High-Risk Lesions Detected by MRI-Guided Core Biopsy: Upgrade Rates at Surgical Excision and Implications for Management.

OBJECTIVE. The purpose of our study was to evaluate the upgrade rates of high-risk lesions (HRLs) diagnosed by MRI-guided core biopsy and to assess which clinical and imaging characteristics are predictive of upgrade to malignancy. MATERIALS AND METHODS. A retrospective review was performed of all women who presented to an academic breast radiology center for MRI-guided biopsy between January 1, 2015, and November 30, 2018. Histopathologic results from each biopsy were extracted. HRLs-that is, atypical ductal hyperplasia (ADH), lobular carcinoma in situ (LCIS), atypical lobular hyperplasia (ALH), radial scar, papilloma, flat epithelial atypia (FEA), benign vascular lesion (BVL), and mucocelelike lesion-were included for analysis. Clinical history, imaging characteristics, surgical outcome, and follow-up data were recorded. Radiologic-pathologic correlation was performed. RESULTS. Of 810 MRI-guided biopsies, 189 cases (23.3%) met the inclusion criteria for HRLs. Of the 189 HRLs, 30 cases were excluded for the following reasons: 15 cases were lost to follow-up, six cases were in patients who received neoadjuvant chemotherapy after biopsy, two lesions that were not excised had less than 2 years of imaging follow-up, and seven lesions had radiologic-pathologic discordance at retrospective review. Of the 159 HRLs in our study cohort, 13 (8.2%) were upgraded to carcinoma. Surgical upgrade rates were high for ADH (22.5%, 9/40) and FEA (33.3%, 1/3); moderate for LCIS (6.3%, 3/48); and low for ALH (0.0%, 0/11), radial scar (0.0%, 0/28), papilloma (0.0%, 0/26), and BVL (0.0%, 0/3). Of the upgraded lesions, 69.2% (9/13) were upgraded to ductal carcinoma in situ (DCIS) or well-differentiated carcinoma. ADH lesions were significantly more likely to be upgraded than non-ADH lesions (p = .005). CONCLUSION. ADH diagnosed by MRI-guided core biopsy warrants surgical excision. The other HRLs, however, may be candidates for imaging follow-up rather than excision, especially after meticulous radiologic-pathologic correlation.

Incidental breast carcinoma: incidence, management, and outcomes in 4804 bilateral reduction mammoplasties.

INTRODUCTION: Bilateral reduction mammoplasty is one of the most common plastic surgery procedures performed in the U.S. This study examines the incidence, management, and prognosis of incidental breast cancer identified in reduction specimens from a large cohort of reduction mammoplasty patients. METHODS: Breast pathology reports were retrospectively reviewed for evidence of incidental cancers in bilateral reduction mammoplasty specimens from five institutions between 1990 and 2017. RESULTS: A total of 4804 women met the inclusion criteria of this study; incidental cancer was identified in 45 breasts of 39 (0.8%) patients. Six patients (15%) had bilateral cancer. Overall, the maximum diagnosis by breast was 16 invasive cancers and 29 ductal carcinomas in situs. Thirty-three patients had unilateral cancer, 15 (45.5%) of which had high-risk lesions in the contralateral breast. Twenty-one patients underwent mastectomy (12 bilateral and nine unilateral), residual cancer was found in 10 in 25 (40%) therapeutic mastectomies. Seven patients did not undergo mastectomy received breast radiation. The median follow-up was 92 months. No local recurrences were observed in the patients undergoing mastectomy or radiation. Three of 11 (27%) patients who did not undergo mastectomy or radiation developed a local recurrence. The overall survival rate was 87.2% and disease-free survival was 82.1%. CONCLUSIONS: Patients undergoing reduction mammoplasty for macromastia have a small but definite risk of incidental breast cancer. The high rate of bilateral cancer, contralateral high-risk lesions, and residual disease at mastectomy mandates thorough pathologic evaluation and careful follow-up of these patients. Mastectomy or breast radiation is recommended for local control given the high likelihood of local recurrence without either.

