Ductal carcinoma in situ and atypical ductal hyperplasia of the breast diagnosed at stereotactic core biopsy

Abstract: Stereotactic core needle biopsy (SCNB) allows specific histopathologic diagnoses to be made without surgery and has been demonstrated to be an accurate, cost-effective method of diagnosing breast disease, particularly nonpalpable lesions. However, recent studies have concluded that the diagnosis of atypical ductal hyperplasia (ADH) by means of SCNB has resulted in nearly equal odds that a coexisting malignant lesion will be missed. Furthermore, others have concluded that SCNB diagnosed as DCIS cannot reliably indicate the absence of tumor invasion in surgical excision. Between 1993 and 1998, 1,221 consecutive SCNB of mammographically identified lesions were performed using a 14-gauge automated device with an average of 5.3 cores obtained per lesion. ADH was identified in 19 (1.6%) lesions and DCIS in 89 (7.3%). Surgical biopsy was performed in 89 of these patients and histopathologic results from SCNB and surgical biopsies were reviewed and correlated. In 12 cases of ADH diagnosed by SCNB, surgical biopsy showed ADH in 8 (67%) cases and DCIS in the other 4 (33%) cases. In 77 cases of DCIS diagnosed by SCNB, a surgical biopsy showed DCIS in 55 (71%) cases, 6 more cases (8%) had DCIS with focal microinvasion, and 15 (19%) had invasive ductal carcinoma. In one case no residual tumor was found at surgery. In the author's patient population, the diagnosis of ADH at SCNB indicates high probability of DCIS or residual ADH in the surgical biopsy. The diagnosis of DCIS at SCNB is confirmed in the majority of surgical biopsies; however, a significant number of cases may show microinvasion or invasive carcinoma.     

Vacuum-assisted stereotactic breast biopsy: histologic underestimation of malignant lesions

HYPOTHESIS: The histopathologic correlation between stereotactic core needle biopsy and subsequent surgical excision of mammographically detected nonpalpable breast abnormalities is improved with a larger-core (11-gauge) device. DESIGN: Retrospective medical record and histopathologic review. SETTING: University-based academic practice setting. PATIENTS: Two hundred one patients who underwent surgical excision of mammographic abnormalities that had undergone biopsy with an 11-gauge vacuum-assisted stereotactic core biopsy device. MAIN OUTCOME MEASURE: Correlation between stereotactic biopsy histologic results and the histologic results of subsequent surgical specimens. RESULTS: Results of stereotactic biopsy performed on 851 patients revealed atypical hyperplasia in 46 lesions, ductal carcinoma in situ (DCIS) in 89 lesions, and invasive cancer in 73 mammographic abnormalities. Subsequent surgical excision of the 46 atypical lesions revealed 2 cases of DCIS (4.3%) and 4 cases of invasive carcinoma (8.7%). Lesions diagnosed as DCIS on stereotactic biopsy proved to be invasive carcinoma in 10 (11.2%) of 89 patients on subsequent excision. Stereotactic biopsy completely removed 21 (23.6%) of 89 DCIS lesions and 20 (27.4%) of 73 invasive carcinomas. CONCLUSIONS: In summary, 11-gauge vacuum-assisted core breast biopsy accurately predicts the degree of disease in the majority of malignant lesions; however, understaging still occurs in 11% to 13% of lesions showing atypical hyperplasia or DCIS.     

Factors associated with upgrading to malignancy at surgery of atypical ductal hyperplasia diagnosed on core biopsy

Previous studies have shown that 4-54% of breast lesions reported on core biopsies as atypical ductal hyperplasia (ADH) are upgraded on further excision to ductal carcinoma in situ (DCIS) or invasive carcinoma. We evaluated the rate of upgrading ADH to carcinoma at surgery for ADH diagnosed by percutaneous biopsy, and examined characteristics associated with malignancy. We identified 13,488 consecutive biopsies conducted at one center over a nine-year period. A total of 422 biopsies with ADH in 415 patients were included. DCIS or invasive carcinoma was found in 132 cases (31.3% upgrading). Multivariate model revealed that ipsilateral breast symptoms, mammographic lesion other than microcalcifications alone, 14G core needle biopsy, papilloma co-diagnosis, severe ADH and pathologists with lower volume of ADH diagnosis were factors statistically associated with malignancy. However, no subgroups were identified for safe clinical-only follow-up. Surgery is recommended in all cases of ADH diagnosed by percutaneous breast biopsy.     

