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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Greene AJE, Davis J, Moon J, Dubin I, Cruz A, Gupta M, Moazzez A, Ozao-Choy J, Gupta E, Manchandia T, Kalantari BN, Rahbar G, Dauphine C. Determination of Factors Associated with Upstage in Atypical Ductal Hyperplasia to Identify Low-Risk Patients Where Active Surveillance May be an Alternative. Ann Surg Oncol 2024; 31:3177-3185. [PMID: 38386195 PMCID: PMC10997526 DOI: 10.1245/s10434-024-15041-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 01/28/2024] [Indexed: 02/23/2024]
Abstract
BACKGROUND Excision is routinely recommended for atypical ductal hyperplasia (ADH) found on core biopsy given cancer upstage rates of near 20%. Identifying a cohort at low-risk for upstage may avoid low-value surgery. Objectives were to elucidate factors predictive of upstage in ADH, specifically near-complete core sampling, to potentially define a group at low upstage risk. PATIENTS AND METHODS This retrospective, cross-sectional, multi-institutional study from 2015 to 2019 of 221 ADH lesions in 216 patients who underwent excision or active observation (≥ 12 months imaging surveillance, mean follow-up 32.6 months) evaluated clinical, radiologic, pathologic, and procedural factors for association with upstage. Radiologists prospectively examined imaging for lesional size and sampling proportion. RESULTS Upstage occurred in 37 (16.7%) lesions, 25 (67.6%) to ductal carcinoma in situ (DCIS) and 12 (32.4%) to invasive cancer. Factors independently predictive of upstage were lesion size ≥ 10 mm (OR 5.47, 95% CI 2.03-14.77, p < 0.001), pathologic suspicion for DCIS (OR 12.29, 95% CI 3.24-46.56, p < 0.001), and calcification distribution pattern (OR 8.08, 95% CI 2.04-32.00, p = 0.003, "regional"; OR 19.28, 95% CI 3.47-106.97, p < 0.001, "linear"). Near-complete sampling was not correlated with upstage (p = 0.64). All three significant predictors were absent in 65 (29.4%) cases, with a 1.5% upstage rate. CONCLUSIONS The upstage rate among 221 ADH lesions was 16.7%, highest in lesions ≥ 10 mm, with pathologic suspicion of DCIS, and linear/regional calcifications on mammography. Conversely, 30% of the cohort exhibited all low-risk factors, with an upstage rate < 2%, suggesting that active surveillance may be permissible in lieu of surgery.
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Affiliation(s)
| | - Joshua Davis
- Department of Radiology, Harbor-UCLA Medical Center, Torrance, CA, USA
- Department of Breast Radiology, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, NY, USA
| | - Jessica Moon
- Department of Radiology, Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Iram Dubin
- Department of Radiology, Olive View Medical Center, Sylmar, CA, USA
- Department of Radiology, UCLA Medical Center, Los Angeles, CA, USA
| | - Anastasia Cruz
- Department of Radiology, USC+LAC Medical Center, Los Angeles, CA, USA
- Department of Radiology, Sharp Coronado Hospital and Healthcare Center, Coronado, CA, USA
| | - Megha Gupta
- Department of Radiology, USC+LAC Medical Center, Los Angeles, CA, USA
| | - Ashkan Moazzez
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Junko Ozao-Choy
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Esha Gupta
- Department of Radiology, High Desert Regional Health Center, Lancaster, CA, USA
| | - Tejas Manchandia
- Department of Radiology, UCLA Medical Center, Los Angeles, CA, USA
- Department of Radiology, USC+LAC Medical Center, Los Angeles, CA, USA
| | - Babak N Kalantari
- Department of Radiology, Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Guita Rahbar
- Department of Radiology, Olive View Medical Center, Sylmar, CA, USA
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Marin C, Weiss A, Gooch JC. Updates in the Surgical Management of Benign and High-Risk Breast Lesions. Clin Breast Cancer 2023:S1526-8209(23)00312-9. [PMID: 38171944 DOI: 10.1016/j.clbc.2023.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 12/18/2023] [Accepted: 12/19/2023] [Indexed: 01/05/2024]
Abstract
Benign breast disease (BBD) is a heterogenous group of lesions often classified as nonproliferative or proliferative, with the latter group further categorized based on the presence of atypia. Although nonproliferative lesions are more common, the risk of breast cancer is elevated in women with proliferative lesions. Historically, the majority of proliferative lesions were excised due to concern for future and/or concomitant breast cancer at the site of the index lesion. However, contemporary data suggest that the risk of cancer associated with various proliferative lesions may be lower than previously thought, and management of BBD has become more nuanced. In this review, we will focus on recent updates in the management of a select group of benign and high-risk lesions.
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Affiliation(s)
- Chelsea Marin
- Department of Surgery, Division of Surgical Oncology, University of Rochester Medical Center, Rochester, NY
| | - Anna Weiss
- Department of Surgery, Division of Surgical Oncology, University of Rochester Medical Center, Rochester, NY; Wilmot Cancer Center, University of Rochester Medical Center, Rochester, NY
| | - Jessica C Gooch
- Department of Surgery, Division of Surgical Oncology, University of Rochester Medical Center, Rochester, NY; Wilmot Cancer Center, University of Rochester Medical Center, Rochester, NY.
