Are We Overtreating Papillomas Diagnosed on Core Needle Biopsy?

Background

Breast papillomas often are diagnosed with core needle biopsy (CNB). Most studies support excision for atypical papillomas, because as many as one half will be upgraded to malignancy on final pathology. The literature is less clear on the management of papillomas without atypia on CNB. Our goal was to determine factors associated with pathology upgrade on excision.

Methods

Our pathology database was searched for breast papillomas diagnosed by CNB during the past 10 years. We identified 277 charts and excluded lesions associated with atypia or malignancy on CNB. Two groups were identified: papillomas that were surgically excised (group 1) and those that were not (group 2). Charts were reviewed for the subsequent diagnosis of cancer or high-risk lesions. Appropriate statistical tests were used to analyze the data.

Results

A total of 193 papillomas were identified. Eighty-two lesions were excised (42%). Caucasian women were more likely to undergo excision (p = 0.03). Twelve percent of excised lesions were upgraded to malignancy. Increasing age was a predictor of upgrading, but this was not significant. Clinical presentation, lesion location, biopsy technique, and breast cancer history were not associated with pathology upgrade. Two lesions in group 2 ultimately required excision due to enlargement, and both were upgraded to malignancy.

Conclusions

Twenty-four percent of papillomas diagnosed on CNB have upgraded pathology on excision—half to malignancy. All of the cancers diagnosed were stage 0 or I. For patients in whom excision was not performed, 2 of 111 papillomas were later excised and upgraded to malignancy.     

Management of Intraductal Papillomas of the Breast: An Analysis of 129 Cases and Their Outcome

Introduction  The management of intraductal papillomas of the breast has been controversial; some advocate surgical excision of all lesions despite benign pathologic features, whereas others excise only those specimens with atypia. Methods  We conducted a retrospective review of 129 core-biopsy-proven papillomas of the breast with atypia (n = 43) and without atypia (n = 86) and determined the rate of missed carcinoma in surgically excised specimen in each group. Results  Carcinoma was found in 22.5% of the surgically excised specimens in the atypia group (9/40) and in 3% of the surgically excised specimens in the no atypia group (1/29). Conclusions  Our findings confirm the practice that papillomas with atypical features should be excised, and suggest that in patients with adequate follow-up, benign papillomas may be managed conservatively. Presented as a poster at the meeting of the Society of Surgical Oncology, March 5-8, 2009, Phoenix Arizona.     

Papillary lesions of the breast: To excise or observe?

Papillary lesions of the breast range from benign to atypical to malignant. Although papillomas without frank cancer are benign, their management remains controversial. When a core needle biopsy of a lesion yields a diagnosis of intraductal papilloma with atypia, excision is generally recommended to rule out a concurrent malignant neoplasm. For intraductal papillomas without atypia, however, recommendations for excision versus observation are variable. The aims of this study are to evaluate the rate of concurrent malignancies for intraductal papilloma diagnosed on core needle biopsy and to assess the long‐term risk of developing cancer after the diagnosis of a papillary lesion. This single institution retrospective study analyzed 259 patients that were diagnosed with intraductal papilloma (IDP) by core needle biopsy from 1995 to 2010. Patients were grouped by initial diagnosis into three groups (papilloma without atypia, papilloma with atypia, and papilloma with atypical duct hyperplasia or atypical lobular hyperplasia (ADH/ALH) and followed up for long‐term outcomes. After a core needle biopsy showing IDP with atypia or IDP + ADH/ALH, surgical excision yielded a diagnosis of concomitant invasive or ductal in situ cancer in greater that 30% of cases. For intraductal papilloma without atypia, the likelihood of cancer was much lower. Moreover, even with excision, the finding of intraductal papilloma with atypia carries a significant risk of developing cancer long‐term, and such patients should be followed carefully and perhaps should be considered for chemoprevention.     