Atypical ductal hyperplasia of the breast diagnosed by 11-gauge directional vacuum-assisted biopsy

BACKGROUND: Small nonpalpable mammographic abnormalities are frequently diagnosed by percutaneous stereotactically guided core needle biopsy. The reliability of the histologic diagnosis of atypical ductal hyperplasia (ADH) made from tissue obtained by 11-gauge directional, vacuum-assisted biopsy of these nonpalpable breast lesions is unknown. METHODS: The records of 31 patients who were found to have ADH by 11-gauge directional vacuum-assisted biopsy were reviewed. All of these patients subsequently underwent surgical excision with needle localization biopsy of the ADH and they are the subjects of this retrospective study. RESULTS: Eleven of the 31 patients with ADH on 11-gauge directional vacuum-assisted biopsy were upgraded to ductal carcinoma in situ or infiltrating carcinoma by the excisional biopsy. This was a 35% underestimation of malignancy in our patients. CONCLUSIONS: When the histologic diagnosis of ADH is made from tissue harvested by an 11-gauge directional vacuum assisted biopsy, surgical excision of the entire abnormality is recommended to avoid underdiagnosis of breast cancer.     

The management of lobular neoplasia identified on percutaneous core breast biopsy

The management of lobular neoplasia (LN) found on percutaneous core biopsy remains a clinical dilemma. The purpose of this study was to establish guidelines for the management of LN when obtained on percutaneous core needle biopsy. A retrospective review of the Breast Imaging Tissue Sampling Database at New York Presbyterian Hospital-Columbia Comprehensive Breast Center was performed from 1998 to 2000. A total of 1460 percutaneous core breast biopsies were performed using 11- or 14-gauge needles with LN identified in 43 biopsies from 34 patients. Eleven biopsies were ultrasound guided for nonpalpable masses and 32 were stereotactically guided for mammographically detected densities (10) and microcalcifications (22). The 43 LN biopsies were divided into three groups based on additional findings associated with LN on core biopsy: group I (n = 19), LN with invasive cancer or ductal carcinoma in situ (DCIS); group II (n = 11), LN plus a second indication for open surgical biopsy, such as atypical ductal hyperplasia (ADH), radial scar, phyllodes tumor, or intraductal papilloma; and group III (n = 13), LN plus benign fibrocystic changes. In group I, 19 of 19 biopsies (100%) yielded invasive cancer or DCIS on surgical biopsy versus 3 of 11 (27%) for group II, and 1 of 13 (8%) for group III. Outcomes in group III are described as follows: three patients were lost to follow-up, three patients did not undergo surgical biopsy but demonstrated more than 1 year of mammographic stability following core biopsy. Of the remaining seven patients, two had LN and ADH on surgical biopsy (one had a contralateral cancer), one had atypical lobular hyperplasia (with a contralateral cancer), two had LN and benign fibrocystic changes, one had LN and intraductal papilloma, and one had LN and invasive ductal carcinoma (IDC) with DCIS (with a contralateral cancer). These results suggest that surgical biopsy is indicated for patients with LN when found on core biopsy and when the biopsy demonstrates invasive cancer, DCIS, or other indications for surgical biopsy such as ADH, or in the examination of a patient with a synchronous contralateral breast cancer. The diagnosis of LN alone without these indications on percutaneous biopsy may not warrant routine surgical biopsy.     

