Spectrum): Current Status and Future Directions. Cancers (Basel) 2022; 14:cancers14030507. [PMID: 35158775 PMCID: PMC8833401 DOI: 10.3390/cancers14030507] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 01/12/2022] [Accepted: 01/17/2022] [Indexed: 02/04/2023] Open
Abstract
Intraepithelial mammary ductal neoplasia is a spectrum of disease that varies from atypical ductal hyperplasia (ADH), low-grade (LG), intermediate-grade (IG), to high-grade (HG) ductal carcinoma in situ (DCIS). While ADH has the lowest prognostic significance, HG-DCIS carries the highest risk. Due to widely used screening mammography, the number of intraepithelial mammary ductal neoplastic lesions has increased. The consequence of this practice is the increase in the number of patients who are overdiagnosed and, therefore, overtreated. The active surveillance (AS) trials are initiated to separate lesions that require active treatment from those that can be safely monitored and only be treated when they develop a change in the clinical/radiologic characteristics. At the same time, the natural history of these lesions can be evaluated. This review aims to evaluate ADH/DCIS as a spectrum of intraductal neoplastic disease (risk and histomorphology); examine the controversies of distinguishing ADH vs. DCIS and the grading of DCIS; review the upgrading for both ADH and DCIS with emphasis on the variation of methods of detection and the definitions of upgrading; and evaluate the impact of all these variables on the AS trials.
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Li X, Sun K, Chai W, Zhu H, Yan F. Role of breast MRI in predicting histologic upgrade risks in high-risk breast lesions: A review. Eur J Radiol 2021; 142:109855. [PMID: 34303150 DOI: 10.1016/j.ejrad.2021.109855] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 06/28/2021] [Accepted: 07/05/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE This article reviews the frequency, upgrade rate and valuable imaging characteristics for predicting the histologic upgrade risks of high-risk lesions on MRI, so as to provide a reference for the management of the lesions. METHODS A comprehensive search for relevant publications from January 2011 to January 2021 was conducted in the PubMed database. The frequency, upgrade rate and valuable imaging characteristics for predicting the upgrade risks of high-risk lesions on MRI included in the articles were reviewed, and the management of high-risk lesions was provided with a reference according to the review results. RESULTS AND CONCLUSIONS In terms of management options, Atypical ductal hyperplasia (ADH) and Lobular neoplasia (LN) (the top two high-risk lesions with the highest upgrade rate and frequency) were treated with surgical resection. However, the final treatment decision for other high-risk lesions should be made by a multidisciplinary committee. In terms of the value of breast MRI in predicting the upgrade risks of high-risk lesions, the lesions that were confirmed to upgrade after surgery showed some enhancement characteristics, especially for ADH and LN. At the same time, Dynamic contrast-enhanced MRI (DCE-MRI) has a high negative predictive value (NPV) in predicting the upgrade risks of the high-risk lesions, hence misdiagnosis and overtreatment can be reduced. Diffusion-weighted imaging (DWI) and relative apparent diffusion coefficient (rADC) can be used to predict the upgrade risks of the lesions, and the ADC of upgraded lesions is lower than that of non-upgraded lesions. However, these conclusions should be confirmed by further studies.
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Affiliation(s)
- Xue Li
- Department of Radiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No. 197 Ruijin Er Road, Shanghai 200025, China.
| | - Kun Sun
- Department of Radiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No. 197 Ruijin Er Road, Shanghai 200025, China.
| | - Weimin Chai
- Department of Radiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No. 197 Ruijin Er Road, Shanghai 200025, China.
| | - Hong Zhu
- Department of Radiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No. 197 Ruijin Er Road, Shanghai 200025, China.
| | - Fuhua Yan
- Department of Radiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No. 197 Ruijin Er Road, Shanghai 200025, China.