Management of intraductal papilloma without atypia of the breast diagnosed on core biopsy: Size and sampling matter

Due to the potential for atypia (atypical ductal or lobular hyperplasia) or carcinoma (in situ or invasive) on excision, aggressive reflex surgical excision protocols following core biopsy diagnosis of papillary lesions of the breast (ie, intraductal papilloma) are commonplace. Concepts in risk stratification, including radiologic‐pathologic correlation, are emerging in an effort to curb unnecessary surgeries. To this end, we examined all excised intraductal papillomas diagnosed at our institution from 2010‐2015 (N = 336) and found an overall atypia rate of 20%. To investigate further, we stratified all excised papillomas according to total lesion size (range = 1‐40 mm) and found that the atypia rate for lesions ≤1.2 cm (16% with atypia) was statistically significantly lower (P = .008) than the atypia rate for lesions >1.2 cm (36% with atypia). To explore to effects of radiologic‐pathologic correlation on the ability of the core biopsy to accurately predict nonatypical lesions we assessed thirteen consecutive paired nonatypical core biopsy/follow‐up surgical excision specimens for the percent of the total lesion (on imaging) sampled by the core biopsy (measured histologically). None of the thirteen paired specimens showed upgrade on excision (0/13); the percent of total lesion sampled by biopsy in this cohort averaged 59%. We propose that in the absence of discordant clinical/radiological findings, small lesions (≤1.2 cm) with radiologic‐pathologic concordance (>50% sampling of total lesion by core biopsy) may safely forego surgery for close clinical and radiographic follow‐up.     

Papillary lesions of the breast diagnosed by core needle biopsy: 71 cases with surgical follow-up

Background

Papillary breast lesions comprise a spectrum of histopathologic diagnoses ranging from benign papillomas to papillary carcinomas. There is ongoing controversy regarding the management of papillary lesions diagnosed by core needle biopsy (CNB). Some authors advocate observation of papillary lesions when the CNB is benign, while others recommend surgical excision of all papillary lesions. The current study assessed the adequacy of CNB in evaluating papillary breast lesions.

Methods

A search of the pathology database at our institution identified 122 papillary lesions diagnosed by CNB. The study population consisted of 71 papillary lesions that were subsequently surgically excised.

Results

Of the 71 papillary lesions excised, 8 were malignant, 16 were atypical, and 47 were benign at the time of CNB. Of the 47 papillary lesions thought to be benign, 13 (28%) revealed atypia and 4 (9%) revealed malignancy upon surgical excision. Of the 13 atypical papillary lesions on CNB, 7 lesions (54%) were associated with malignancy upon excision. Slightly over half the upgrades were due to finding atypia or malignancy in the tissue surrounding the papillary lesion. The total rate of upgrades from the CNB diagnosis to the excisional diagnosis was 38%.

Conclusions

When a core biopsy of a papillary lesion is encountered, there is a strong likelihood of discovering atypia or malignancy in the index lesion or in close proximity. Therefore, surgical excision should be performed to avoid missing a malignancy and to allow for accurate breast cancer risk assessment that can impact survival and decisions regarding chemoprevention.     

Completely Removing Solitary Intraductal Papillomas Using the Mammotome System Guided by Ultrasonography Is Feasible and Safe

Background

Because of the potential for an intraductal papilloma to progress to malignancy and the likelihood of detecting unexpected coexisting malignant disease, complete removal of the intraductal papilloma is safer than merely sampling it. The purpose of this study was to estimate the feasibility and safety of excising a solitary intraductal papilloma using the Mammotome system guided by ultrasonography (US).

Methods

We retrospectively reviewed the clinical information of 136 patients who underwent excision of solitary intraductal papillomas using the 8-gauge probe with the US-guided Mammotome system between December 2005 and December 2011 at our institution. Their lesions had been suspected preoperatively or were occasionally diagnosed postoperatively.

Results

There were no local recurrences during the follow-up period. Of the patients who showed atypia and underwent re-excision, only 2 (6.1 %) had local ductal atypia. The patients with atypia were significantly older than the patients without atypia (p < 0.05).

Conclusions

Using the US-guided 8-gauge probe Mammotome system to completely remove a solitary intraductal papilloma is feasible and safe. Close follow-up may be considered for those whose lesions exhibit atypia.     

Management of Benign Intraductal Solitary Papilloma Diagnosed on Core Needle Biopsy

Background

The purpose of this study was to determine whether surgical excision of benign solitary intraductal papillomas (BSIP) diagnosed by core needle biopsy (CNBx) without an associated high-risk lesion and concordant with imaging is justified.

