Atypical Ductal Hyperplasia and Lobular Neoplasia: Update and Easing of Guidelines

Atypical ductal hyperplasia diagnosed by US-guided core needle biopsy: clinical, pathological and US features associated with upgrading to malignancy

BACKGROUND

To develop a predictive model to identify atypical ductal hyperplasia (ADH) that was underestimated by US-guided core needle biopsy (CNB) and to evaluate the risk factors for underestimation for ADH with intraductal papilloma diagnosed by CNB.

METHODS

In this retrospective study, 300 CNB-diagnosed ADH lesions in 291 consecutive women between January 2014 and July 2023 were included and divided into training set (n = 181), internal validation set (n = 54), and external validation set (n = 65). The review included clinical, pathological, and US features, as well as final outcomes. Multivariate logistic regression was employed to establish predictive model and to evaluate risk factors. Model performance was evaluated using area under the receiver operating characteristic curve (AUC), calibration curve, decision curve analysis, and utility (patient stratification into low and high-risk groups). Model was validated both internally and externally by calculating its performance on validation sets.

RESULTS

The upgrade rate to malignancy was 51.0%. Predictors included in the model were age, the pathological pattern of ADH with intraductal papilloma or ADH alone, Ki-67 positivity, and imaging-pathological discordance. The AUC was 0.915 (95% CI: 0.858, 0.955) in the training set, 0.906 (95% CI: 0.785, 0.972) in the internal validation set, and 0.934 (95% CI: 0.836, 0.983) in the external validation set. Using a cutoff value of 0.11, 38.3% of nonmalignant lesions in the training set were stratified into low-risk group with an upgrade rate of 4.1%. Similar results were obtained in the validation sets. For ADH with intraductal papilloma, age and imaging-pathological discordance were the independent risk factors for malignancy upgrading.

CONCLUSIONS

The model established to predict ADH upgrading can help in individualized risk management. If predictors of non-upgraded ADH lesions can be confirmed with larger studies, more than one-third of non-malignant lesions are expected to be candidates for non-excision.

TRIAL REGISTRATION

This is a retrospective study.

Navigating the Uncertainty of B3 Breast Lesions: Diagnostic Challenges and Evolving Management Strategies

B3 breast lesions, classified as lesions of uncertain malignant potential, present a significant diagnostic and therapeutic challenge due to their heterogeneous nature and variable risk of progression to malignancy. These lesions, which include atypical ductal hyperplasia (ADH), papillary lesions (PLs), flat epithelial atypia (FEA), radial scars (RSs), lobular neoplasia (LN), and phyllodes tumors (PTs), occupy a "grey zone" between benign and malignant pathologies, making their management complex and often controversial. This article explores the diagnostic difficulties associated with B3 lesions, focusing on the limitations of current imaging techniques, including mammography, ultrasound, and magnetic resonance imaging (MRI), as well as the challenges in histopathological interpretation. Core needle biopsy (CNB) and vacuum-assisted biopsy (VAB) are widely used for diagnosis, but both methods have inherent limitations, including sampling errors and the inability to determine malignancy in some cases definitively. The therapeutic approach to B3 lesions is nuanced, with treatment decisions strongly influenced by factors such as the lesion size, radiological findings, histopathological characteristics, and patient factors. While some lesions can be safely monitored with watchful waiting, others may require vacuum-assisted excision (VAE) or surgical excision to rule out malignancy. The decision-making process is further complicated by the discordance between the BI-RADS score and biopsy results, as well as the presence of additional risk factors, such as microcalcifications. This review provides an in-depth analysis of the current diagnostic challenges and treatment strategies for B3 lesions, emphasizing the importance of a multidisciplinary approach to management. By synthesizing the most recent research, this article aims to provide clinicians with a clearer understanding of the complexities involved in diagnosing and treating B3 breast lesions while highlighting areas for future research, such as artificial intelligence and genomics, to improve the diagnostic accuracy and patient outcomes.