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Zhang C, Wang EY, Liu F, Ruhul Quddus M, James Sung C. Type of Architecture, Presence of Punctate Necrosis, and Extent of Involvement in Atypical Ductal Hyperplasia Can Predict the Diagnosis of Breast Carcinoma on Excision: A Clinicopathologic Study of 143 Cases. Int J Surg Pathol 2021; 29:716-721. [PMID: 33881947 DOI: 10.1177/10668969211010954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The literature shows a wide range in the frequencies of finding breast carcinoma in the excised specimens following a biopsy diagnosis of atypical ductal hyperplasia (ADH), likely due to a poor diagnostic reproducibility among different pathologists as well as an inherent heterogeneity in ADH. We evaluated whether histologic subtyping of ADH would help predict the risk of breast carcinoma. Our study consisted of 143 cases of ADH diagnosed by core needle biopsy and followed by excision. Of these, 54 cases (37.8%) showed carcinoma in the excised specimens (47 cases of ductal carcinoma in situ alone, 3 cases of invasive ductal carcinoma alone, and 4 cases of mixed invasive ductal carcinoma and ductal carcinoma in situ). We arbitrarily divided ADH into two subtypes: type A was considered when one or more ducts were completely replaced by low-grade ductal carcinoma in situ type cells but the lesion was <2 mm and type B was considered when one or more ducts were partially involved by low-grade ductal carcinoma in situ type cells regardless of lesion size. Type A was associated with a significantly higher frequency of breast carcinoma (63.6%) than type B (30.0%). ADH containing punctate necrosis showed a higher association of carcinoma (66.7%) compared to those without necrosis (35.1%). Within type B ADH, involvement of 3 or more foci had a higher frequency of carcinoma (50.0%) than involvement of fewer foci (26.6%). These histologic features of ADH may prove useful in predicting the likelihood of breast carcinoma and provide helpful information for patient's management.
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Affiliation(s)
- Cunxian Zhang
- Kent Hospital, Warwick, RI, USA.,22209Women & Infants Hospital of Rhode Island, Providence, RI, USA.,Warren Alpert Medical School, 6752Brown University, Providence, RI, USA
| | - Edmond Y Wang
- 22209Women & Infants Hospital of Rhode Island, Providence, RI, USA.,Now with Meditech, One Constitution Way, Foxborough, MA, USA
| | - Fang Liu
- 22209Women & Infants Hospital of Rhode Island, Providence, RI, USA.,Warren Alpert Medical School, 6752Brown University, Providence, RI, USA.,Now with Saint Vincent Hospital, Worcester Medical Center, Worcester, MA, USA
| | - M Ruhul Quddus
- 22209Women & Infants Hospital of Rhode Island, Providence, RI, USA.,Warren Alpert Medical School, 6752Brown University, Providence, RI, USA
| | - C James Sung
- 22209Women & Infants Hospital of Rhode Island, Providence, RI, USA.,Warren Alpert Medical School, 6752Brown University, Providence, RI, USA
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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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High-Risk Lesions Detected by MRI-Guided Core Biopsy: Upgrade Rates at Surgical Excision and Implications for Management. AJR Am J Roentgenol 2021; 216:622-632. [PMID: 33439046 DOI: 10.2214/ajr.20.23040] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
OBJECTIVE. The purpose of our study was to evaluate the upgrade rates of high-risk lesions (HRLs) diagnosed by MRI-guided core biopsy and to assess which clinical and imaging characteristics are predictive of upgrade to malignancy. MATERIALS AND METHODS. A retrospective review was performed of all women who presented to an academic breast radiology center for MRI-guided biopsy between January 1, 2015, and November 30, 2018. Histopathologic results from each biopsy were extracted. HRLs-that is, atypical ductal hyperplasia (ADH), lobular carcinoma in situ (LCIS), atypical lobular hyperplasia (ALH), radial scar, papilloma, flat epithelial atypia (FEA), benign vascular lesion (BVL), and mucocelelike lesion-were included for analysis. Clinical history, imaging characteristics, surgical outcome, and follow-up data were recorded. Radiologic-pathologic correlation was performed. RESULTS. Of 810 MRI-guided biopsies, 189 cases (23.3%) met the inclusion criteria for HRLs. Of the 189 HRLs, 30 cases were excluded for the following reasons: 15 cases were lost to follow-up, six cases were in patients who received neoadjuvant chemotherapy after biopsy, two lesions that were not excised had less than 2 years of imaging follow-up, and seven lesions had radiologic-pathologic discordance at retrospective review. Of the 159 HRLs in our study cohort, 13 (8.2%) were upgraded to carcinoma. Surgical upgrade rates were high for ADH (22.5%, 9/40) and FEA (33.3%, 1/3); moderate for LCIS (6.3%, 3/48); and low for ALH (0.0%, 0/11), radial scar (0.0%, 0/28), papilloma (0.0%, 0/26), and BVL (0.0%, 0/3). Of the upgraded lesions, 69.2% (9/13) were upgraded to ductal carcinoma in situ (DCIS) or well-differentiated carcinoma. ADH lesions were significantly more likely to be upgraded than non-ADH lesions (p = .005). CONCLUSION. ADH diagnosed by MRI-guided core biopsy warrants surgical excision. The other HRLs, however, may be candidates for imaging follow-up rather than excision, especially after meticulous radiologic-pathologic correlation.