Methods

A review of all papillary lesions diagnosed by CNBx from January 2003 to June 2010 was performed. Available histologic and radiologic materials were evaluated in a blinded fashion by three pathologists and three dedicated breast radiologists, respectively, to assess for concordance. The papillary lesions were designated as benign, atypical, or malignant. There were 16 BSIPs excluded because of an adjacent high-risk lesion or same-quadrant ipsilateral cancer. All immediate and delayed excisional specimens were reviewed. Clinical and radiologic data were recorded.

Results

A total of 299 papillary lesions diagnosed on CNBx and concordant with imaging were identified. Of these, 240 (80 %) were classified as benign, 49 (16 %) atypical, and 10 (3 %) malignant. After exclusions, 77 of 224 women in our study cohort (34 %) underwent surgical excision with no atypical or malignant upgrades. Of the remaining 147 women diagnosed with a BSIP on CNBx, 47 (32 %) were lost to follow-up and 100 (68 %) were observed. All 100 observed patients had stable imaging findings at follow-up (4.8–93.8 months, mean 36.0 months).

Conclusions

The likelihood of diagnosing atypia or malignancy after surgical excision of a BSIP diagnosed on CNBx without associated high-risk lesion or ipsilateral quadrant malignancy is extremely low. For this distinct subset of patients with a BSIP, these data justify close imaging follow-up, rather than surgical excision.     

Management of Papillary Lesions of the Breast: Can Larger Core Needle Biopsy Samples Identify Patients Who May Avoid Surgical Excision?

Background

The ability to distinguish benign from atypical/malignant papillary lesions on core needle biopsy is limited by the representative nature of the biopsy method, thus follow-up excision is usually recommended. We aimed to determine if larger samples of tissue obtained by core needle biopsy can more reliably predict the true benign nature of a papilloma.

Methods

We reviewed the pathology slides and medical records of 51 patients who were diagnosed with benign papillomas on core needle biopsy from 2000 to 2010, who subsequently underwent surgical excision. The characteristics of the core needle biopsy that were associated with retention of benign histology on excision were determined and analyzed.

Results

Atypical ductal hyperplasia and carcinoma were identified in 5.8 % (3/51) and 5.8 % (3/51) of papillary lesions, respectively, when excised. Patients whose lesions were diagnosed as benign on excision were significantly distinguished by the area (mm²) of tissue sampled by core needle biopsy (mean ± standard deviation (SD): 101.5 ± 106.5) compared with those with atypia or carcinoma on excision (mean ± SD: 41.7 ± 24.0, P = 0.003). All biopsies performed with 12-gauge or larger needles retained benign features on excision. Core needle biopsy tissue samples consisting of ≥7 cores, or measuring >96 mm² in aggregate, had a negative predictive value for atypia/malignancy of 100 %.

Conclusions

Larger tissue samples significantly improved the predictive value of benign histology on core needle biopsy. A papilloma sampled by a 12-gauge or larger needle, ≥7 cores, or >96 mm² retained its benign features upon excision.     

Incidental Intraductal Papillomas (<2 mm) of the Breast Diagnosed on Needle Core Biopsy do not Need to be Excised