乳腺X线立体定位活检方法的评价及选择

目的对目前乳腺X线立体定位下常用的3种活检方法进行评价。方法自2000年1月起,对361例乳腺病灶进行乳腺X线立体定位活检,其中弹射式空芯针活检（ST—CNB）73例、真空辅助旋切活检（ST-VAB）74例以及手术活检214例。在中位随访时间为18个月（6～66个月）时,比较3种X线立体定位活检方法的准确性以及临床应用特点。结果乳腺X线立体定位手术活检、ST-CNB和ST—VAB诊断乳腺癌的漏诊率分别为0、2．7％和0。微创活检诊断乳腺导管上皮不典型增生的低估率为33％,诊断乳腺导管内癌的低估率为53％。微创活检在操作时间、对乳房外形的影响及并发症等方面明显优于手术活检。微创活检使69％的可疑病灶避免了手术。结论乳腺X线立体定位微创活检,尤其是真空辅助旋切活检是一种准确、安全、简便的诊断方法,因此可作为乳腺X线中度可疑（BIRADS-4）病灶的首选诊断方法,但如果活检结果为不典型增生应进一步行X线立体定位手术活检;而对于高度可疑（BIRADS-5）病灶,宜直接选择手术活检诊断。     

The significance of atypical lobular hyperplasia at percutaneous breast biopsy

Atypical lobular hyperplasia (ALH) is occasionally found in specimens obtained by percutaneous stereotactic vacuum-assisted breast biopsy for microcalcifications. Since malignancy is often found at surgical excision when atypical ductal hyperplasia is found at percutaneous biopsy, we reviewed our pathologic findings from surgery for ALH at percutaneous biopsy. This was a retrospective review of all percutaneous breast biopsy specimens for mammographic microcalcifications obtained from a single institution over a 30-month period. The pathologic findings from percutaneous biopsy were correlated with the radiologic appearance and the pathology from surgical excision. ALH was found in 13 of 766 (1.7%) stereotactic vacuum-assisted core needle biopsies performed for mammographic microcalcifications. Subsequent surgery in six patients revealed ductal carcinoma in situ (DCIS) in two patients and one case of invasive ductal carcinoma. Surgical excision is indicated for areas with ALH discovered by percutaneous biopsy for mammographic microcalcifications.     

Nonmalignant lesions in breast core needle biopsies: to excise or not to excise?

Large core needle biopsies using stereotactic mammography or ultrasound guidance are now commonly performed as the initial diagnostic approach to nonpalpable breast lesions. Although the subsequent management of patients with invasive cancer, ductal carcinoma in situ, and most benign lesions diagnosed on core needle biopsy specimens is straightforward, certain nonmalignant lesions pose dilemmas with regard to the most appropriate clinical management following core needle biopsy. The purpose of this article is to review the available data regarding several nonmalignant breast lesions, which when encountered in core needle biopsy specimens raise repeated management questions. These include atypical ductal hyperplasia, lobular neoplasia (atypical lobular hyperplasia and lobular carcinoma in situ), papillary lesions, radial scars, fibroepithelial lesions, mucocele-like lesions, and columnar cell lesions.     

Comparison of the diagnostic accuracy of a vacuum-assisted percutaneous intact specimen sampling device to a vacuum-assisted core needle sampling device for breast biopsy: initial experience

The objective of this research was to determine whether biopsy of the breast using a percutaneous intact specimen sampling device influences the underestimation rate of ductal carcinoma in situ (DCIS) compared to a vacuum-assisted core needle biopsy (VACNB) device. This study was a retrospective comparison of two series of 800 consecutive patients that underwent stereotactic biopsy of the breast for mammographic lesions presenting as microcalcifications classified by our institution as Breast Imaging Reporting and Data System (BI-RADS) 4 or 5. In the first series of patients (n = 800), a VACNB device was used; in the second series (n = 800), a vacuum-assisted percutaneous intact specimen biopsy (VAPIB) device was used. Initial diagnoses were made from the histopathologic examination of the tissue retrieved at biopsy. Lesions presenting as DCIS or atypical ductal hyperplasia (ADH) after percutaneous biopsy were then compared to the histopathologic analysis of specimens retrieved at surgical biopsy. DCIS upgrades were defined as cases in which the diagnosis of the stereotactic biopsy was DCIS and the diagnosis of the subsequent surgical excision was infiltrating ductal carcinoma (IDC). ADH upgrades were defined as cases in which the diagnosis of the stereotactic biopsy specimen was ADH and the diagnosis of the surgical excision was DCIS, lobular carcinoma in situ (LCIS), or IDC. The lesions retrieved by both biopsy techniques yielded a similar pathology distribution. Underestimation of DCIS occurred less frequently (p = 0.06) in the biopsy samples taken using the intact biopsy device (1/31, 3.2%) as compared to biopsy samples taken using the core needle biopsy device (7/36, 19.4%). No significant adverse events were reported. Breast biopsy can be performed safely and accurately using a vacuum-assisted percutaneous intact specimen sampling device. In this study, such a device trended toward fewer underestimations of DCIS at biopsy compared to the vacuum-assisted core needle sampling biopsy method.     

