High risk (B3) breast lesions: What is the incidence of malignancy for individual lesion subtypes? A systematic review and meta-analysis

Abstract

Introduction Provide evidence to support evolving management strategies for high-risk (B3) breast lesions by assessing risk of carcinoma in subgroups of B3 lesions using systematic review and meta-analysis. MethodsDatabases identified observational studies between 1980 and 2015 that reported on underestimation of malignancy following B3 lesion diagnosis at core needle biopsy.Critical appraisal, quality assessment, data extraction and meta-analysis was undertaken to calculate rate of malignancy of the whole B3 group and individual lesions. Study heterogeneity and association between variables and underestimation rate was investigated using random effects logistic modelling.Results Meta-analysis, using data from 129 studies, assessed 11 423 lesions of which 2160 were upgraded to malignancy after surgical excision biopsy (17% malignancy rate, 95% CI 15 to 19%). Malignancy rates varied from 6% in radial scars with no atypia (95% CI 2 to 13%, I2 72.8%), to 32% in papillomas with atypia (95% CI 23 to 41%, I2 57.4%). Differences in upgrade rates between atypical and non-atypical lesions were statistically significant (p<0.05). Study heterogeneity could not be explained by differences in core biopsy size or year of publication.Conclusions This comprehensive, inclusive assessment of all published literature, provides an accurate estimate of malignancy risk in subgroups of B3 lesions, to guide tailored management strategies. Some lesions have a high risk of malignancy, while others have a much lower risk, and could be safely managed with surveillance strategies rather than surgery.

B3 lesion upgrade rates in a tertiary Australian breast centre: a 8‐year experience (2012–2019)

“…The overall upgrade rate in our cohort was comparatively low when compared with published literature (13.04% versus 10-26% reported in the literature) supporting a more conservative approach to managing B3 lesions. [5][6][7] In our cohort, papillary lesions without atypia had an overall upgrade rate of 4.72%, which is consistent with recent international series which report overall upgrade rates of 2.3-7%. [8][9][10] Of these lesions, those larger than 8 mm demonstrated a higher upgrade rate (13.63%) than those smaller than 8 mm (0%).…”

“…This is lower than the upgrade rate for radial scars reported in the literature, which ranges from 0.9% to 27%. [3][4][5][6][7]13,14,32 The vast majority of radial scars in our cohort did not display atypia, which may account for the absence of malignant upgrades. For radial scars without atypia, the upgrade rate is 0-6%, while for radial scars with atypia, the upgrade rate is 18-40%.…”

“…23,26,27 Management of ADH may have implications for DCIS, as ADH is regarded as a precursor lesion to DCIS. 5,[21][22][23] To date, there are several large prospective randomized controlled trials investigating active surveillance for low-risk DCIS compared to conventional surgery with or without adjuvant radiotherapy or hormonal therapy: LOw Risk DCIS study (LORD, Europe), The LOw RISk DCIS trial (LORIS, UK) and Comparing an Operation to Monitoring, With or Without Endocrine Therapy (COMET, USA). [28][29][30][31] All three trials are currently still recruiting.…”

The patient’s pathway for breast cancer in the COVID‐19 era: An Italian single‐center experience

“…The surgery selection criteria which prioritize the treatment of malignant breast lesions at immediate risk of life are leading to an accumulation of lesions included in B3 and C1 priority classes with a prolongation of their waiting times. With particular regard to this group of patients, as the positive predictive value for malignancy of lesions of uncertain malignant potential varies from 6 to 32%, according to different histotypes, this delay may compromise the prognosis of these patients 14 …”

Bloody Nipple Discharge in a Man with Benign Papillomas: A Case Report

“…If needle core biopsy demonstrates a seemingly benign intraductal papilloma, it should be noted that up to 10.7% are upgraded with atypia and malignancy subsequently identified on surgical excision specimens [6]. With the presence of atypia on core biopsy, 32% are subsequently upgraded to malignancy by surgical excision [7]. Total duct excision, for centrally sited, retroareolar papillomas, is generally well tolerated though carries the risk of nipple necrosis, nipple inversion and the loss of nipple sensation.…”