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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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Uzan C, Mazouni C, Rossoni C, De Korvin B, de Lara CT, Cohen M, Chabbert N, Zilberman S, Boussion V, Vincent Salomon A, Espie M, Coutant C, Marchal F, Salviat F, Boulanger L, Doutriaux-Dumoulin I, Jouve E, Mathelin C, de Saint Hilaire P, Mollard J, Balleyguier C, Joyon N, Triki ML, Delaloge S, Michiels S. Prospective Multicenter Study Validate a Prediction Model for Surgery Uptake Among Women with Atypical Breast Lesions. Ann Surg Oncol 2020; 28:2138-2145. [PMID: 32920723 DOI: 10.1245/s10434-020-09107-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 08/18/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Diagnosis of atypical breast lesions (ABLs) leads to unnecessary surgery in 75-90% of women. We have previously developed a model including age, complete radiological target excision after biopsy, and focus size that predicts the probability of cancer at surgery. The present study aimed to validate this model in a prospective multicenter setting. - METHODS Women with a recently diagnosed ABL on image-guided biopsy were recruited in 18 centers, before wire-guided localized excisional lumpectomy. Primary outcome was the negative predictive value (NPV) of the model. RESULTS The NOMAT model could be used in 287 of the 300 patients included (195 with ADH). At surgery, 12 invasive (all grade 1), and 43 in situ carcinomas were identified (all ABL: 55/287, 19%; ADH only: 49/195, 25%). The area under the receiving operating characteristics curve of the model was 0.64 (95% CI 0.58-0.69) for all ABL, and 0.63 for ADH only (95% CI 0.56-0.70). For the pre-specified threshold of 20% predicted probability of cancer, NPV was 82% (77-87%) for all ABL, and 77% (95% CI 71-83%) for patients with ADH. At a 10% threshold, NPV was 89% (84-94%) for all ABL, and 85% (95% CI 78--92%) for the ADH. At this threshold, 58% of the whole ABL population (and 54% of ADH patients) could have avoided surgery with only 2 missed invasive cancers. CONCLUSION The NOMAT model could be useful to avoid unnecessary surgery among women with ABL, including for patients with ADH. CLINICAL TRIAL REGISTRATION NCT02523612.
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Affiliation(s)
- Catherine Uzan
- AP-HP (Assistance Publique des Hôpitaux de Paris), Department of Gynecological and Breast Surgery and Oncology, Pitié-Salpêtrière University Hospital, Paris, France. .,Sorbonne University, INSERM UMR_S_938, "Cancer Biology and Therapeutics", Centre de Recherche Saint-Antoine (CRSA), Paris, France. .,Institut Universitaire de Cancérologie (IUC), Paris, France.
