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

Abstract

Background Although the rate of carcinoma upgrade for atypical ductal hyperplasia (ADH) diagnosed on core needle biopsy (CNB) is variable, current standard treatment consists of surgical excision (SE) for all ADH CNB diagnoses. Our objective was to identify features of ADH on CNB that may stratify carcinoma upgrade risk on SE. Methods We retrospectively analyzed cases diagnosed as ADH on CNB. An independent slide review and detailed analysis of radiological and clinical data was performed. Statistical analyses were used to identify predictors for upgrade. Using variables predictive of upgrade, a model to stratify the probability of upgrade of ADH diagnosed on CNB was constructed. Results We identified 124 ADH cases with subsequent SE. Of these, 62 cases (50%) were upgraded to carcinoma. Features predictive of upgrade were as follows: diagnosis of “At least ADH”, percentage of cores involved by ADH, radiologic lesion size, presence of ipsilateral carcinoma, and patient age. A 4‐tiered predictive model using percentage of cores involved by ADH, histologic extent of ADH, radiologic lesion size, and patient age was constructed. This predictive model has a fair accuracy, with an area under the ROC curve of 0.76. Conclusion We have identified several predictors of carcinoma upgrade for ADH diagnosed on CNB. Our predictive model may be used to stratify the risk of carcinoma upgrade on SE.

Development and Validation of a Simple-to-Use Nomogram for Predicting the Upgrade of Atypical Ductal Hyperplasia on Core Needle Biopsy in Ultrasound-Detected Breast Lesions

“…Similar to the previous studies. We also found that the upgrade was more associated with multifocal ADH than the focal one, which was consistent with previous studies (5,6,8,10,12,26). This is probably due to the fact that the foci of ADH may be present at the periphery of DCIS (27).…”

“…For example, we had 587 cases and 395 events, whereas most published studies had 45 to 422 cases with up to 133 events. With regard to the age of patients, several studies reported various risks in the age category where some found no increase in the risk (24,25), others reported significant risks in univariable analysis but not in the multivariable analysis (10,11), and some had significant in multivariable analysis (8). The results obtained in this study indicated that the upgrade rate was higher in middle age years (40-70) and lower at the extremes of age (<40/>70), which was consistent with the findings of another study with a large sample size (9).…”

“…Previous studies have attempted to identify features which are correlated with the likelihood of ADH upgrade, including age, lesion size, type of biopsy gauge, number of cores, and extent of ADH (5,6,8). However, none of these features can reliably stratify patients into different treatment subgroups (8)(9)(10). The diversity or even conflict in risk factors might be due to the study design because the investigated potential risk factors varied widely and most of the studies were single institution studies with a limited number of cases.…”

“…The diversity or even conflict in risk factors might be due to the study design because the investigated potential risk factors varied widely and most of the studies were single institution studies with a limited number of cases. Some studies have suggested that combining imaging features with biopsy and clinical characteristics maybe necessary for improving the preoperative prediction of final pathological diagnosis for ADH (6,8,(11)(12)(13)(14). The ultrasound (US) features such as margin, size of the lesions, and echogenicity features, are vital for the detection and discrimination of benign and malignant lesions (15), and also help in prediction of axillary lymph node metastasis in breast cancer (16).…”

Utility of stromal lymphocytes in diagnosis and predicting upgrade of B3 breast lesions from core biopsies

“…Many efforts to identify predictive biomarkers of upgraded B3 lesions have failed because of either a lack of specificity: the “low risk” group still has a considerable risk of upgrade [29], the predictive feature is not reproducible [30, 31] or the feature is only prognostic after full excision [28, 32]. Overall, predictive features are inconsistent across studies and many of the features require highly experienced pathologists and radiologists to interpret the available data.…”