Most authors recommend excision of intraductal papillomas diagnosed on core needle biopsy. This leads to the question of whether or not excision is necessary for incidental intraductal papillomas on core needle biopsy as opposed to those corresponding to imaging findings. Using the pathology computerized data base we retrospectively identified 46 incidental intraductal papillomas diagnosed on core needle biopsy from 1/2000 to 12/2008. Clinical, radiologic, and pathologic information was gathered and correlated. All core needle biopsies were reviewed to confirm the diagnosis of incidental intraductal papillomas, and excision specimens reviewed when available. Of the 46 patients, follow‐up information was available in only 38. The age of the patients ranged from 39 to 82 years (mean = 48 years). Most incidental intraductal papillomas were diagnosed by mammotome core needle biopsy (36 cases). A total of 33 cases were performed for calcifications with the following indications: clustered = 21, new = 4, pleomorphic = 3, increasing = 3, indeterminant = 2. The correlating diagnoses included the following: fibrocystic changes with calcium phosphate = 18 or calcium oxalate = 10, fibroadenoma with calcifications = 5. The three masses were: two cases of cystic papillary apocrine metaplasia (I Ultrasound and 1 MRI) and 1 fibroadenoma (Ultrasound). In all cases, the intraductal papillomas were ≤0.2 cm, were not associated with calcifications, and were incidental to them or the underlying mass. A total of 14 patients underwent excision, whereas the remaining 24 have remained radiologically stable for over 12 months. The excision specimen findings were: fibrocystic changes = 8 and intraductal papilloma = 6. With the exception of one case, all the intraductal papilloma remained incidental to imaging findings. In this solitary case, the calcifications were described as pleomorphic and corresponded to fibrocystic changes calcifications on core needle biopsy. However, on excision, residual pleomorphic calcifications on mammogram correlated with both fibrocystic changes and intraductal papilloma. No cases were upstaged on excision to atypical duct hyperplasia or intraductal or invasive carcinoma. With the exception of one case, all incidental intraductal papillomas diagnosed on core needle biopsy were either completely excised or remained incidental. The exception occurred due to sampling error and accounted for the change from an incidental intraductal papillomas on core needle biopsy to one that was associated with calcifications on excision. Given the complete lack of upstaging, it is difficult to recommend excision of incidental intraductal papillomas diagnosed on core needle biopsy provided the index lesion has been adequately sampled and radiologic follow‐up is maintained.     

Ultrasound‐guided 7‐gauge vacuum‐assisted core biopsy: Could it be sufficient for the diagnosis and treatment of intraductal papilloma?

The aim of this study was to evaluate whether ultrasound‐guided 7‐gauge vacuum‐assisted core biopsy is sufficient for the diagnosis and treatment of intraductal papilloma and to evaluate the lesion characteristics and histologic features affecting the excision rate of papilloma with vacuum‐assisted core biopsy. Between March 2008 and October 2016, 2816 patients underwent US‐guided, 7‐gauge vacuum‐assisted core biopsy (VACB). In them, 101 (3.6%) were demonstrated to have intraductal papilloma by pathology. The accurate diagnostic rate and excision rate of intraductal papilloma after vacuum‐assisted core biopsy were evaluated by open surgical biopsy or follow‐up US. The lesion characteristics and histologic features were analyzed to identify factors affecting the excision rate of papilloma after VACB. Of the 101 intraductal papillomas, 83 (82.2%) cases were benign papilloma. Two cases were intraductal papilloma accompanied by invasive carcinoma. Sixteen (15.8%) cases were with signs of atypical hyperplasia. In them, one intraductal papilloma accompanied by severe atypical hyperplasia underwent further surgery, and it was demonstrated to have intraductal papilloma accompanied by invasive carcinoma. The accurate diagnostic rate of intraductal papillomas by 7‐gauge VACB was 99.0% (100/101). There was no recurrence or malignant transformation in 85.1% (86/101) intraductal papillomas after 7‐gauge vacuum‐assisted core biopsy. Intraductal papilloma with largest diameter <1 cm, with clear margin, without branch involvement or calcification had a significantly higher excision rate. Seven‐gauge VACB is an effective method for the diagnosis of intraductal papilloma of the breast. If histopathological examination confirms a benign character of the lesion, surgery may be avoided but regular follow‐up is recommended. If histopathological examination confirms a papilloma with moderate to severe atypical hyperplasia, it was strongly recommended for surgical excision. Lesion characteristics and histologic features could affect the excision rate of intraductal papillomas with VACB.     

Benign breast papilloma: Is surgical excision necessary?

In many centers internationally, current standard of care is to excise all papillomas of the breast, despite recently reported low rates of upgrade to malignancy on final excision. The objective of this study was to determine the upgrade rate to malignancy in patients with papilloma without atypia. A retrospective review of a prospectively maintained database of all cases of benign intraductal papilloma in a tertiary referral symptomatic breast unit between July 2008 and July 2018 was performed. Patients with evidence of malignancy or atypia on core biopsy and those with a history of breast cancer or genetic mutations predisposing to breast cancer were excluded. One hundred and seventy‐three cases of benign papilloma diagnosed on core biopsy were identified. Following exclusions, the final cohort comprised of 138 patients. Mean age at presentation was 51. Mean follow‐up time was 9.6 months. The most common symptom was a lump (40%). Of the 124 patients who underwent excision, three had ductal carcinoma in situ and there were no cases of invasive disease, giving an upgrade rate to malignancy of 2.4%. Upgrade to other high‐risk lesions (atypical lobular and ductal hyperplasia and lobular carcinoma in situ) was demonstrated in 15 cases (12.1%). Benign papilloma was confirmed in 100 cases (81.5%), and 6 (4.8%) had no residual papilloma found on final excision. Twelve patients (8.7%) were managed conservatively. Of those, one later went on to develop malignancy. Patients with a diagnosis of benign papilloma without atypia on core biopsy have a low risk of upgrade to malignancy on final pathology, suggesting that observation may be a safe alternative to surgical excision. Further research is warranted to determine which patients can be safely managed conservatively.     

