Rates of upgrade to malignancy for 271 cases of flat epithelial atypia (FEA) diagnosed by breast core biopsy

Abstract

Flat epithelial atypia (FEA) is a borderline lesion that might represent an early stage in the development of certain low-grade carcinomas in situ and invasive cancers. There are no guidelines on its management. Our objectives were to determine the upgrade to malignancy rate and identify a subpopulation of patients that might undergo just mammographic surveillance. We retrospectively reviewed the data for 271 FEA cases among 5,555 breast core biopsies obtained over a 7-year period (January 2003-2010). We collated clinical data (age, history of cancer, menopausal status), radiological data (lesion type, size, Bi-Rads category), technical data (number of biopsies, needle gauge, excision quality) and histological data and sought correlations between these factors and upgrade rate. The 271 FEA comprised 128 cases of pure FEA, 135 cases of FEA + atypical ductal hyperplasia, and 8 cases of FEA + atypical lobular hyperplasia. Overall, 184 patients underwent surgery and 46 mammographic surveillance. Surgery detected 34 cases of malignancy (23 CIS, 7 invasive cancers, and 4 mixed cases) giving a 15% upgrade rate. Quality of excision was the only factor associated with under-diagnosis. The presence of FEA at biopsy warrants surgery.

Flat epithelial atypia and risk of breast cancer: A Mayo cohort study

“…Although outside the scope of the current investigation, other retrospective studies have reported that cancer is found in approximately 3% to 13% of women with FEA on core needle biopsy who subsequently undergo surgical excision. 13,[30][31][32][33][34][35][36] This finding is not surprising, given the association between FEA and AH that we observed, and the known risk of an upgrade to cancer with surgical excision of AH. In addition to a small risk of detecting cancer at the time of surgical excision, multiple studies have reported finding other high-risk lesions (AH or lobular carcinoma in situ) in 20% to 52% of women undergoing excision of FEA found at core needle biopsy.…”

“…An issue in the current clinical management of FEA is the question of surgical excision when FEA is diagnosed with core needle biopsy. Although outside the scope of the current investigation, other retrospective studies have reported that cancer is found in approximately 3% to 13% of women with FEA on core needle biopsy who subsequently undergo surgical excision . This finding is not surprising, given the association between FEA and AH that we observed, and the known risk of an upgrade to cancer with surgical excision of AH.…”

Does Isolated Flat Epithelial Atypia on Vacuum-assisted Breast Core Biopsy Require Surgical Excision?

“…Recently there have been multiple studies looking at FEA, some recommend excision some do not recommend excision , and some recommend a multi‐disciplinary review . However, the low incidence of upgrade of isolated FEA to malignancy , was a common element of all these studies, including our study.…”

Do columnar cell lesions exist in the male breast?

“…As reported in our systematic review, CCL-A diagnosed in core needle biopsies showed the presence of cancer in 9.4% of the subsequent excisions. 14 In more recent publications the underestimation risks ranged between 3.2% and 19%, [15][16][17][18][19][20][21][22][23][24] dependent upon study method differences, as some of the studies did not take into account radiological findings and radiological-pathological discordances. In larger vacuum biopsies more material is investigated, often showing lower underestimation risks [sometimes with no (in-situ) cancer] in subsequent excision biopsies.…”