| | | | | | | | | | | | | | | | | | - Anne Vincent Salomon
- Institut Curie, Université Paris-Sciences Lettres, INSERM U934, Département de Médecine Diagnostique et Théranostique, Paris, France
| | - Marc Espie
- University of Paris, Hôpital Saint Louis, APHP, Paris, France
| | | | - Frederic Marchal
- Institut de Cancérologie de Lorraine, Vandœuvre-lès-Nancy, France
| | - Flore Salviat
- Service de Biostatistique et d'Épidémiologie, Gustave Roussy, Villejuif, France.,CESP INSERM U1018, Université Paris-Sud, Université Paris-Saclay, Villejuif, France
| | | | | | - Eva Jouve
- Institut Claudius Regaud-Oncopole, Toulouse, France
| | - Carole Mathelin
- Les Hôpitaux universitaires de Strasbourg, Strasbourg, France
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Khoury T, Jabbour N, Peng X, Yan L, Quinn M. Atypical Ductal Hyperplasia and Those Bordering on Ductal Carcinoma In Situ Should Be Included in the Active Surveillance Clinical Trials. Am J Clin Pathol 2020; 153:131-138. [PMID: 31602455 DOI: 10.1093/ajcp/aqz143] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVES Women with atypical ductal hyperplasia (ADH), unlike those with ductal carcinoma in situ (DCIS), are denied eligibility for active surveillance clinical trials. METHODS We applied the inclusion criteria of the Comparison of Operative to Monitoring and Endocrine Therapy (COMET) trial to the cases of women (n = 165) at the Roswell Park Cancer Institute who had a diagnosis of ADH, ADH bordering on DCIS, or low- to intermediate-grade DCIS on core biopsy taken during screening mammography. Upgrade of lesions to high risk was based on invasive carcinoma, high-grade DCIS, or DCIS with comedo necrosis. RESULTS In total, nine (5.5%) lesions were upgraded: two (1.7%) reported ADH, one (5.9%) reported ADH bordering on DCIS, and six (19.4%) reported DCIS (P = .002); and two (1.6%) reclassified ADH vs seven (17.1%) reclassified DCIS (P < .001). In multivariate analysis, only increased number of foci had the potential to predict high risk (odds ratio: 1.39; P = .06). CONCLUSIONS We conclude that ADH and ADH bordering on DCIS have lower upgrade rates than DCIS. We recommend opening an active surveillance clinical trial for women with these diagnoses.
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Affiliation(s)
- Thaer Khoury
- Department of Pathology, Roswell Park Cancer Institute, Buffalo, NY
| | - Nashwan Jabbour
- Department of Pathology, Roswell Park Cancer Institute, Buffalo, NY
| | - Xuan Peng
- Department of Biostatics, Roswell Park Cancer Institute, Buffalo, NY
| | - Li Yan
- Department of Biostatics, Roswell Park Cancer Institute, Buffalo, NY
| | - Marie Quinn
- Department of Radiology, Roswell Park Cancer Institute, Buffalo, NY
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14
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Atypical Ductal Hyperplasia and Lobular Neoplasia: Update and Easing of Guidelines. AJR Am J Roentgenol 2019; 214:265-275. [PMID: 31825261 DOI: 10.2214/ajr.19.21991] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE. Atypical ductal hyperplasia (ADH), atypical lobular hyperplasia (ALH), and lobular carcinoma in situ (LCIS) are among high-risk lesions that have been previously recommended for surgical excision when diagnosed on core needle biopsy. Recent studies have examined whether imaging surveillance is a reasonable alternative to surgical management for these lesions. This article synthesizes the evidence regarding management of atypical hyperplasia and LCIS diagnosed on core needle biopsy and clinical implications of these diagnoses on future breast cancer risk as well as highlights areas of further research needed to improve practice guidelines for these high-risk lesions. CONCLUSION. Although surgical excision is still recommended after diagnosis of ADH on core needle biopsy, in specific circumstances ALH and LCIS can safely be managed by imaging surveillance.