Immediate and delayed risk of breast cancer associated with classic lobular carcinoma in situ and its variants

OBJECTIVE

To determine the risk of breast cancer due to lobular carcinoma in situ (LCIS).

METHODS

This retrospective IRB-approved study identified cases of LCIS after percutaneous breast biopsy from 7/2005 to 7/2022. Excluded were cases with less than 2 years of imaging surveillance or a concurrent ipsilateral breast cancer diagnosis within 6 months of the LCIS diagnosis. Final outcomes of cancer versus no cancer were determined by pathology at surgical excision or the absence of cancer on imaging surveillance.

RESULTS

A total of 116 LCIS lesions were identified. The primary imaging findings targeted for percutaneous biopsy included calcifications (50.0%, 58/116), MR enhancing lesions (25.0%, 29/116), noncalcified mammographic architectural distortions (10.3%, 12/116), or masses (14.7%, 17/116). Surgical excision was performed in 49.1% (57/116) and imaging surveillance was performed in 50.9% (59/116) of LCIS cases. There were 22 cancers of which 11 cancers were discovered at immediate excision [19.3% (11/57) immediate upgrade] and 11 cancers developed later while on imaging surveillance [18.6% (11/59) delayed risk for cancer]. Among all 22 cancers, 63.6% (14/22) occurred at the site of LCIS (11 at immediate excision and 3 at surveillance) and 36.4% (8/22) occurred at a location away from the site of LCIS (6 in a different quadrant and 2 in the contralateral breast).

CONCLUSION

LCIS has both an immediate risk (19.3%) and a delayed risk (18.6%) for cancer with 90.9% occurring in the ipsilateral breast (63.6% at and 27.3% away from the site of LCIS) and 9.1% occurring in the contralateral breast.

Atypia Involving Fibroadenomas: Outcomes and Upgrade Rates

OBJECTIVE

Fibroadenomas (FAs) involved by atypia are rare. Consensus guidelines for management of FAs involved by atypia when diagnosed on image-guided biopsy do not exist because of limited data reporting surgical upgrade rates to ductal carcinoma in situ (DCIS) or invasive malignancy. Therefore, these lesions commonly undergo surgical excision.

METHODS

This single-institution retrospective study identified cases of FAs involved by atypical ductal hyperplasia (ADH), atypical lobular hyperplasia (ALH), and/or lobular carcinoma in situ (LCIS) diagnosed on image-guided biopsy between January 2014 and April 2023 to determine upgrade rates. Cases with incidental atypia adjacent to but not involving FAs were excluded.

RESULTS

Among 1736 FAs diagnosed on image-guided biopsy, 32 cases (1.8%) were FAs involved by atypia including 43.8% (14/32) ALH, 28.1% (9/32) ADH, 18.8% (6/32) LCIS, 6.3% (2/32) LCIS + ALH, and 3.1% (1/32) unspecified atypia. The most common imaging finding was a mass. Most cases, 81.3% (26/32), underwent subsequent surgical excisional biopsy. A single case of ADH involving and adjacent to an FA was upgraded to FA involved by low-grade DCIS on excision for an overall surgical upgrade rate of 3.8%. There were no cases upgraded to invasive malignancy. For those omitting surgical excision, there was no subsequent malignancy diagnosis at the FA biopsy site over a mean follow-up of 73 months.

CONCLUSION

Cases of radiologic-pathologic concordant FAs involved by atypia have a low upgrade rate of 3.8% and should undergo multidisciplinary review. Larger multi-institutional analysis is needed to determine whether guidelines for excision of atypia should apply to atypia involving FAs.

Lobular Neoplasia Diagnosed by MRI-Guided Breast Biopsy: Identifying Upgrade Rate to Malignancy and Outcomes of Clinical and Surgical Management

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.