Biopsy needle technique and the accuracy of diagnosis of atypical ductal hyperplasia for mammographic abnormalities

The evaluation of mammographic abnormalities has become a substantial effort for surgeons and radiologists. The vacuum-assisted core biopsy (VACB) has been touted as a more accurate tool for the evaluation of mammographic lesions. Diagnosis of atypical ductal hyperplasia (ADH) from a percutaneous needle biopsy of the breast is associated with a significant risk of missing a significant breast lesion. We compared 2 methods of sampling with stereotactic-guided breast biopsy, 14-gauge automated gun core biopsy (AGCB) and VACB, on the accuracy of diagnosis of ADH at a single institution. All cases of ADH, without associated malignancy, found via image-guided breast biopsy of nonpalpable lesions between March 1996 and April 2002 were evaluated. VACB biopsy needles were utilized between July 1998 to April 2002 (686 patients) and 14-gauge AGCB from March 1996 to June 1998 (350 patients). The results of these biopsies were reviewed and compared to surgical biopsy and pathological records. ADH alone was found in 53 cases (5.1% of biopsies; mean age 57.9 years). Of these, 39 patients with ADH subsequently underwent wire-localized excisional biopsy. The other 14 patients were observed. VACB biopsy understaged 7 of 29 (24%) patients with ADH (all of which were DCIS), AGCB understaged 4 of 10 cases (40%) with one being invasive. Of the patients in the core biopsy group who were initially followed, 2 developed significant lesions within 3 years of follow-up in the same quadrant of the breast. If these cases are added to the AGCB group, then 50 per cent were understaged and significantly more invasive lesions were understaged than with VACB (17% vs. 0%; P = 0.018). The VACB resulted in less understaging of ADH than AGCB. However, there remains a significant risk of missing DCIS in this setting even with the VACB. Furthermore, the risk of understaging an invasive lesion is significantly lower in this setting with a VACB than an AGCB. Although the risk of understaging ADH is lower with the VACB, we continue to recommend excisional biopsy in a good-risk patient when a diagnosis of ADH is rendered via VACB biopsy.     

Review of 125 SiteSelect stereotactic large-core breast biopsy procedures

Advances in stereotactic breast biopsies have introduced a variety of devices that yield different sizes of tissue samples. The choice of biopsy device should be based on which technique is most likely to yield a definitive diagnosis at the time of the initial biopsy. This is a prospective study of 104 patients who underwent a total of 125 stereotactic breast biopsies using the SiteSelect large-core biopsy device. From May 1999 to June 2001, 104 patients underwent 125 stereotactic breast biopsies with the SiteSelect large-core biopsy device. One hundred four 15 mm SiteSelect biopsies, eighteen 10 mm SiteSelect biopsies, and three 22 mm SiteSelect biopsies were performed. Atypical ductal hyperplasia (ADH) and ductal carcinoma in situ (DCIS) were found in 15% of the biopsies and infiltrating cancer was found in another 15% of the biopsies. Seventy-eight percent of the ADH and 90% of the DCIS lesions were associated with indeterminate calcifications noted on mammogram. Two of the 22 mm SiteSelect excisions yielded a specimen that contained the entire cancer with clear surgical margins. All of the patients with DCIS or invasive carcinoma underwent definitive surgical and adjuvant therapy. The sensitivity and specificity of SiteSelect in this series of patients was 100%. The SiteSelect biopsy procedure is safe, well tolerated by patients, and can be performed under local anesthesia. SiteSelect is comparable to an open excisional biopsy in its ability to obtain adequate tissue for accurate diagnosis, but excises significantly less normal surrounding breast tissue. Based on the data, indications for primary use of SiteSelect are indeterminate calcifications on mammogram, rebiopsy of a vacuum-assisted biopsy site that yielded atypia on pathologic examination, and complete excision of a lesion suspicious for invasive carcinoma in order to assess actual size and margin status.     