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15
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Schiaffino S, Calabrese M, Melani EF, Trimboli RM, Cozzi A, Carbonaro LA, Di Leo G, Sardanelli F. Upgrade Rate of Percutaneously Diagnosed Pure Atypical Ductal Hyperplasia: Systematic Review and Meta-Analysis of 6458 Lesions. Radiology 2019; 294:76-86. [PMID: 31660803 DOI: 10.1148/radiol.2019190748] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Background Management of percutaneously diagnosed pure atypical ductal hyperplasia (ADH) is an unresolved clinical issue. Purpose To calculate the pooled upgrade rate of percutaneously diagnosed pure ADH. Materials and Methods A search of MEDLINE and EMBASE databases was performed in October 2018. Preferred Reporting Items for Systematic Reviews and Meta-Analyses, or PRISMA, guidelines were followed. A fixed- or random-effects model was used, along with subgroup and meta-regression analyses. The Newcastle-Ottawa scale was used for study quality, and the Egger test was used for publication bias. Results Of 521 articles, 93 were analyzed, providing data for 6458 ADHs (5911 were managed with surgical excision and 547 with follow-up). Twenty-four studies used core-needle biopsy; 44, vacuum-assisted biopsy; 21, both core-needle and vacuum-assisted biopsy; and four, unspecified techniques. Biopsy was performed with stereotactic guidance in 29 studies; with US guidance in nine, with MRI guidance in nine, and with mixed guidance in eight. Overall heterogeneity was high (I2 = 80%). Subgroup analysis according to management yielded a pooled upgrade rate of 29% (95% confidence interval [CI]: 26%, 32%) for surgically excised lesions and 5% (95% CI: 4%, 8%) for lesions managed with follow-up (P < .001). Heterogeneity was entirely associated with surgically excised lesions (I2 = 78%) rather than those managed with follow-up (I2 = 0%). Most variability was explained by guidance and needle caliper (P = .15). At subgroup analysis of surgically excised lesions, the pooled upgrade rate was 42% (95% CI: 31%, 53%) for US guidance, 23% (95% CI: 19%, 27%) for stereotactic biopsy, and 32% (95% CI: 22%, 43%) for MRI guidance, with heterogeneity (52%, 63%, and 56%, respectively) still showing the effect of needle caliper. When the authors considered patients with apparent complete lesion removal after biopsy (subgroups in 14 studies), the pooled upgrade rate was 14% (95% CI: 8%, 23%). Study quality was low to medium; the risk of publication bias was low (P = .10). Conclusion Because of a pooled upgrade rate higher than 2% (independent of biopsy technique, needle size, imaging guidance, and apparent complete lesion removal), atypical ductal hyperplasia diagnosed with percutaneous needle biopsy should be managed with surgical excision. © RSNA, 2019 Online supplemental material is available for this article. See also the editorial by Brem in this issue.
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Affiliation(s)
- Simone Schiaffino
- From the Unit of Radiology, IRCCS Policlinico San Donato, San Donato Milanese, Italy (S.S., L.A.C., G.D.L., F.S.); Unit of Radiology, IRCCS Policlinico San Martino, Genoa, Italy (M.C.); Unit of Radiology, Ente Ospedaliero Ospedali Galliera, Genoa, Italy (E.F.M.); and Department of Biomedical Sciences for Health, Università degli Studi di Milano, Via Mangiagalli 31, 20133 Milan, Italy (R.M.T., A.C., F.S.)
| | - Massimo Calabrese
- From the Unit of Radiology, IRCCS Policlinico San Donato, San Donato Milanese, Italy (S.S., L.A.C., G.D.L., F.S.); Unit of Radiology, IRCCS Policlinico San Martino, Genoa, Italy (M.C.); Unit of Radiology, Ente Ospedaliero Ospedali Galliera, Genoa, Italy (E.F.M.); and Department of Biomedical Sciences for Health, Università degli Studi di Milano, Via Mangiagalli 31, 20133 Milan, Italy (R.M.T., A.C., F.S.)
| | - Enrico Francesco Melani
- From the Unit of Radiology, IRCCS Policlinico San Donato, San Donato Milanese, Italy (S.S., L.A.C., G.D.L., F.S.); Unit of Radiology, IRCCS Policlinico San Martino, Genoa, Italy (M.C.); Unit of Radiology, Ente Ospedaliero Ospedali Galliera, Genoa, Italy (E.F.M.); and Department of Biomedical Sciences for Health, Università degli Studi di Milano, Via Mangiagalli 31, 20133 Milan, Italy (R.M.T., A.C., F.S.)
| | - Rubina Manuela Trimboli
- From the Unit of Radiology, IRCCS Policlinico San Donato, San Donato Milanese, Italy (S.S., L.A.C., G.D.L., F.S.); Unit of Radiology, IRCCS Policlinico San Martino, Genoa, Italy (M.C.); Unit of Radiology, Ente Ospedaliero Ospedali Galliera, Genoa, Italy (E.F.M.); and Department of Biomedical Sciences for Health, Università degli Studi di Milano, Via Mangiagalli 31, 20133 Milan, Italy (R.M.T., A.C., F.S.)
| | - Andrea Cozzi
- From the Unit of Radiology, IRCCS Policlinico San Donato, San Donato Milanese, Italy (S.S., L.A.C., G.D.L., F.S.); Unit of Radiology, IRCCS Policlinico San Martino, Genoa, Italy (M.C.); Unit of Radiology, Ente Ospedaliero Ospedali Galliera, Genoa, Italy (E.F.M.); and Department of Biomedical Sciences for Health, Università degli Studi di Milano, Via Mangiagalli 31, 20133 Milan, Italy (R.M.T., A.C., F.S.)
