External Validation of a Risk Stratification Score for B3 Breast Lesions Detected at Ultrasound Core Needle Biopsy

High-risk breast lesions: role of multi-parametric DCE-MRI in detection and histopathological upgrade prediction

Background

High-risk breast lesions represent 3–21% of all breast lesions and are non-obligate precursors of malignancy. Various studies have evaluated the value of DCE-MRI including DWI and ADC mapping in the detection of high-risk breast lesions, differentiating them from malignant lesions and predicting upgrade risk after surgical excision reducing misdiagnosis and overtreatment. This study is a retrospective review of all image-guided breast biopsy procedures performed in 2021 at our institution, identified 68 patients with histopathologically proven high-risk breast and available MRI examinations with no concurrent ipsilateral malignancy. Image analysis of MRI examinations included morphological criteria, enhancement pattern, dynamic curves, DWI and ADC mapping assessment. Since our knowledge of high-risk breast lesions is still growing, this study is important to evaluate the merits of DCE-MRI in the assessment of high-risk breast lesions, to allow optimization of treatment, better limit it to those women at risk, and avoid overtreatment in women at low risk.

Results

The mean ADC value of high-risk breast lesions was not significantly different from that of malignant breast lesions (p value = 0.015). Non-mass enhancement and type III enhancing curve proved to be significant indicators of high-risk breast lesions upgrade in surgical pathology. Cut-off average ADC value for differentiating upgraded high-risk lesions from non-upgraded high-risk lesions proved 1.24 mm2/sec with sensitivity and specificity of 94 & 100%, respectively.

Discussion

Management of high-risk breast lesions is important in the screening setting, as they are non-obligate precursors of malignancy, and also function as risk indicators. Frequency and upgrade rates of high-risk lesions detected by MRI provide a reference for clinical management. DCE-MRI has a high negative predictive value in predicting the upgrade risk of high-risk lesions. In this study, non-mass enhancement and type III curve were proven to be indicators of high-risk lesion upgrade. Limitations of the study included small number of patients and limited follow-up period.

Conclusions

The use of multi-parametric DCE-MRI including DWI and ADC mapping provides complementary information to detect high-risk breast lesions and predict their upgrade rate.

Breast lesions excised via vacuum-assisted system: could we get any clues for B3 lesions before excision biopsy?

Background

The purpose of this study was to determine the validity of the ultrasound features as well as patient characteristics assigned to B3 (uncertain malignant potential) breast lesions before vacuum-assisted excision biopsy (VAEB).

Methods

This study population consisted of 2245 women with breast-nodular abnormalities, which were conducted ultrasound-guided VAEB (US-VAEB). Patient’s clinical and anamnestic data and lesion-related ultrasonic feature variables of B3 captured before US-VAEB were compared with those of benign or malignant cases, using histopathological results as a benchmark.

Results

The proportions of benign, B3 and malignant breast lesions diagnosed post-US-VAEB were 88.5, 8.2 and 3.4% respectively. B3 high frequent occurred in BI-RADS-US grade 3 (7.7%), grade 4a (11.0%) and grade 4b (9.1%). The overall malignancy underestimation rate of B3 was 4.4% (8/183). Malignant lesions were found mostly in the range of BI-RADS grade 4b (27.3%), grade 4c (33.3%) and grade 5 (100%). Multivariate binary logistic regression analyses (B3 vs benign) showed that non-menopausal patients (95% CI 1.628–8.616, P = 0.002), single (95% CI 1.370–2.650, P = 0.000) or vascularity (95% CI 1.745–4.150, P = 0.000) nodules in ultrasonic features were significant risk factors for B3 occurrences. In addition, patients elder than 50 years (95% CI 3.178–19.816, P = 0.000), unclear margin (95% CI 3.571–14.119, P = 0.000) or suspicious calcification (95% CI 4.010–30.733, P = 0.000) lesions were significantly associated with higher risks of malignant potentials for B3 cases (malignant vs B3).

Conclusion

The results of this study indicate that ultrasound findings and patients’ characteristics might provide valuable information for distinguishing B3 lesions from benign breast abnormalities before VAEB, and help to reduce malignancy underestimation of B3.

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).

Radial Scar: a management dilemma

Radial scar (RS) or complex sclerosing lesions (CSL) if > 10 mm is a benign lesion with an increasing incidence of diagnosis (ranging from 0.6 to 3.7%) and represents a challenge both for radiologists and for pathologists. The digital mammography and digital breast tomosynthesis appearances of RS are well documented, according to the literature. On ultrasound, variable aspects can be detected. Magnetic resonance imaging contribution to differential diagnosis with carcinoma is growing. As for the management, a vacuum-assisted biopsy (VAB) with large core is recommended after a percutaneous diagnosis of RS due to potential sampling error. According to the recent International Consensus Conference, a RS/CSL lesion, which is visible on imaging, should undergo therapeutic excision with VAB. Thereafter, surveillance is justified. The aim of this review is to provide a practical guide for the recognition of RS on imaging, illustrating radiological findings according to the most recent literature, and to delineate the management strategies that follow.