Mammotome旋切术在乳腺肿块活检中的应用

目的探讨Mammotome旋切术在乳房肿块活检中的应用价值及对检测出的不典型增生病例的外科治疗方法.方法2003年3月～2004年1月对我院32例39处乳腺病灶超声引导下Mammotome微创旋切术及相应外科手术治疗.结果32例39处乳腺病灶中,乳腺纤维腺病24例(31处病灶),浆细胞性乳腺炎1例,非典型增生4例,乳腺癌3例.4例非典型增生中2例接受再手术,结果证实为非典型增生;1例轻度非典型增生和1例介于中度与重度非典型增生之间,口服他莫昔芬.结论对Mammotome旋切术检出的重度非典型增生,必须接受再次手术;对术前可触及肿块的中度以下的非典型增生,建议手术切除;对术前不能触及肿块的中度以下的非典型增生(不合并家族史),在肿块已全切情况下,可不手术,予他莫昔芬口服并随访.     

Diagnostic Utility of ABBI(R) (Advanced Breast Biopsy Instrumentation) for Nonpalpable Breast Lesions in Korea

Abstract: Introduction of mammography along with particular attention for the diagnosis and treatment of nonpalpable breast lesions has led to the development of nonresectional biopsies such as mammography-guided core needle biopsy, ultrasound-guided fine needle aspiration cytology, and localization and excisional biopsy. The Advanced Breast Biopsy Instrumentation (ABBI®) system, a recently developed device, has made it possible to remove a lesion completely under local anesthesia, thus providing a more reliable and rapid evaluation on an outpatient basis. We studied 159 patients with nonpalpable breast lesions from December 1996 to August 1998. Fifty-nine patients received core needle biopsies and 100 patients received excision with the ABBI system. The ABBI system patients had postexcisional mammography and specimen radiographs to confirm complete excision of the lesions. Pathologists examined permanent section specimens. In cases of malignancy, total mastectomy or reexcision was performed to secure a tumor-free margin. We collected malignant lesions in 23 of 159 patients, of whom 17 had ductal carcinoma in situ (DCIS). Postoperative histopathologic reports showed DCIS in 11 and infiltrating ductal carcinoma (IDC) in 2 among the 13 malignancies proven by stereotactic core biopsy. Among 10 malignancies proven by the ABBI system, there were 6 DCIS, 1 lobular carcinoma in situ (LCIS), and 3 IDC. In seven patients in whom mammography suggested malignancy but core biopsy showed benign lesion, localization and excisional biopsy confirmed DCIS in four of seven patients. The ABBI system is a more reliable and rapid method of evaluating breast lesions compared with stereotactic core biopsy. It is usually done under local anesthesia, minimizing the deformity of the breast. Therefore the ABBI system can be used as a preferred technique over conventional localization and excisional biopsy.     

Core biopsy of the breast with atypical ductal hyperplasia: a probabilistic approach to reporting