| | - Luca Alessandro Carbonaro
- From the Unit of Radiology, IRCCS Policlinico San Donato, San Donato Milanese, Italy (S.S., L.A.C., G.D.L., F.S.); Unit of Radiology, IRCCS Policlinico San Martino, Genoa, Italy (M.C.); Unit of Radiology, Ente Ospedaliero Ospedali Galliera, Genoa, Italy (E.F.M.); and Department of Biomedical Sciences for Health, Università degli Studi di Milano, Via Mangiagalli 31, 20133 Milan, Italy (R.M.T., A.C., F.S.)
| | - Giovanni Di Leo
- From the Unit of Radiology, IRCCS Policlinico San Donato, San Donato Milanese, Italy (S.S., L.A.C., G.D.L., F.S.); Unit of Radiology, IRCCS Policlinico San Martino, Genoa, Italy (M.C.); Unit of Radiology, Ente Ospedaliero Ospedali Galliera, Genoa, Italy (E.F.M.); and Department of Biomedical Sciences for Health, Università degli Studi di Milano, Via Mangiagalli 31, 20133 Milan, Italy (R.M.T., A.C., F.S.)
| | - Francesco Sardanelli
- From the Unit of Radiology, IRCCS Policlinico San Donato, San Donato Milanese, Italy (S.S., L.A.C., G.D.L., F.S.); Unit of Radiology, IRCCS Policlinico San Martino, Genoa, Italy (M.C.); Unit of Radiology, Ente Ospedaliero Ospedali Galliera, Genoa, Italy (E.F.M.); and Department of Biomedical Sciences for Health, Università degli Studi di Milano, Via Mangiagalli 31, 20133 Milan, Italy (R.M.T., A.C., F.S.)
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Harrington L, diFlorio-Alexander R, Trinh K, MacKenzie T, Suriawinata A, Hassanpour S. Prediction of Atypical Ductal Hyperplasia Upgrades Through a Machine Learning Approach to Reduce Unnecessary Surgical Excisions. JCO Clin Cancer Inform 2019; 2:1-11. [PMID: 30652620 PMCID: PMC6874044 DOI: 10.1200/cci.18.00083] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Surgical excision is currently recommended for all occurrences of atypical ductal hyperplasia (ADH) found on core needle biopsies for malignancy diagnoses and treatment of lesions. The excision of all ADH lesions may lead to overtreatment, which results in invasive surgeries for benign lesions in many women. A machine learning method to predict ADH upgrade may help clinicians and patients decide whether combined active surveillance and hormonal therapy is a reasonable alternative to surgical excision. METHODS The following six machine learning models were developed to predict ADH upgrade from core needle biopsy: gradient-boosting trees, random forest, radial support vector machine (SVM), weighted K-nearest neighbors (KNN), logistic elastic net, and logistic regression. The study cohort consisted of 128 lesions from 124 women at a tertiary academic care center in New Hampshire who had ADH on core needle biopsy and who underwent an associated surgical excision from 2011 to 2017. RESULTS The best-performing models were gradient-boosting trees (area under the curve [AUC], 68%; accuracy, 78%) and random forest (AUC, 67%; accuracy, 77%). The top five most important features that determined ADH upgrade were age at biopsy, lesion size, number of biopsies, needle gauge, and personal and family history of breast cancer. Using the random forest model, 98% of all malignancies would have been diagnosed through surgical biopsies, whereas 16% of unnecessary surgeries on benign lesions could have been avoided (ie, 87% sensitivity at 45% specificity). CONCLUSION These results add to the growing body of support for machine learning models as useful aids for clinicians and patients in decisions about the clinical management of ADH.
