All atypia diagnosed at stereotactic vacuum-assisted breast biopsy do not need surgical excision

Abstract

The necessity of excision is debatable when atypia are diagnosed at stereotactic vacuum-assisted breast biopsy (microbiopsy). Among the 287 surgical excisions performed at Institut Bergonié from 1999 to 2009, we selected a case-control study group of 151 excisions; 52 involving all the diagnosed cancers and 99 randomly selected among the 235 excisions without cancer, following atypical microbiopsy (24 flat epithelial atypia; 50 atypical ductal hyperplasia; 14 lobular neoplasia; 63 mixed lesions). Mammographical calcification (type, extension, complete removal) and histological criteria of epithelial atypia (type, number of foci, size/extension), topography and microcalcification extension at microbiopsy were compared according to the presence or absence of cancer at excision. Factors associated with cancer at excision were Breast Imaging Reporting and Data System (BI-RADS5) lesions, large and/or multiple foci of mammographical calcifications, histological type, number, size and extension of atypical foci. Flat epithelial atypia alone was never associated with cancer at excision. BI-RADS5, atypical ductal hyperplasia (alone or predominant) and 43 foci of atypia were identified as independent pejorative factors. There was never any cancer at excision when these pejorative factors were absent (n ¼ 31). Presence of one (n ¼ 59), two (n ¼ 23) or three (n ¼ 14) factors was associated with cancer in 24, 15 and 13 cases with an odds ratio ¼ 5.8 (95% CI: 3-11.2) for each additional factor. We recommend that mammographical data and histological characteristics be taken into account in the decision-making process after diagnosis of atypia on microbiopsy. With experienced senologists and strict histological criteria, some patients could be spared surgery resulting in significant patient, financial and time advantages.

Atypical ductal hyperplasia on core needle biopsy: Development of a predictive model stratifying carcinoma upgrade risk on excision

“…The histologic extent of ADH was also a significant predictor on multivariate analysis, 2.32 mm in cases with upgrade versus 1.77 mm in non‐upgrade cases. Similar to our findings, Mascarel et al found that upgrade was more likely as the histologic extent of the epithelial atypia increased. In the study by Khoury et al the histologic extent of ADH was also associated with upgrade, 1.42 mm for non‐upgrade cases and 2.09 mm for cases with upgrade.…”

“…Our findings are consistent with the results from prior studies. Mascarel et al analyzed the rate of upgrade for lesions with epithelial atypia diagnosed on CNB and found that upgrade was significantly more likely as the number and percentage of cores with epithelial atypia increased. Khoury et al and Wagoner et al studied ADH diagnosed on CNB and showed that the rate of upgrade was significantly associated with the number of cores involved.…”

Atypical Lobular Hyperplasia and Lobular Carcinoma in Situ at Core Breast Biopsy: Use of Careful Radiologic-Pathologic Correlation to Recommend Excision or Observation

“…In our retrospective study, this would have translated to 32 (64%) actual excisions avoided (37 surgeries recommended minus the five surgeries deferred) (95% CI: 50%, 77%). more focally aggressive natural history, leading to frank malignancy in a substantial number of cases (33,(37)(38)(39). Obligatory surgical excision allows for increased volumetric analysis and removes review and none ultimately upgraded at surgery (malignancy rate, 0%; 95% CI: 0%, 8%).…”

Outcome of a new patient pathway for managing B3 breast lesions by vacuum-assisted biopsy: time to change current UK practice?

“…The management of all B3 lesions has traditionally been open diagnostic surgical excision biopsy. However, it is increasingly recognised that some B3 subtypes are only associated with a very low risk of malignancy, and therefore, surgical excision for all represents overtreatment 3 4…”