The diagnosis of atypical ductal hyperplasia (ADH) at needle core breast biopsy (NCB) is typically regarded as an indication for surgical excision. Although ADH is an intermediate risk nonobligate precursor lesion, the rationale for further therapy is the result of a reported high prevalence of a concomitant more advanced lesion (typically ductal carcinoma in situ) as the index lesion. To assess whether certain histopathologic features of ADH in NCB are predictive of open biopsy outcomes, the authors correlated the extent and pattern of ADH in 47 core biopsies (11-or 14-gauge) with the subsequent surgical specimen. Extent of ADH on NCB was ascertained by determining the number of large ducts and/or terminal duct-lobular units affected, with involvement of one large duct or one terminal duct-lobular unit representing a single focus, involvement of one duct and one terminal duct-lobular unit as two foci, and so on. Of the 47 cases, ADH was restricted to < or =2 foci in 24 cases (51.1%), confined to 3 foci in 8 cases (17.0%), and involved > or =4 foci in 15 cases (31.9%). The corresponding histopathologic findings at excision were benign lesions without atypia (n = 14), focal residual ADH (n = 13), atypical lobular hyperplasia (n = 3), ductal carcinoma in situ (n = 15), and invasive mammary carcinoma (n = 2). When the number of foci of involvement by ADH on NCB (based on an average of 11.6 cores per case) was correlated with the open biopsy results, all cases of ADH limited to < or =2 foci had no worse lesion on excision, whereas ADH present in > or =4 foci was found to be a strong predictor of a more advanced lesion on excision (p <0.0001, chi2). When histologic pattern was evaluated, all cases of pure micropapillary ADH on NCB showed pure micropapillary ductal carcinoma in situ on excision.     

Underestimation of malignancy of atypical ductal hyperplasia diagnosed on 11-gauge stereotactically guided Mammotome breast biopsy: an Asian breast screen experience

The incidence of malignancy in excision biopsies performed for atypical ductal hyperplasia (ADH) diagnosed on needle biopsies has decreased since the advent of larger tissue sampling and improved accuracy using vacuum-assisted Mammotome biopsy. We undertook a retrospective study to identify predictive factors for understaging of ADH diagnosed on 11-gauge Mammotome biopsy, to determine whether it was possible to avoid surgical excision in women where mammographically visible calcifications had been completely removed. Sixty-one biopsy diagnosed ADH lesions were correlated with surgical excision findings that revealed DCIS in 14 (23%). The mammographic and biopsy features were statistically analyzed using Fisher's exact test. There was no association between morphology, extent of calcifications, number of cores sampled with underestimation of malignancy (P=0.503, 0.709, 0.551 respectively). In the absence of residual calcifications, the frequency of underestimation of carcinoma still occurred in 17%.     

Breast Lesion Excision Sample (BLES Biopsy) Combining Stereotactic Biopsy and Radiofrequency: Is it a Safe and Accurate Procedure in Case of BIRADS 4 and 5 Breast Lesions?

The aim of this study was to evaluate the accuracy and safety of breast lesion excision system (BLES) procedure with an Intact system device, under stereotactic and ultrasound guidance. Retrospective data review of 32 breast lesions BI‐RADS 4 or 5 underwent Intact procedures, from March 2010 to January 2012. Underestimation rates of atypical ductal hyperplasia (ADH) and ductal carcinoma in situ (DCIS) were evaluated; percentage of complete radiologic and histologic removal of the breast lesion were analyzed, as were the complications due to procedure. Complete radiologic excision of the target lesion was achieved in all masses and 58.6% of calcifications. Lesion size was less than 11 mm (mean size 5.6 mm). Underestimation of ADH and DCIS was 0% and 10%, respectively. Low complication rate was noted: only one hematoma. BLES appears an accurate and safe biopsy system for sampling nonpalpable breast lesions, especially in case of microcalcifications clusters categorized as BI‐RADS 4 and 5.     

Surgical upgrade rate of breast atypia to malignancy: An academic center's experience and validation of a predictive model

Atypical ductal hyperplasia (ADH), atypical lobular hyperplasia (ALH), and lobular carcinoma in situ (LCIS) are commonly seen on breast core needle biopsy (CNB). Many institutions recommend excision of these lesions to exclude malignancy. A retrospective chart review was performed on patients who had ADH, ALH, or LCIS on breast CNB from 1/1/08 to 12/31/10 who subsequently had surgical excision of the biopsy site. Study objectives included determining upgrade to malignancy at surgical excision, identification of predictors of upgrade, and validation of a recently published predictive model. Clinical and demographic factors, pathology, characteristics of the biopsy procedure and visible residual lesion were recorded. T test and chi‐squared test were used to identify predictors. Classification tree was used to predict upgrade. 151 patients had mean age of 53 years. The mean maximum lesion size on imaging was 11 mm. The primary atypia was ADH in 63.6%, ALH in 27.8%, and LCIS in 8.6%. 16.6% of patients had upgrade to malignancy, with 72% DCIS and 28% invasive carcinoma. Risk factors for upgrade included maximum lesion size (P = .002) and radiographic presence of residual lesion (P = .001). A predictive model based on these factors had sensitivity 78%, specificity 80% and AUC = 0.88. Validating a published nomogram with our data produced accuracy figures (AUC = 0.65) within published CI of 0.63‐0.82. In CNB specimens containing ADH, ALH, or LCIS, initial lesion size and presence of residual lesion are predictors of upgrade to malignancy. A validated model may be helpful in developing patient management strategies.     