Flat epithelial atypia of the breast: characteristics and behaviors

Background

Flat epithelial atypia (FEA) increasingly is being recognized as a pathologic entity on core needle biopsies. However, definitive management of this columnar cell lesion remains debatable because its malignant potential is unknown.

Methods

A PubMed search for “flat epithelial atypia” and “columnar cell lesions” was performed.

Results

FEA commonly was encountered in the background of higher-grade lesions such as atypical ductal hyperplasia, ductal carcinoma in situ, and tubular and lobular carcinomas. Its molecular and cytogenetic profile revealed some alterations similar to precancerous lesions. Pure FEA on core needle biopsies was upgraded to higher-grade lesions on subsequent surgical excision.

Conclusions

Current management of FEA is best achieved through a multidisciplinary review considering various factors to determine if surgical excision is warranted. Further studies are required to elucidate the malignant potential of this columnar cell lesion.     

Breast Papilloma without Atypia and Risk of Breast Carcinoma

The incidence of asymptomatic papilloma has increased with the rising popularity of core needle biopsy for breast lesions. In this study, the risk of benign papilloma without atypia for subsequent breast carcinoma during follow‐up was evaluated. From January 2000 to December 2010, among 39,461 women with breast ultrasonography, 37,847 women with benign papilloma on biopsy or excision, with benign diseases on biopsy, and with only ultrasonography performed were recruited. Women with concurrent or prior high‐risk lesions (atypia, phyllodes tumor, or lobular neoplasm) or malignancies, or with a follow‐up period of less than 12 months were excluded. The eligible 12,302 women were classified into three groups; papilloma (n = 265, patients with benign papilloma without atypia at excision), benign (n = 3,066, patients with benign results other than high risk results on core needle biopsy), and ultrasonography (n = 8,971, patients who underwent ultrasonography only without biopsy or surgery). The relative risks (RRs) of the papilloma and benign groups were calculated with intervals of 2 years using the Poisson regression analysis with age, family history, follow‐up period, and breast parenchymal density being adjusted, and the ultrasonography group was used as a reference. The RR of the papilloma group was 4.8 (95% confidence interval [CI], 2.5–9.0), significantly higher than 1.5 (95% CI, 1.0–2.1) of the benign group. In the first 2 years, the RR of the papilloma group was 5.2 (95% CI, 2.2–12.6) but it dropped to 2.2 (95% CI, 0.5–9.2) during the next 2 years. Afterward, the RR increased over time although statistical significance was not achieved. Benign papilloma without atypia increased breast cancer risk fivefold when the ultrasonography group was used as a reference, higher than other benign lesions.     

Is surgical excision necessary in benign papillary lesions initially diagnosed at core biopsy?

Debate continues regarding the use of surgical excision in benign papillary lesions initially diagnosed at core biopsy. The objective of this study is to propose management guidelines for benign papillary breast lesions initially diagnosed at core biopsy. Between January 2003 and January 2006, 76 lesions were identified as benign papillary lesions at initial core needle biopsy (n=68) or vacuum biopsy (n=8). After surgical excision, six of the 68 benign papillary lesions initially diagnosed at core needle biopsy were confirmed as malignant papillary neoplasms, giving a false-negative rate of core needle biopsy of 8.8%. Three of the eight atypical papillomas initially diagnosed at core needle biopsy were confirmed as papillary cancer in final pathology, giving a false-negative rate of 37.5%. In the analysis of the difference between benign papillary lesions and atypia or malignant papillary lesions, malignant papillary lesions were located more peripherally (p=0.005) than benign lesions and were larger (>1.5 cm, p=0.017). It is concluded that atypical papillomas at initial core biopsy or large, clinically peripherally located papillomas (>1.5 cm) need additional surgical excision.     