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Miceli R, Mercado CL, Hernandez O, Chhor C. Active Surveillance for Atypical Ductal Hyperplasia and Ductal Carcinoma In Situ. J 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] [What about the content of this article? (0)] [Affiliation(s)] [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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Han LK, Hussain A, Dodelzon K, Ginter PS, Towne WS, Marti JL. Active Surveillance of Atypical Ductal Hyperplasia of the Breast. Clin Breast Cancer 2023:S1526-8209(23)00130-1. [PMID: 37328333 DOI: 10.1016/j.clbc.2023.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 04/25/2023] [Accepted: 05/17/2023] [Indexed: 06/18/2023]
Abstract
BACKGROUND When needle core biopsy (NCB) of the breast yields atypical ductal hyperplasia (ADH), excision is typically recommended. The natural history of ADH undergoing active surveillance (AS) is not well described. We investigate the rates of upgrade to malignancy of excised ADH and the rates of radiographic progression under AS. MATERIALS AND METHODS We retrospectively reviewed records of 220 cases of ADH on NCB. Of patients who had surgery within 6 months of NCB, we examined the malignancy upgrade rate. In the AS cohort, we examined rates of radiographic progression on interval imaging. RESULTS The malignancy upgrade rate among patients who underwent immediate excision (n = 185) was 15.7%: 14.1% (n = 26) ductal carcinoma in situ (DCIS) and 1.6% (n = 3) invasive ductal carcinoma (IDC). Upgrade to malignancy was less common in lesions <4 mm in size (0%) or with focal ADH (5%), and more common among lesions presenting with a radiographic mass (26%). Among the 35 patients who underwent AS, median follow-up was 20 months. Two lesions progressed on imaging (incidence 3.8% at 2 years). One patient without radiographic progression was found to have IDC at delayed surgery. The remaining lesions remained stable (46%), decreased in size (11%), or resolved (37%). CONCLUSIONS Our findings suggest that AS is a safe approach to managing ADH on NCB for most patients. This could spare many patients with ADH from unnecessary surgery. Given that AS is being investigated for low-risk DCIS in multiple international prospective trials, these results suggest that AS should also be investigated for ADH.
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Affiliation(s)
- Lynn K Han
- Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY
| | - Anum Hussain
- Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY
| | - Katerina Dodelzon
- Department of Radiology, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY
| | - Paula S Ginter
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, NY
| | - William S Towne
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, NY
| | - Jennifer L Marti
- Division of Breast Surgery, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, New York, NY.
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Horvat JV. High-Risk Lesion Management. Semin Ultrasound CT MR 2023; 44:46-55. [PMID: 36792273 DOI: 10.1053/j.sult.2022.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
High-risk lesions or lesions of uncertain malignant potential are frequent findings on image-guided needle biopsy of the breast and comprise a number of distinct entities. These lesions are known for having risk of underlying malignancy and are usually associated with an increased lifetime risk for breast cancer. Surgical excision was traditionally recommended for all high-risk lesions but recent studies have demonstrated that vacuum-assisted excision or surveillance may be adequate for some lesions. While management of high-risk lesion varies among institutions, this chapter describes the management recommendations based on recent literature of the most frequent types of lesions.
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Affiliation(s)
- Joao V Horvat
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY.
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Marti JL. ASO Author Reflections: A Plea Against Blind Fear of Benign 'High-Risk' Lesions of the Breast: Five Recommendations to Minimize Unnecessary Treatment. Ann Surg Oncol 2021; 28:6041-6043. [PMID: 33876357 DOI: 10.1245/s10434-021-09978-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 03/25/2021] [Indexed: 11/18/2022]
Affiliation(s)
- Jennifer L Marti
- Divisions of Breast and Endocrine Surgery, Department of Surgery, Weill Cornell Medicine, Weill Cornell Breast Center, New York-Presbyterian Hospital, New York, NY, USA.
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Guo YN, Su M. ASO Author Reflections: Perineural Invasion in pN0M0 Esophageal Squamous Cell Carcinoma: Let Pathology Strengthen the Clinical Oncology Practice. Ann Surg Oncol 2020; 27:4382-4383. [PMID: 32632885 DOI: 10.1245/s10434-020-08698-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Indexed: 02/05/2023]
Affiliation(s)
- Yuan-Ning Guo
- Department of Pathology and Institute of Clinical Pathology, Shantou University Medical College, Shantou, China
| | - Min Su
- Department of Pathology and Institute of Clinical Pathology, Shantou University Medical College, Shantou, China.
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Kuerer HM, Blair SL. The Virtual Scientific Sessions from the American Society of Breast Surgeons During the COVID-19 Pandemic. Ann Surg Oncol 2020; 27:4585-4587. [PMID: 32812104 PMCID: PMC7433665 DOI: 10.1245/s10434-020-08946-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 07/13/2020] [Indexed: 12/13/2022]
Affiliation(s)
- Henry M Kuerer
- Division of Surgery, Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA. .,Department of General Surgery, University of California, San Diego, CA, USA.
| | - Sarah L Blair
- Division of Surgery, Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Department of General Surgery, University of California, San Diego, CA, USA
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