Atypical Ductal Hyperplasia and Lobular In Situ Neoplasm: High-Risk Lesions Challenging Breast Cancer Prevention

This retrospective study investigates the histopathological outcomes, upgrade rates, and disease-free survival (DFS) of high-risk breast lesions, including atypical ductal hyperplasia (ADH or DIN1b) and lobular in situ neoplasms (LIN), following Vacuum-Assisted Breast Biopsy (VABB) and surgical excision. The study addresses the challenge posed by these lesions due to their association with synchronous or adjacent Breast Cancer (BC) and increased future BC risk. The research, comprising 320 patients who underwent stereotactic VABB, focuses on 246 individuals with a diagnosis of ADH (120) or LIN (126) observed at follow-up. Pathological assessments, categorized by the UK B-coding system, were conducted, and biopsy samples were compared with corresponding excision specimens to determine upgrade rates for in situ or invasive carcinoma. Surgical excision was consistently performed for diagnosed ADH or LIN. Finally, patient follow-ups were assessed and compared between LIN and ADH groups to identify recurrence signs, defined as histologically confirmed breast lesions on either the same or opposite side. The results reveal that 176 (71.5%) patients showed no upgrade post-surgery, with ADH exhibiting a higher upgrade rate to in situ pathology than LIN1 (Atypical Lobular Hyperplasia, ALH)/LIN2 (Low-Grade Lobular in situ Carcinoma, LCIS) (38% vs. 20%, respectively, p-value = 0.002). Considering only patients without upgrade, DFS at 10 years was 77%, 64%, and 72% for ADH, LIN1, and LIN2 patients, respectively (p-value = 0.92). The study underscores the importance of a multidisciplinary approach, recognizing the evolving role of VABB. It emphasizes the need for careful follow-up, particularly for lobular lesions, offering valuable insights for clinicians navigating the complex landscape of high-risk breast lesions. The findings advocate for heightened awareness and vigilance in managing these lesions, contributing to the ongoing refinement of clinical strategies in BC care.

Contrast-enhanced ultrasound to predict malignant upgrading of atypical ductal hyperplasia

BACKGROUND

A malignancy might be found at surgery in cases of atypical ductal hyperplasia (ADH) diagnosed via US-guided core needle biopsy (CNB). The objective of this study was to investigate the diagnostic performance of contrast-enhanced ultrasound (CEUS) in predicting ADH diagnosed by US-guided CNB that was upgraded to malignancy after surgery.

METHODS

In this retrospective study, 110 CNB-diagnosed ADH lesions in 109 consecutive women who underwent US, CEUS, and surgery between June 2018 and June 2023 were included. CEUS was incorporated into US BI-RADS and yielded a CEUS-adjusted BI-RADS. The diagnostic performance of US BI-RADS and CEUS-adjusted BI-RADS for ADH were analyzed and compared.

RESULTS

The mean age of the 109 women was 49.7 years ± 11.6 (SD). The upgrade rate of ADH at CNB was 48.2% (53 of 110). The sensitivity, specificity, positive predictive value, and negative predictive value of CEUS for identification of malignant upgrading were 96.2%, 66.7%,72.9%, and 95.0%, respectively, based on BI-RADS category 4B threshold. The two false-negative cases were low-grade ductal carcinoma in situ. Compared with the US, CEUS-adjusted BI-RADS had better specificity for lesions smaller than 2 cm (76.7% vs. 96.7%, P = 0.031). After CEUS, 16 (10 malignant and 6 nonmalignant) of the 45 original US BI-RADS category 4A lesions were up-classified to BI-RADS 4B, and 3 (1 malignant and 2 nonmalignant) of the 41 original US BI-RADS category 4B lesions were down-classified to BI-RADS 4A.

CONCLUSIONS

CEUS is helpful in predicting malignant upgrading of ADH, especially for lesions smaller than 2 cm and those classified as BI-RADS 4A and 4B on ultrasound.

Management of screening-detected lobular neoplasia in the era of digital breast tomosynthesis: A preliminary study

PURPOSE

The purpose of this study is to determine upgrade rates of lobular neoplasia detected by screening digital breast tomosynthesis (DBT) and to determine imaging and clinicopathological features that may influence risk of upgrade.