Chemoprevention acceptance and adherence in women with high-risk breast lesions.

Patients with atypical hyperplasia and lobular carcinoma in situ (LCIS) (atypical breast lesions) are at high risk of developing breast cancer, and chemoprevention has been shown to confer a substantial reduction in that risk. Despite this, the overall rate of chemoprevention utilization in this group is low. This study evaluates the efficacy of a formal individualized education and counseling session on patient acceptance and adherence to chemoprevention. Patients with atypical breast lesions having an individualized education and counseling session in a single surgical oncology practice were prospectively entered into a database from 2001 to 2016, and with IRB approval, their data were analyzed. Chemoprevention recommendations, acceptance, duration of treatment, and side effects were recorded. A total of 536 patients were included in this study. Mean age at diagnosis was 52 years (range: 19-86 years). Chemoprevention was recommended for 386 (72%) of whom 199 (52%) elected to take medication or participate in a chemoprevention clinical trial. At the time of this writing, 72 patients had completed therapy, 69 were still in treatment, and 58 had stopped chemoprevention prematurely. Approximately 55% of the women who accepted chemoprevention in this study will complete 5 years of therapy. A formal individualized education and counseling session can improve chemoprevention acceptance and achieve a reasonable completion rate, thus reducing cancer incidence in women with atypical breast lesions.

Screening breast magnetic resonance imaging in women with atypia or lobular carcinoma in situ.

BACKGROUND: Atypical lesions and lobular carcinoma in situ (LCIS) are associated with an increased risk of breast malignancy. The utility of breast magnetic resonance imaging (MRI) screening in this cohort of women after excision of a high-risk lesion has not been previously established. The objective of this study was to investigate outcomes of breast MRI surveillance in this subgroup of high-risk patients. MATERIALS AND METHODS: We performed a retrospective review of women who required excision of an atypical lesion or LCIS who underwent at least one screening breast MRI from April 2005-December 2011. We collected information on demographics, number of second-look imaging studies recommended, number of biopsies performed and pathologic outcomes. RESULTS: A total of 179 patients met the inclusion criteria, including 131 (73%) with atypical lesions and 48 (27%) with LCIS. Second-look imaging was recommended for 31 of 131 (23.7%) patients with atypical lesions and 8 of 48 (16.7%) with LCIS. Ten biopsies were performed in the atypical cohort (7.6%) with two revealing a malignancy (Positive Predictive Value [PPV] of 20%). In the LCIS cohort, five biopsies were performed (10.4%) with one revealing a malignancy (PPV of 20%). CONCLUSIONS: The benefit of breast MRI surveillance in patients after excision of atypical lesions or LCIS has not been clearly delineated previously. Our data demonstrate that the use of screening breast MRI in this cohort results in additional work-up in one-fifth of patients, but a PPV of only 20%. Large, prospective studies would be needed to determine whether breast cancer outcomes differ between patients undergoing conventional breast screening and those undergoing conventional breast screening plus breast MRI surveillance.

Atypical Ductal Hyperplasia and Lobular In Situ Neoplasm: High-Risk Lesions Challenging Breast Cancer Prevention.

