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

Abstract

BackgroundThe rate of carcinoma upgrade for atypical ductal hyperplasia (ADH) diagnosed on core needle biopsy (CNB) is variable on open excision. The purpose of the present study was to develop and validate a simple-to-use nomogram for predicting the upgrade of ADH diagnosed with ultrasound (US)-guided core needle biopsy in patients with US-detected breast lesions.MethodsTwo retrospective sets, the training set (n = 401) and the validation set (n = 186), from Fudan University Shanghai Cancer Center between January 2014 and December 2019 were retrospectively analyzed. Clinicopathological and US features were selected using univariate and multivariable logistic regression, and the significant features were incorporated to build a nomogram model. Model discrimination and calibration were assessed in the training set and validation set.ResultsOf the 587 ADH biopsies, 67.7% (training set: 267/401, 66.6%; validation set: 128/186, 68.8%) were upgraded to cancers. In the multivariable analysis, the risk factors were age [odds ratio (OR) 2.739, 95% confidence interval (CI): 1.525–5.672], mass palpation (OR 3.008, 95% CI: 1.624–5.672), calcifications on US (OR 4.752, 95% CI: 2.569–9.276), ADH extent (OR 3.150, 95% CI: 1.951–5.155), and suspected malignancy (OR 4.162, CI: 2.289–7.980). The model showed good discrimination, with an area under curve (AUC) of 0.783 (95% CI: 0.736–0.831), and good calibration (p = 0.543). The application of the nomogram in the validation set still had good discrimination (AUC = 0.753, 95% CI: 0.666–0.841) and calibration (p = 0.565). Instead of surgical excision of all ADHs, if those categorized with the model to be at low risk for upgrade were surveillanced and the remainder were excised, then 63.7% (37/58) of surgeries of benign lesions could have been avoided and 78.1% (100/128) malignant lesions could be treated in time.ConclusionsThis study developed a simple-to-use nomogram by incorporating clinicopathological and US features with the overarching goal of predicting the probability of upgrade in women with ADH. The nomogram could be expected to decrease unnecessary surgery by nearly two-third and to identify most of the malignant lesions, helping guide clinical decision making with regard to surveillance versus surgical excision of ADH lesions.

Long-Term Follow-Up of High-Risk Breast Lesions at Vacuum-Assisted Biopsy without Subsequent Surgical Resection

“…This underlines the importance of long-term follow-up in women with a B3-lesion, which is especially true for ADH and LN. In addition, our findings suggest that the follow-up interval should be individualized based on the initial B3 histology, with more frequent follow-up recommended for women with ADH or complex B3-lesions [6, 31, 36]. These results imply that there might be no need for annual follow-up or even shorter intervals in the first years after the VAB diagnosis of a noncomplex, non-ADH B3-lesion after omitting a subsequent OE [18, 19].…”

Preneoplastic Low-Risk Mammary Ductal Lesions (Atypical Ductal Hyperplasia and Ductal Carcinoma In Situ Spectrum): Current Status and Future Directions

“…The following variables were constructed in the nomogram including age, mass palpation, calcifications on US, ADH extent, and suspected malignancy. The AUC values were 0.783 in the training set and 0.753 in the validation set [44]. The author concludes that, in addition to the clinical use, this risk modeling approach could be useful in assessing the results of the AS trials.…”

“…The rate of upgrading with US or MRI was observed to be higher than stereotactic guidance, 48% and 32%, respectively, and upgrading to iBC was 22% and 10%, respectively [39]. The reason for the higher upgrading rate for US-detected lesions is that these lesions are usually mass-forming [44]. MRI-detected lesions are usually performed for high-risk patients or for staging purposes on patients who already have a diagnosis of carcinoma in the same or in the contralateral breast [45].…”

“…However, if the risk versus benefit of surgery comes into question, the treating physician can use published literature for guidance. Two nomograms have been published (see above), one for cases detected by screening mammography and one for cases detected by US [20,44]. Caplain et al developed institutional guidelines that ADH does not require to be excised if it is (a) <6 mm in size and completely removed or (b) <6 mm in size and incompletely removed but with <2 foci.…”