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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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Bychkovsky B, Laws A, Katlin F, Hans M, Knust Graichen M, Pace LE, Scheib R, Garber JE, King TA. Initiation and tolerance of chemoprevention among women with high-risk breast lesions: the potential of low-dose tamoxifen. Breast Cancer Res Treat 2022. [PMID: 35378642 DOI: 10.1007/s10549-022-06577-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 03/17/2022] [Indexed: 11/05/2022]
Abstract
Purpose High-risk lesions (HRLs) of the breast are an indication for chemoprevention, yet uptake is low, largely due to concerns about side effects. In 2019, low-dose (5 mg) tamoxifen was demonstrated to reduce breast cancer risk with improved tolerance. We describe chemoprevention uptake in an academic clinic before and after the introduction of low-dose tamoxifen. Methods Females age ≥ 35 with HRLs who established care from April 2017 through January 2020 and eligible for chemoprevention were included. Rates of chemoprevention initiation before and after the introduction of low-dose tamoxifen (pre-2019 vs. post-2019) were compared with chi-squared tests. Logistic regression identified demographic and clinical factors associated with chemoprevention initiation. Kaplan–Meier methods determined the rates of discontinuation. Results Among 660 eligible females with HRLs, 22.7% initiated chemoprevention. Median time from first visit to chemoprevention initiation was 54 days (interquartile range (IQR): 0–209); 31.0% (46/150) started chemoprevention > 6 months after their initial visit. Chemoprevention uptake was not significantly different pre-2019 vs. post-2019 (21.2% vs. 26.3%, p = 0.16); however, post-2019, low-dose tamoxifen became the most popular option (41.5%, 34/82). On multivariable analyses, age and breast cancer family history were significantly associated with chemoprevention initiation. Discontinuation rates at 1 year were lowest for low-dose tamoxifen (6.7%) vs. tamoxifen 20 mg (15.0%), raloxifene (20.4%), or an aromatase inhibitor (20.0%). Conclusion In this modern cohort, 22.7% of females with HRLs initiated chemoprevention with 31.0% initiating chemoprevention > 6 months after their first visit. Low-dose tamoxifen is now the most popular choice for chemoprevention, with low discontinuation rates at 1 year. Supplementary Information The online version contains supplementary material available at 10.1007/s10549-022-06577-5.
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Lucioni M, Rossi C, Lomoro P, Ballati F, Fanizza M, Ferrari A, Garcia-Etienne CA, Boveri E, Meloni G, Sommaruga MG, Ferraris E, Lasagna A, Bonzano E, Paulli M, Sgarella A, Di Giulio G. Positive predictive value for malignancy of uncertain malignant potential (B3) breast lesions diagnosed on vacuum-assisted biopsy (VAB): is surgical excision still recommended? Eur Radiol 2020; 31:920-927. [PMID: 32816199 DOI: 10.1007/s00330-020-07161-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 06/20/2020] [Accepted: 08/06/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE Breast lesions classified as of "uncertain malignant potential" represent a heterogeneous group of abnormalities with an increased risk of associated malignancy. Clinical management of B3 lesions diagnosed on vacuum-assisted breast biopsy (VABB) is still challenging: surgical excision is no longer the only available treatment and VABB may be sufficient for therapeutic excision. The aim of the present study is to evaluate the positive predictive value (PPV) for malignancy in B3 lesions that underwent surgical excision, identifying possible upgrading predictive factors and characterizing the malignant lesions eventually diagnosed. These results are compared with a subset of patients with B3 lesions who underwent follow-up. METHODS A total of 1250 VABBs were performed between January 2006 and December 2017 at our center. In total, 150 B3 cases were diagnosed and 68 of them underwent surgical excision. VABB findings were correlated with excision histology. A PPV for malignancy for each B3 subtype was derived. RESULTS The overall PPV rate was 28%, with the highest upgrade rate for atypical ductal hyperplasia (41%), followed by classical lobular neoplasia (29%) and flat epithelial atypia (11%). Only two cases of carcinoma were detected in the follow-up cohort, both associated with atypical ductal hyperplasia at VABB. CONCLUSION Open surgery is recommended in case of atypical ductal hyperplasia while, for other B3 lesions, excision with VABB only may be an acceptable alternative if radio-pathological correlation is assessed, if all microcalcifications have been removed by VABB, and if the lesion lacks high-risk cytological features. KEY POINTS • Surgical treatment is strongly recommended in case of ADH, while the upgrade rate in case of pure FEA, especially following complete microcalcification removal by VABB, may be sufficiently low to advice surveillance as a management strategy. • The use of 11-G- or 8-G-needle VABB, resulting in possible complete diagnostic excision of the lesion, can be an acceptable alternative in case of RS, considering open surgery only for selected high-risk patients. • LN management is more controversial: surgical excision may be recommended following classical LN diagnosis on breast biopsy if an additional B3 lesion is concurrently detected while in the presence of isolated LN with adequate radiological-pathological correlation follow-up alone could be an acceptable option.