A review of needle core biopsy diagnosed radial scars in the Welsh Breast Screening Programme

INTRODUCTION

Radial scars are benign breast lesions; their appearance on mammography may, however, mimic carcinoma. Needle core biopsy is performed for pre-operative diagnosis and, currently in Wales, all lesions with benign biopsy results are surgically excised. We have reviewed all cases of needle core biopsy-diagnosed radial scars from the Welsh breast screening programme, Breast Test Wales (BTW), and investigated the outcome of radial scars based on histology from surgical excision in order to evaluate the appropriateness of the current management of these lesions in Wales.

PATIENTS AND METHODS

All needle core biopsy diagnosed radial scars were identified from the BTW screening database from the start of screening in 1989 until the end of 2007.

RESULTS

A total of 118 patients were diagnosed with radial scars on needle core biopsy; two patients had bilateral radial scars. Median patient age was 54 years (range, 49-68 years). Ninety-five lesions (79%) were thought to be pure radial scars on needle core biopsy; however, only 81 pure radial scars were identified on excision biopsy histology. Carcinoma was present in seven patients and ductal carcinoma in situ in nine patients at excision biopsy. In two patients, the cancers occurred in lesions reported as pure radial scars on needle core biopsy. Twenty-two lesions showed atypical ductal or lobular hyperplasia (ADH/ALH) or both on excision biopsy; 14 of these lesions were classed as pure radial scars by needle core biopsy.

CONCLUSIONS

All core biopsy diagnosed radial scars, presenting as screen detected abnormalities, should be excised due to their association with premalignant and malignant conditions.     

Intraductal Papilloma of the Breast: Prevalence of Malignancy and Natural History Under Active Surveillance

Background

The optimal management of intraductal papillomas (IPs) without atypia diagnosed on needle core biopsy (NCB) is unclear. This study analyzed the malignancy risk of immediately excised IPs and characterized the behavior of IPs under active surveillance (AS).

Methods

We retrospectively reviewed the pathology and imaging records of patients diagnosed with IPs without atypia on NCB during a 10-year period (1999–2019). The malignancy upgrade rate was assessed in patients who had an immediate surgical excision, and the rates of both radiographic progression and development of malignancy were assessed in a cohort of patients undergoing AS.

Results

The inclusion criteria were met in 152 patients with 175 IPs with a mean age of 51?±?13 years. The average size of the IPs on initial imaging was 8?±?4 mm. Most of the lesions (57%, n?=?99) were immediately excised, whereas 76 (43%) underwent AS with interval imaging with a median follow-up period of 15 months (range, 5–111 months). Among the immediately excised IPs, surgical pathology revealed benign findings in 97% (n?=?96) and ductal carcinoma in situ in 3% (n?=?3). In the AS cohort, 72% (n?=?55) of the IPs remained stable, and 25% (n?=?19) resolved or decreased in size. At 2 years, 4% had increased in size on imaging and were subsequently excised, with ductal carcinoma in situ (DCIS, n?=?1) and benign pathology (n?=?1) noted on final pathology.

Conclusions

In a large series of breast IPs without atypia, no invasive carcinoma was observed after immediate excision, and 96% of the lesions had not progressed on AS. This suggests that patients with IP shown on NCB can safely undergo AS, with surgery reserved for radiographic lesion progression.

     

Evaluating the frequency of upgrade to malignancy following surgical excision of high‐risk breast lesions and ductal carcinoma in situ identified by core needle biopsy

