Upgrade rates of high-risk breast lesions diagnosed on core needle biopsy: a single-institution experience and literature review

Abstract

Optimal management of high-risk breast lesions detected by mammogram yielding atypical ductal hyperplasia, flat epithelial atypia, atypical lobular hyperplasia, lobular carcinoma in situ, and radial scar without atypia on core needle biopsy is controversial. This is a single-institution retrospective review of 5750 core needle biopsy cases seen over 14.5 years, including 249 (4.3%), 72 (1.3%), 50 (0.9%), 37 (0.6%), and 54 (0.9%) cases of atypical ductal hyperplasia, flat epithelial atypia, atypical lobular hyperplasia, lobular carcinoma in situ, and radial scar without atypia, respectively. Patient age, radiologic characteristics, needle gauge, and excision diagnoses were recorded. Of 462 high-risk cases analyzed, 333 (72%) underwent excision. Upgrade rate to ductal carcinoma in situ, pleomorphic carcinoma in situ, or invasive mammary carcinoma was 18% for atypical ductal hyperplasia, 11% for flat epithelial atypia, 9% for atypical lobular hyperplasia, 28% for lobular carcinoma in situ, and 16% for radial scar. Carcinoma diagnosed on excision was more likely to be in situ than invasive, and if invasive, more likely to be low grade than high grade. Overall, cases that were benign (vs high risk or carcinoma) on excision were less likely to have residual calcifications after biopsy (17% vs 27%, P=0.013), and more likely to have a smaller mass size (<1 cm) (82% vs 50%, P=0.001). On subgroup analysis, atypical ductal hyperplasia cases that were benign (vs high risk or carcinoma) on excision were more likely to have smaller mass size (<1 cm) (P=0.025). Lobular neoplasia diagnosed incidentally (vs targeted) on core needle biopsy was less likely to upgrade on excision (5% vs 39%, P=0.002). A comprehensive literature review was performed, identifying 116 studies reporting high-risk lesion upgrade rates, and our upgrade rates were similar to those of more recent larger studies. Careful radiological-pathological correlation is needed to identify high-risk lesion subgroups that may not need excision.

Trends in frequency and outcome of high‐risk breast lesions at core needle biopsy in women recalled at biennial screening mammography, a multiinstitutional study

“…Several studies advocate radiologic imaging follow‐up for nonatypical papillomas as the malignancy rate of these lesions may be less than 2.5%, whereas others have found that up to 33% of these lesions may prove malignant and therefore recommend complete surgical excision . Considerable variation in the upgrading of flat epithelial atypia, atypical ductal hyperplasia, LCIS/atypical lobular hyperplasia and radial scar to malignancy has been reported (flat epithelial atypia: 0–15%, atypical ductal hyperplasia: 22%–32%, LCIS/atypical lobular hyperplasia: 2%–29%, radial scar: 0%–23%), resulting in mixed recommendations that range from radiologic surveillance to diagnostic surgical excision of every high‐risk lesion . In our series, 29% of excised high‐risk lesions proved to be malignant; 20.7% DCIS and 8.3% invasive breast cancer, respectively.…”

Breast cancer risk associated with atypical hyperplasia and lobular carcinoma in situ initially diagnosed on core‐needle biopsy

“…In an analysis of greater than 76,000 breast biopsies of all types, the rate of diagnosis of AH and LCIS was approximately 4% . These diagnoses appear to account for a similar proportion of core‐needle biopsies (CNBs) . Some smaller studies have reported AH or LCIS in 1% or 2% of cases and in up to 10% to 15% of vacuum‐assisted stereotactic CNBs …”

“…After surgical excision, patients may be offered chemoprevention with a selective estrogen receptor (ER) modulator (SERM) (tamoxifen or raloxifene) or an aromatase inhibitor (anastrazole or exemestane) to reduce their future risk of developing carcinoma in either breast . Several studies have examined the rate of upgrade to carcinoma after a CNB diagnosis of ADH, ALH, or LCIS . A recent study of ADH diagnosed on CNB suggests that the 10‐year risk estimates for patients diagnosed on CNB may be lower than that for those diagnosed by open biopsy .…”

Expression of miR-18a and miR-210 in Normal Breast Tissue as Candidate Biomarkers of Breast Cancer Risk

“…Although women with atypical hyperplasia are at markedly increased risk of breast cancer, they comprise under 10% of benign biopsies (23). Of all the women who develop breast cancer, at least 75% do not have a history of prior benign biopsy (24), and of those who do, most do not have atypical hyperplasia.…”