Carcinoma arising from preexisting pregnancy-like and cystic hypersecretory hyperplasia lesions of the breast: a clinicopathologic study of 9 patients

The intimate histologic relationship of pregnancy-like hyperplasia (PLH) and cystic hypersecretory hyperplasia (CHH) has been previously reported. However, none of these published cases contained coexisting carcinoma. In this study, we describe 9 additional cases of this lesion, all of which also revealed ductal carcinoma in situ (DCIS) as well as invasive carcinoma in 1 case. Hematoxylin and eosin-stained slides were reviewed for all cases. All were women who ranged in age from 35 to 49 years (mean 42.0 years; median 42.5 years). Reasons for surgical biopsy were calcifications in 6, breast mass in 2, and nipple discharge in 1. One patient with a mass also experienced nipple discharge. Three women initially underwent needle core biopsy and 6 had an excisional biopsy. Six women ultimately had mastectomies. Histologically, 5 had CHH merging with coexisting PLH. Atypia was seen in one or both components. All 9 cases contained DCIS. Two cases showed micropapillary DCIS, one of which appeared to arise from atypical PLH, while 4 of the 7 cases containing cystic hypersecretory DCIS appeared to arise from coexisting atypical CHH. Well-differentiated invasive carcinoma was identified in 1 case adjacent to cystic hypersecretory DCIS. Subsequent sentinel lymph node biopsy in this case revealed micrometastatic disease. Clinical follow-up was obtained in 9 patients and ranged from 10 to 69 months. All patients were free of disease at the time of last follow-up. Careful clinical follow-up is recommended for lesions that display atypia in PLH, CHH, or a histologically combined lesion. If these lesions are found on a needle core biopsy specimen, an excisional biopsy is recommended. DCIS, usually micropapillary or cystic hypersecretory types, and rarely invasive carcinoma can arise in this setting. Affected patients are typically younger than those with more common types of breast carcinoma.     

Appropriate management of atypical ductal hyperplasia diagnosed by stereotactic core needle breast biopsy

Background: Stereotactic core needle breast biopsy (SCNBB) is a minimally invasive technique used to sample nonpalpable mammographic abnormalities. The optimal management of atypical ductal hyperplasia (ADH) diagnosed by SCNBB is unknown. We hypothesized that ADH diagnosed by SCNBB should be evaluated by excisional breast biopsy (EBB) because of the risk of identifying carcinoma in association with ADH that would be missed if a diagnostic sampling technique alone was utilized. Methods: To test this hypothesis, a prospective diagnostic protocol was created which called for SCNBB instead of EBB for patients with mammographic abnormalities considered suspicious for malignancy. If ADH was noted on histologic evaluation of the cores, patients were advised to undergo an EBB. Results: A review of the initial 900 patients evaluated by SCNBB yielded 39 patients (4.3%) with ADH detected by SCNBB. Thirty-six of these 39 patients agreed to proceed with EBB: 19 patients demonstrated benign findings including atypical ductal hyperplasia, 13 patients demonstrated non-invasive ductal carcinoma, and 4 patients had evidence of invasive carcinoma. Conclusions: A 47% rate of detecting noninvasive or invasive breast carcinoma supports the hypothesis that ADH detected by a sampling technique, such as SCNBB, should be managed by EBB.Presented at the 49th Annual Cancer Symposium of The Society of Surgical Oncology, Atlanta, Georgia, March 21–24, 1996.