METHODS

Medical records were reviewed of consecutive women who presented with screening DBT-detected atypical lobular hyperplasia (ALH) and/or lobular carcinoma in situ (LCIS) from January 1, 2013, to June 30, 2020. Included patients underwent needle biopsy and had surgery or at least two-year imaging follow-up. Imaging and clinicopathological features were compared between upgraded and nonupgraded cases of lobular neoplasia using the Pearson's chi-squared test and the Wilcoxon signed-rank test.

RESULTS

During the study period, 107 women (mean age 55 years, range 40-88 years) with 110 cases of ALH and/or LCIS underwent surgery (80.9%, n = 89) or at least two-year imaging follow-up (19.1%, n = 21). The overall upgrade rate to cancer was 5.5% (6/110), and the upgrade rate to invasive cancer was 3.6% (4/110). The upgrade rate of ALH to cancer was 4.1% (3/74), whereas the upgrade rate of LCIS to cancer was 9.4% (3/32) (p = .28). The upgrade rate of cases presenting as calcifications was 4.2% (3/71), whereas the upgrade rates of cases presenting as noncalcified findings was 7.7% (3/39) (p = .44).

CONCLUSIONS

The upgrade rate of screening DBT-detected lobular neoplasia is less than 6%. Surveillance rather than surgery can be considered for lobular neoplasia, particularly in patients with ALH and in those with screening-detected calcifications leading to the diagnosis.

Imaging Characteristics of and Multidisciplinary Management Considerations for Atypical Ductal Hyperplasia and Flat Epithelial Atypia: Review of Current Literature

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.

Estrogens and the risk of breast cancer: A narrative review of literature

In female mammals, the development and regulation of the reproductive system and non-reproductive system are significantly influenced by estrogens (oestrogens). In addition, lipid metabolism is another physiological role of estrogens. Estrogens act through different types of receptors to introduce signals to the target cell by affecting many estrogen response elements. Breast cancer is considered mostly a hormone-dependent disease. Approximately 70% of breast cancers express progesterone receptors and/or estrogen receptors, and they are a good marker for cancer prognosis. This review will discuss estrogen metabolism and the interaction of estrogen metabolites with breast cancer. The carcinogenic role of estrogen is discussed in light of both conventional and atypical cancers susceptible to hormones, such as prostate, endometrial, and lung cancer, as we examine how estrogen contributes to the formation and activation of breast cancer. In addition, this review will discuss other factors that can be associated with estrogen-driven breast cancer.

Third International Consensus Conference on lesions of uncertain malignant potential in the breast (B3 lesions)

The heterogeneous group of B3 lesions in the breast harbors lesions with different malignant potential and progression risk. As several studies about B3 lesions have been published since the last Consensus in 2018, the 3rd International Consensus Conference discussed the six most relevant B3 lesions (atypical ductal hyperplasia (ADH), flat epithelial atypia (FEA), classical lobular neoplasia (LN), radial scar (RS), papillary lesions (PL) without atypia, and phyllodes tumors (PT)) and made recommendations for diagnostic and therapeutic approaches. Following a presentation of current data of each B3 lesion, the international and interdisciplinary panel of 33 specialists and key opinion leaders voted on the recommendations for further management after core-needle biopsy (CNB) and vacuum-assisted biopsy (VAB). In case of B3 lesion diagnosis on CNB, OE was recommended in ADH and PT, whereas in the other B3 lesions, vacuum-assisted excision was considered an equivalent alternative to OE. In ADH, most panelists (76%) recommended an open excision (OE) after diagnosis on VAB, whereas observation after a complete VAB-removal on imaging was accepted by 34%. In LN, the majority of the panel (90%) preferred observation following complete VAB-removal. Results were similar in RS (82%), PL (100%), and FEA (100%). In benign PT, a slim majority (55%) also recommended an observation after a complete VAB-removal. VAB with subsequent active surveillance can replace an open surgical intervention for most B3 lesions (RS, FEA, PL, PT, and LN). Compared to previous recommendations, there is an increasing trend to a de-escalating strategy in classical LN. Due to the higher risk of upgrade into malignancy, OE remains the preferred approach after the diagnosis of ADH.