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Affiliation(s)
- Lia Harrington
- Lia Harrington, Todd MacKenzie, and Saeed Hassanpour, Geisel School of Medicine at Dartmouth College, Hanover; Roberta diFlorio-Alexander, Katherine Trinh, and Arief Suriawinata, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Roberta diFlorio-Alexander
- Lia Harrington, Todd MacKenzie, and Saeed Hassanpour, Geisel School of Medicine at Dartmouth College, Hanover; Roberta diFlorio-Alexander, Katherine Trinh, and Arief Suriawinata, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Katherine Trinh
- Lia Harrington, Todd MacKenzie, and Saeed Hassanpour, Geisel School of Medicine at Dartmouth College, Hanover; Roberta diFlorio-Alexander, Katherine Trinh, and Arief Suriawinata, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Todd MacKenzie
- Lia Harrington, Todd MacKenzie, and Saeed Hassanpour, Geisel School of Medicine at Dartmouth College, Hanover; Roberta diFlorio-Alexander, Katherine Trinh, and Arief Suriawinata, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Arief Suriawinata
- Lia Harrington, Todd MacKenzie, and Saeed Hassanpour, Geisel School of Medicine at Dartmouth College, Hanover; Roberta diFlorio-Alexander, Katherine Trinh, and Arief Suriawinata, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Saeed Hassanpour
- Lia Harrington, Todd MacKenzie, and Saeed Hassanpour, Geisel School of Medicine at Dartmouth College, Hanover; Roberta diFlorio-Alexander, Katherine Trinh, and Arief Suriawinata, Dartmouth-Hitchcock Medical Center, Lebanon, NH
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17
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Beaulieu-Jones BR, Ring N, Frazee TE, DiFlorio-Alexander RM, Rosenkranz KM. Screening vs staging magnetic resonance imaging-guided core needle breast biopsies: Does MRI indication impact upgrade rate? Breast J 2019; 26:216-219. [PMID: 31495016 DOI: 10.1111/tbj.13530] [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: 01/21/2019] [Revised: 07/10/2019] [Accepted: 07/12/2019] [Indexed: 11/29/2022]
Abstract
Adjunct magnetic resonance imaging (MRI) for both screening high-risk patients and staging for patients with newly diagnosed breast cancer leads to an increased number of biopsies and increased detection of atypical lesions. We assessed whether the malignancy upgrade frequency for high-risk atypia identified via MRI-guided biopsies varied based on indication: high-risk screening vs staging for malignancy. Among 399 MRI-guided biopsies, 46 (11.5%) high-risk lesions (ADH, ALH, and LCIS) were identified. Surgical excision was performed on 37% of 46%, and 24.3% were upgraded to invasive malignancy or DCIS. Of lesions identified by staging MRI, a slightly higher percentage, 28.5%, were upgraded (P = .36). Our data suggest that surgeons should carefully consider excisional biopsy for atypia identified on MRI regardless of indication.
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Affiliation(s)
- Brendin R Beaulieu-Jones
- Department of Surgery, Boston University, Boston, Massachusetts.,Geisel School of Medicine at Dartmouth, Hanover, New Hampshire.,Department of Surgery, Dartmouth-Hitchcock, Lebanon, New Hampshire
| | - Natalie Ring
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire.,Department of Radiology, Dartmouth-Hitchcock, Lebanon, New Hampshire
| | - Tracy E Frazee
- Department of Radiology, Dartmouth-Hitchcock, Lebanon, New Hampshire
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18
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Salagean ED, Slodkowska E, Nofech‐Mozes S, Hanna W, Parra‐Herran C, Lu F. Atypical ductal hyperplasia on core needle biopsy: Development of a predictive model stratifying carcinoma upgrade risk on excision. Breast J 2019; 25:56-61. [DOI: 10.1111/tbj.13155] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Revised: 05/02/2018] [Accepted: 05/07/2018] [Indexed: 11/27/2022]
Affiliation(s)
- Elena Diana Salagean
- Department of Laboratory Medicine and Pathobiology University of Toronto Toronto Canada
| | - Elzbieta Slodkowska
- Department of Laboratory Medicine and Pathobiology University of Toronto Toronto Canada
- Division of Anatomic PathologySunnybrook Health Science Centre Toronto Canada
| | - Sharon Nofech‐Mozes
- Department of Laboratory Medicine and Pathobiology University of Toronto Toronto Canada
- Division of Anatomic PathologySunnybrook Health Science Centre Toronto Canada
| | - Wedad Hanna
- Department of Laboratory Medicine and Pathobiology University of Toronto Toronto Canada
- Division of Anatomic PathologySunnybrook Health Science Centre Toronto Canada
| | - Carlos Parra‐Herran
- Department of Laboratory Medicine and Pathobiology University of Toronto Toronto Canada
- Division of Anatomic PathologySunnybrook Health Science Centre Toronto Canada
| | - Fang‐I Lu
- Department of Laboratory Medicine and Pathobiology University of Toronto Toronto Canada
- Division of Anatomic PathologySunnybrook Health Science Centre Toronto Canada
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19
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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: 146] [Impact Index Per Article: 24.3] [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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East EG, Carter CS, Kleer CG. Atypical Ductal Lesions of the Breast: Criteria, Significance, and Laboratory Updates. Arch Pathol Lab Med 2018; 142:1182-1185. [DOI: 10.5858/arpa.2018-0221-ra] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Context.—
Atypical ductal hyperplasia (ADH) is a challenging diagnosis defined by cytologic and architectural features that carries an increased risk of subsequent carcinoma when diagnosed in isolation. In addition, ADH may secondarily involve benign breast lesions, wherein it carries variable clinical significance.