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Affiliation(s)
- Marco Lucioni
- Anatomic Pathology Section, Department of Human Pathology, University of Pavia, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Chiara Rossi
- Anatomic Pathology Section, Department of Human Pathology, University of Pavia, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Pascal Lomoro
- Breast Imaging Department, Valduce Hospital, Via Dante Alighieri 11, 22100, Como, Italy.
| | - Francesco Ballati
- Breast Imaging Department, University of Pavia, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Marianna Fanizza
- Breast Imaging Department, University of Pavia, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Alberta Ferrari
- Breast Surgery Department, Fondazione IRCCS Policlinico San Matteo, Università degli Studi di Pavia, Pavia, Italy
| | - Carlos A Garcia-Etienne
- Breast Surgery Department, Fondazione IRCCS Policlinico San Matteo, Università degli Studi di Pavia, Pavia, Italy
| | - Emanuela Boveri
- Anatomic Pathology Section, Department of Human Pathology, University of Pavia, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Giulia Meloni
- Breast Imaging Department, University of Pavia, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Maria Grazia Sommaruga
- Breast Imaging Department, University of Pavia, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Elisa Ferraris
- Medical Oncology, Fondazione IRCCS Policlinico San Matteo and, Università degli Studi, Pavia, Italy
| | - Angioletta Lasagna
- Medical Oncology, Fondazione IRCCS Policlinico San Matteo and, Università degli Studi, Pavia, Italy
| | - Elisabetta Bonzano
- University of Pavia and Department of Radiation Oncology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Marco Paulli
- Anatomic Pathology Section, Department of Human Pathology, University of Pavia, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Adele Sgarella
- Breast Surgery Department, Fondazione IRCCS Policlinico San Matteo, Università degli Studi di Pavia, Pavia, Italy
| | - Giuseppe Di Giulio
- Breast Imaging Department, University of Pavia, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
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Abstract
PURPOSE OF REVIEW The aim of this review is to summarize recently published literature addressing atypical ductal hyperplasia (ADH), lobular neoplasia (atypical lobular hyperplasia [ALH] and classic lobular carcinoma in situ [C-LCIS]), non-classic lobular carcinoma in situ (NC-LCIS), papillary lesions, and flat epithelial atypia (FEA). RECENT FINDINGS While ADH, ALN, and C-LCIS are well-established markers of an increased risk of future breast cancers, the risk implications are less clear for papillary lesions and FEA. NC-LCIS is the least well-characterized lesion, with scant published literature on its natural history and surgical management when encountered on needle biopsy. Recent data suggest that lobular neoplasia on core biopsy of a BI-RADS ≤ 4 concordant lesion does not require an excision, while ADH, atypical papillomas, and NC-LCIS should be excised. Evidence on FEA and papillomas without atypia suggests a low risk of upgrade on excision, and prospective studies on the upgrade of these lesions are ongoing.
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Affiliation(s)
- Faina Nakhlis
- Department of Surgery, Brigham and Women's Hospital, 75 Francis St., Boston, MA, 02115, USA. .,Surgical Oncology, Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, 450 Brookline Ave., Boston, MA, 02115, USA.
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