Prevalence, Impact, and Diagnostic Challenges of Benign Breast Disease: A Narrative Review

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.

Crossroads: the role of biomarkers in the management of lumps in the breast

Premalignant lesions in the breast pose a difficult decision-making problem, whether to treat proactively and accept the side effects or to engage in watchful waiting and possibly encounter a later diagnosis of invasive cancer. A biomarker or set of biomarkers to inform on the individual progression risk would be beneficial to the patient and cost-effective for the healthcare system. The gene products of tumor progression may be expressed in early non-cancerous ("premalignant") lesions, where they are associated with a high probability for full transformation in breast cancers. One such molecule is the OPN splice variant-c. OPN-c is also present in a fraction of the premalignant lesions, where it reflects an elevated risk for progression to cancer within 5 years, regardless of the lesion's subtype. This marker has the properties needed to facilitate decisions to treat at the premalignant stage.

Circulating microRNA Biomarker for Detecting Breast Cancer in High-Risk Benign Breast Tumors

High-risk benign breast tumors are known to develop breast cancer at high rates. However, it is still controversial whether they should be removed during diagnosis or followed up until cancer development becomes evident. Therefore, this study sought to identify circulating microRNAs (miRNAs) that could serve as detection markers of cancers arising from high-risk benign tumors. Small RNA-seq was performed using plasma samples collected from patients with early-stage breast cancer (CA) and high-risk (HB), moderate-risk (MB), and no-risk (Be) benign breast tumors. Proteomic profiling of CA and HB plasma was performed to investigate the underlying functions of the identified miRNAs. Our findings revealed that four miRNAs, hsa-mir-128-3p, hsa-mir-421, hsa-mir-130b-5p, and hsa-mir-28-5p, were differentially expressed in CA vs. HB and had diagnostic power to discriminate CA from HB with AUC scores greater than 0.7. Enriched pathways based on the target genes of these miRNAs indicated their association with IGF-1. Furthermore, the Ingenuity Pathway Analysis performed on the proteomic data revealed that the IGF-1 signaling pathway was significantly enriched in CA vs. HB. In conclusion, these findings suggest that these miRNAs could potentially serve as biomarkers for detecting early-stage breast cancer from high-risk benign tumors by monitoring IGF signaling-induced malignant transformation.

High-Risk Breast Lesions Diagnosed by Ultrasound-Guided Vacuum-Assisted Excision

PURPOSE

The aim of this study was to analyze the role of ultrasound-guided vacuum-assisted excision (US-guided VAE) in the treatment of high-risk breast lesions and to evaluate the clinical and US features of the patients associated with recurrence or development of malignancy.

MATERIALS AND METHODS

Between April 2010 and September 2021, 73 lesions of 73 patients underwent US-guided VAE and were diagnosed with high-risk breast lesions. The incidence of recurrence or development of malignancy for high-risk breast lesions was evaluated at follow-up period. The clinical and US features of the patients were analyzed to identify the factors affecting the recurrence or development of malignancy rate.

RESULTS

Only benign phyllodes tumors on US-guided VAE showed recurrences, while other high-risk breast lesions that were atypical ductal hyperplasia (ADH), lobular neoplasia (atypical lobular hyperplasia/lobular carcinoma in situ), radial scar, and flat epithelial atypia did not show recurrences or malignant transformation. The recurrence rate of the benign phyllodes tumor was 20.8% (5/24) in a mean follow-up period of 34.3 months. The recurrence rate of benign phyllodes tumor with distance from nipple of less than 1 cm was significantly higher than that of lesions with distance from nipple of more than 1 cm (75% vs. 10%, p < 0.05).

CONCLUSIONS

Benign phyllodes tumors without concurrent breast cancer could be safely followed up instead of surgical excision after US-guided VAE when the lesions were classified as BI-RADS 3 or 4A by US.