Excision of high‐risk breast lesions (HRL) continues to be standard of care. Previous studies have shown that HRLs can be upgraded to carcinoma in situ (CIS) or invasive carcinoma (IC) upon excision. A single institution retrospective review was conducted to determine the rate of upgrade of HRLs and ductal carcinoma in situ (DCIS) identified on image‐guided biopsy upon excision. Eight hundred and fifty‐seven patients who underwent core needle biopsy (CNB) following the detection of suspicious lesions (BI‐RADS IV) on mammograms were identified. HRLs and DCIS warranting subsequent surgical excision were found in 129 of 857 patients (15.1%). Overall, 19.6% (10/51) of DCIS, 52.4% (11/21) of ADH, and 17.6% (3/17) of papillomas were upgraded on surgical excision. A statistically significant difference was found between the concordant and discordant groups regarding the number of cores obtained (P = 0.01) and the needle size used to retrieve specimens on CNB (P = 0.01). This study reveals an upgrade rate of 26.7% of HRLs and DCIS diagnosed by CNB on surgical excision and emphasizes the continued use of large bore needles with an adequate number of core specimens when investigating a suspicious breast lesion.     

Large-needle core biopsy in atypical intraductal epithelial hyperplasia including immunohistochemical expression of high molecular weight cytokeratin: analysis of results of a single institution

The diagnosis of atypical intraductal epithelial hyperplasia (AIDH) constitutes 6.3% of the breast core biopsies performed at our institution. Seventy-nine cases that were diagnosed as AIDH on core biopsy and went through excisional biopsy were included. Sixty-four biopsies were performed by an image-guided 11-gauge vacuum device, 11 under sonographic guidance using 14-gauge needles and 4 by a sonographically guided 11-gauge vacuum device. The histopathology of the core biopsies and the surgical excisions were reviewed. Immunohistochemistry was performed on the consecutive sections of core biopsy specimens using high molecular weight cytokeratin (HMW-CK) (DAKO-Cytokeratin, 34βE12). At interpretation of the stain, intensity and percentage of positive cells were taken into account. The immunoprofiles of AIDH were categorized into four groups showing negative (i.e., no staining) or low-, moderate-, high-, and very high-intensity staining. Surgical excision of the 79 lesions revealed carcinoma in only 3 cases (4%)-two infiltrating carcinomas and one intraductal carcinoma—residual AIDH in 44 cases (56%), and epithelial hyperplasia or other benign lesions without atypia in 32 cases (40%). The HMW-CK stain was performed retrospectively on all of the core biopsies and 66 of them contained residual areas with AIDH for staining. Forty-nine (74%) were CK negative or stained with low intensity, but 17 cases (26%) had a moderate- to high-intensity stain. Our study showed a lower incidence of carcinoma on surgical excision following core biopsy for AIDH than other studies. The HMW-CK stain helped to characterize the nature of the intraductal proliferation and to confirm the presence of atypia, as has been previously reported, but frequently was inconclusive. The low incidence of carcinoma brings into question the need for surgical excision of all cases of AIDH diagnosed by core biopsy.     

The Significance of Lobular Carcinoma In Situ and Atypical Lobular Hyperplasia of the Breast

Background

The significance of lobular neoplasia (LN), lobular carcinoma in situ (LCIS) and atypical lobular hyperplasia (ALH)) found at core needle biopsy (CNB) of the breast remains uncertain. There is a consistent risk of underestimating malignancy after the diagnosis of LN on CNB. The aim of this study was to determine if patients with a CNB result of LN need surgical excision.

Methods

Patients were identified by searching the institutions pathology database for the terms ??lobular carcinoma in situ?? and ??atypical lobular hyperplasia?? over 20?years. Excluded from this study were those with core needle biopsy (CNB) results of ductal carcinoma in situ, atypical ductal hyperplasia, radial scar, or papilloma. Upgrade was defined as final surgical pathology of invasive carcinoma and/or ductal carcinoma in situ that was directly correlated to the site of the initial biopsy containing LN.

Results

LN was found at CNB in 285 patients, and 71?% (n?=?201) had subsequent surgical excisions. All patients with pleomorphic LCIS (pLCIS) underwent surgical excision. Following patients with pLCIS, patients with the diagnosis of LCIS were most likely to undergo surgical excision (80?%). Final pathology of the surgically excised specimens confirmed LN in 72?% (n?=?144). Also, 13?% (n?=?26) of the operated patients were upgraded to malignancy, including 8?% of ALH and 19?% of LCIS cases.

Conclusion

This is the largest series of surgical excisional pathology following LN on CNB ever reported. The likelihood of finding malignancy at surgical excision after CNB showing LN was 13?%. Patients with the diagnosis of LN on CNB should be considered for surgical excision.