Objectives.—
To review the diagnostic criteria and clinical significance of ADH in isolation and as it involves benign breast lesions, and to review the evolving literature on its molecular signature.
Data Sources.—
Recently published studies that collectively examine ADH were reviewed.
Conclusions.—
Atypical ductal hyperplasia carries an increased risk of subsequent carcinoma in isolation and when it involves most benign breast lesions. Identifying which cases of ADH will be upgraded to carcinoma has been challenging, and new laboratory developments, such as EZH2 overexpression, may have a future role.
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Affiliation(s)
- Ellen G. East
- From the Department of Pathology, Michigan Medicine, University of Michigan Rogel Cancer Center, Ann Arbor
| | - Cody S. Carter
- From the Department of Pathology, Michigan Medicine, University of Michigan Rogel Cancer Center, Ann Arbor
| | - Celina G. Kleer
- From the Department of Pathology, Michigan Medicine, University of Michigan Rogel Cancer Center, Ann Arbor
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21
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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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22
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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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Co M, Kwong A, Shek T. Factors affecting the under-diagnosis of atypical ductal hyperplasia diagnosed by core needle biopsies – A 10-year retrospective study and review of the literature. Int J Surg 2018; 49:27-31. [DOI: 10.1016/j.ijsu.2017.11.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Revised: 11/03/2017] [Accepted: 11/07/2017] [Indexed: 11/25/2022]
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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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Lobular neoplasia detected in MRI-guided core biopsy carries a high risk for upgrade: a study of 63 cases from four different institutions. Mod Pathol 2016; 29:25-33. [PMID: 26564004 PMCID: PMC5491967 DOI: 10.1038/modpathol.2015.128] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Revised: 10/13/2015] [Accepted: 10/15/2015] [Indexed: 11/09/2022]
Abstract
There are certain criteria to recommend surgical excision for lobular neoplasia diagnosed in mammographically detected core biopsy. The aims of this study are to explore the rate of upgrade of lobular neoplasia detected in magnetic resonance imaging (MRI)-guided biopsy and to investigate the clinicopathological and radiological features that could predict upgrade. We reviewed 1655 MRI-guided core biopsies yielding 63 (4%) cases of lobular neoplasia. Key clinical features were recorded. MRI findings including mass vs non-mass enhancement and the reason for biopsy were also recorded. An upgrade was defined as the presence of invasive carcinoma or ductal carcinoma in situ in subsequent surgical excision. The overall rate of lobular neoplasia in MRI-guided core biopsy ranged from 2 to 7%, with an average of 4%. A total of 15 (24%) cases had an upgrade, including 5 cases of invasive carcinoma and 10 cases of ductal carcinoma in situ. Pure lobular neoplasia was identified in 34 cases, 11 (32%) of which had upgrade. In this group, an ipsilateral concurrent or past history of breast cancer was found to be associated with a higher risk of upgrade (6/11, 55%) than contralateral breast cancer (1 of 12, 8%; P=0.03). To our knowledge, this is the largest series of lobular neoplasia diagnosed in MRI-guided core biopsy. The incidence of lobular neoplasia is relatively low. Lobular neoplasia detected in MRI-guided biopsy carries a high risk for upgrade warranting surgical excision. However, more cases from different types of institutions are needed to verify our results.
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