[B3 lesions of the breast: histological, clinical, and epidemiological aspects : Update]

B3 lesions of the breast are a heterogeneous group of lesions with uncertain malignant potential encompassing a broad spectrum of histologically distinct alterations that often pose challenging decisions if diagnosed on the preoperative core or vacuum biopsies. B3 lesions are mostly detected due to mammographic calcifications or mass lesions and, in most cases, encompass a spectrum of atypical lesions such as atypical ductal hyperplasia, classic lobular neoplasia, flat epithelial atypia, papillomas, fibroepithelial tumors, and rarely other lesions such as mucocele-like lesions, atypical apocrine lesions, and rare stromal proliferations. The use of immunohistochemical stains (estrogen receptors, basal cytokeratin, myoepithelial markers, and stromal marker panel) is useful in the differentiation of these lesions and allowing proper classification. Regarding clinical management of B3 lesions, the radiological-pathological correlation of the given entity plays the most important key element for the proper next diagnostic and therapeutic step.

High-risk and selected benign breast lesions diagnosed on core needle biopsy: Evidence for and against immediate surgical excision

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.

ACR Appropriateness Criteria® Imaging After Breast Surgery

Given that 20% to 40% of women who have percutaneous breast biopsy subsequently undergo breast surgery, knowledge of imaging women with a history of benign (including high-risk) disease or breast cancer is important. For women who had surgery for nonmalignant pathology, the surveillance recommendations are determined by their overall risk. Higher-than-average risk women with a history of benign surgery may require screening mammography starting at an earlier age before 40 and may benefit from screening MRI. For women with breast cancer who have undergone initial excision and have positive margins, imaging with diagnostic mammography or MRI can sometimes guide additional surgical planning. Women who have completed breast conservation therapy for cancer should get annual mammography and may benefit from the addition of MRI or ultrasound to their surveillance regimen. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Digital breast tomosynthesis-guided vacuum-assisted biopsy of suspicious calcifications at different sites within one breast: Is biopsy of more than one location needed?

OBJECTIVE

To investigate how often biopsy of two sites of morphologically similar or equally suspicious calcifications within the same breast yield differing histopathologic results, and how this may affect clinical management.

MATERIALS AND METHODS

We identified patients with two or more sites of calcifications categorized as Breast Imaging Reporting and Data System (BI-RADS) ≥ 4b within the same breast who underwent digital breast tomosynthesis-guided vacuum-assisted biopsy (DBT-guided VAB). We analyzed how often biopsy of two distinct sites yielded the same or differing histopathologic findings. The histopathologic findings were dichotomized into "actionable" and "non-actionable", depending on the respective further management. We then analyzed how often the consecutive management would have been the same or different.

RESULTS

Of 206 women undergoing DBT-guided VAB at our institution within 24 months, 21 consecutive patients (54 ± 10.2 years; range: 35-71) underwent DBT-guided VAB of two distinct sites of calcifications. Management of histologic findings was the same (both sites actionable or both sites non-actionable) in 12/21 (57 %), different in the remaining 9/21 patients (43 %). Of the nine patients whose differing histologic findings would have led to different clinical management, 4/9 had a high-risk lesion (atypical ductal hyperplasia n = 3, papilloma with epithelial atypia n = 1) vs benign changes (adenosis n = 4), 2/9 had high-grade DCIS vs benign changes (adenosis n = 1, fat necrosis n = 1), and 3/9 had invasive cancer (luminal A n = 2, luminal B n = 1) with high-grade DCIS vs pure high-grade DCIS.

CONCLUSIONS

Multiple sites of calcifications within the same breast, even when morphologically similar or equally suspicious, may represent different histopathologic findings with different clinical management implications. Accordingly, in the presence of suspicious calcifications at multiple distinct sites within the same breast, biopsy of more than one site of calcification should be considered.

Pathological outcome of sonographically occult architectural distortions (AD) visible only on digital breast tomosynthesis, and comparison with AD visible also on 2D mammography

PURPOSE

To evaluate the rates of malignant and of high-risk lesions among sonographically occult architectural distortions (AD) visible only on digital breast tomosynthesis (DBT) and compare them with AD visible on 2D mammography (2D) and DBT.

METHOD

The records of 1104 DBT-vacuum assisted biopsies (DBT-VAB) were retrospectively reviewed and 218 cases of AD were identified. Complete radiologic examinations and pathologic results were available for 113 sonographically occult AD (1 clinically-detected, 112 clinically-occult). 2D and DBT images were reviewed and AD were divided into a "DBT-detected" group (visible on only DBT) and a "2D-detected" group (visible both in 2D and DBT). The rates of malignant and of high-risk lesions in the "DBT-detected" AD group were calculated and compared to those of the "2D-detected" AD group.

RESULTS

Thirty-five (31%) of 113 AD were assessed as "DBT-detected", while 78 (69%) as "2D-detected". DBT-VAB results were benign lesions in 63 (56%) AD, high-risk lesions in 32 (28%) AD and malignant lesions in 18 (16%) AD. Four (12.5%) high-risk lesions were upgraded to malignancy at surgery. Based on final pathology, the malignancy rate was significantly higher in the "DBT-detected" group than the "2D-detected" group (34% [12/35 cases] vs 13% [10/78]; p < 0.05). The high-risk lesion rates were 32% (11/35 cases) in the "DBT-detected" group and 22% (17/78 cases) in the "2D-detected" group (p > 0.05).

CONCLUSIONS

AD visible on only DBT proved to be malignant in about one third of cases, which exceeded the malignancy rate of AD visible on also 2D. A similar proportion of DBT-only AD was represented by high-risk lesions.

Identifying women with increased risk of breast cancer and implementing risk-reducing strategies and supplemental imaging

Breast cancer (BC) is the second most common cancer in women, affecting 1 in 8 women in the United States (12.5%) in their lifetime. However, some women have a higher lifetime risk of BC because of genetic and lifestyle factors, mammographic breast density, and reproductive and hormonal factors. Because BC risk is variable, screening and prevention strategies should be individualized after considering patient-specific risk factors. Thus, health care professionals need to be able to assess risk profiles, identify high-risk women, and individualize screening and prevention strategies through a shared decision-making process. In this article, we review the risk factors for BC, risk-assessment models that identify high-risk patients, and preventive medications and lifestyle modifications that may decrease risk. We also discuss the benefits and limitations of various supplemental screening methods.

Tomosynthesis-Guided Vacuum-Assisted Breast Biopsy of Architectural Distortion Without a Sonographic Correlate: A Retrospective Review

BACKGROUND. Digital breast tomosynthesis-guided vacuum-assisted breast biopsy (DBT VAB) allows biopsy of findings seen better or exclusively on digital breast tomosynthesis (DBT), including architectural distortion. Although architectural distortion with an associated sonographic mass correlate has a high risk of malignancy, limited data describe the radiologic-pathologic correlation of tomosynthesis-detected architectural distortion without a sonographic correlate. OBJECTIVE. This study evaluates the malignancy rate of architectural distortions without a sonographic correlate that undergo DBT VAB and provides radiologic-pathologic correlation for benign, high-risk, and malignant entities that are associated with architectural distortion. METHODS. We retrospectively reviewed imaging, as well as pathology slides and/or reports, for DBT VABs performed for architectural distortion without a sonographic correlate at a single institution between June 1, 2017, and January 15, 2020. According to the correlative histopathology, cases were categorized as benign, high risk, or malignant, and specific histopathologic diagnoses were summarized. RESULTS. During the study period, 142 patients (mean age, 59 years) underwent DBT VAB for 151 unique architectural distortions without a sonographic correlate. DBT VAB revealed a malignant diagnosis in 27 (18%), a high-risk lesion in 50 (33%), and a benign diagnosis in 74 (49%). Two cases of atypical ductal hyperplasia were upgraded to malignancy, resulting in a final malignancy rate of 19% (n = 29/151). Most malignant lesions were invasive carcinomas (83%, n = 24/29); most invasive carcinomas were of lobular subtype (54%, n = 13/24). Most high-risk lesions were radial scars/complex sclerosing lesions (62%, n = 31/50). Most benign results represented fibrocystic change (66%, n = 49/74). A subset (11%, n = 8/74) of benign results were considered discordant and subsequently excised, with none representing malignancy. CONCLUSION. The final malignancy rate of 19% in architectural distortion without a sonographic correlate justifies a recommendation for biopsy using DBT VAB. CLINICAL IMPACT. Our results highlight the utility of DBT VAB in the era of DBT. The detailed radiologic-pathologic correlations will assist radiologists in assessing concordance when performing DBT VAB for architectural distortions and provide a reference for future patient management.

High-risk lesions of the breast: concurrent diagnostic tools and management recommendations

Breast lesions with uncertain malignant behavior, also known as high-risk or B3 lesions, are composed of a variety of pathologies with differing risks of associated malignancy. While open excision was previously preferred to manage all high-risk lesions, tailored management has been increasingly favored to reduce overtreatment and spare patients from unnecessary anxiety or high healthcare costs associated with surgical excision. The purpose of this work is to provide the reader with an accurate overview focused on the main high-risk lesions of the breast: atypical intraductal epithelial proliferation (atypical ductal hyperplasia), lobular neoplasia (including the subcategories lobular carcinoma in situ and atypical lobular hyperplasia), flat epithelial atypia, radial scar and papillary lesions, and phyllodes tumor. Beyond merely presenting the radiological aspects of these lesions and the recent literature, information about their potential upgrade rates is discussed in order to provide a useful guide for appropriate clinical management while avoiding the risks of unnecessary surgical intervention (overtreatment).

Managing patients with high-risk breast lesions, precursors on the breast neoplasia pathway

ABSTRACT

Breast cancer remains the most commonly diagnosed cancer among women. Imaging abnormalities may be noted on routine breast cancer screenings and require biopsy for further evaluation. Atypia and carcinoma in situ are nonmalignant lesions identified via breast biopsy and are associated with an increased risk of invasive carcinoma. Because of the lack of specialized breast cancer prevention and risk reduction programs, patients may not be able to access optimal management of the various subtypes of atypia and carcinoma in situ. By understanding the pathology of high-risk breast lesions and the resulting elevated cancer risk, healthcare providers, specifically primary care providers, can better counsel, manage, and treat patients to provide comprehensive quality care.

Lobular neoplasia detected at MRI-guided biopsy: imaging findings and outcomes

OBJECTIVE

To review MRI findings of pure lobular neoplasia (LN) on MRI guided biopsy, evaluate surgical and clinical outcomes, and assess imaging findings predictive of upgrade to malignancy.

METHODS

HIPAA compliant, IRB-approved retrospective review of our MRI-guided breast biopsy database from October 2008-January 2015. Biopsies yielding atypical lobular hyperplasia or lobular carcinoma in situ were included in the analysis; all biopsy slides were reviewed by a dedicated breast pathologist. Imaging indications, MRI findings, and histopathology were reviewed. Statistical analysis was performed using the two-tailed Fisher exact-test and the t-test, and 95% CIs were determined. A p < 0.05 was considered statistically significant.

RESULTS

Database search yielded 943 biopsies in 785 patients of which 65/943 (6.9%) reported LN as the highest risk pathologic lesion. Of 65 cases, 32 were found to have LN as the dominant finding on pathology and constituted the study population. All 32 findings were mammographically and sonographically occult. Three of 32 (9.3%) cases of lobular neoplasia were upgraded to malignancy, all LCIS (one pleomorphic and two classical). The most common MRI finding was focal, heterogenous non-mass enhancement with low T2 signal. No clinical features or imaging findings were predictive of upgrade to malignancy.

CONCLUSION

Incidence of pure lobular neoplasia on MRI guided biopsy is low, with comparatively low incidence of upgrade to malignancy. No imaging or clinical features are predictive of upgrade on surgical excision, therefore, prudent radiologic-pathologic correlation is necessary.