This retrospective study investigates the histopathological outcomes, upgrade rates, and disease-free survival (DFS) of high-risk breast lesions, including atypical ductal hyperplasia (ADH or DIN1b) and lobular in situ neoplasms (LIN), following Vacuum-Assisted Breast Biopsy (VABB) and surgical excision. The study addresses the challenge posed by these lesions due to their association with synchronous or adjacent Breast Cancer (BC) and increased future BC risk. The research, comprising 320 patients who underwent stereotactic VABB, focuses on 246 individuals with a diagnosis of ADH (120) or LIN (126) observed at follow-up. Pathological assessments, categorized by the UK B-coding system, were conducted, and biopsy samples were compared with corresponding excision specimens to determine upgrade rates for in situ or invasive carcinoma. Surgical excision was consistently performed for diagnosed ADH or LIN. Finally, patient follow-ups were assessed and compared between LIN and ADH groups to identify recurrence signs, defined as histologically confirmed breast lesions on either the same or opposite side. The results reveal that 176 (71.5%) patients showed no upgrade post-surgery, with ADH exhibiting a higher upgrade rate to in situ pathology than LIN1 (Atypical Lobular Hyperplasia, ALH)/LIN2 (Low-Grade Lobular in situ Carcinoma, LCIS) (38% vs. 20%, respectively, p-value = 0.002). Considering only patients without upgrade, DFS at 10 years was 77%, 64%, and 72% for ADH, LIN1, and LIN2 patients, respectively (p-value = 0.92). The study underscores the importance of a multidisciplinary approach, recognizing the evolving role of VABB. It emphasizes the need for careful follow-up, particularly for lobular lesions, offering valuable insights for clinicians navigating the complex landscape of high-risk breast lesions. The findings advocate for heightened awareness and vigilance in managing these lesions, contributing to the ongoing refinement of clinical strategies in BC care.

Comparison of two minimally invasive biopsy techniques - Breast Lesion Excision System and vacuum-assisted biopsy - for diagnosing and treating breast lesions.

Introduction: The vacuum-assisted biopsy (VAB) and the Breast Lesion Excision System (BLES) are minimally invasive biopsy techniques, both used as diagnostic and therapeutic tools. The aim of the study is to compare these two methods and assess them in the context of discomfort, early and late complications and their diagnostic and therapeutic potential. Material and methods: The study involved 173 patients who underwent a VAB or a BLES breast biopsy in the period between 2009 and 2016. Approximately 3 months after the biopsy, the patients completed a questionnaire in which they assessed the procedure for discomfort associated with the procedure and the final cosmetic outcome. The cosmetic effect of the biopsy was also assessed by a surgeon. Results: The BLES and the VAB breast biopsies did not differ in terms of pain, duration, and discomfort of the procedure, breast bruising, breast tenderness about 24 h after the procedure or pain lasting over 3 months after the biopsy. Subsequently, the biopsies were evaluated in terms of the cosmetic effect assessed by the patient and by a surgeon and no differences were observed. There were no significant differences between the VAB and the BLES breast biopsies in the course of the procedure, early and late complications and cosmetic effect. Conclusions: Since the BLES breast biopsy makes it possible to evaluate the margins, it is a good alternative to the open breast biopsy.

The value of imaging combined with clinicopathological features in the diagnosis of high-risk breast lesions.

Background: The upgrade of high-risk breast lesions (HRLs) is closely related to subsequent treatment, but the current predictors for upgrade are limited to intratumoral features of single imaging mode. Methods: We retrospectively reviewed 230 HRLs detected by mammography, ultrasound, and magnetic resonance imaging (MRI) before biopsy at the Fudan University Cancer Hospital from January 2017 to March 2018. The clinical features, imaging data according to the Breast Imaging Reporting and Data System (BI-RADS) lexicon, and tumor upgrade situation were received. Based on the different risks of upgrade reported, the lesions were classified into high-risk I [HR-I, with atypical hyperplasia (AH)] and high-risk II (HR-II, without AH). We analyzed the association between clinicopathological and imaging factors and upgrade. We used the receiver operating characteristic (ROC) curve to compare the efficacy of three imaging modes for predicting upgrade. Results: We included 230 HRLs in 230 women in the study, and the overall upgrade rate was 20.4% (47/230). The upgrade rate was higher in HR-I compared to HR-II (38.5% vs. 4.1%, P<0.01). In patients with AH, estrogen receptor-positive (ER+) patients accounted for 81.0% (64/79). For all HRLs and HR-I, in clinical characteristics, age, maximum size of lesion, and menopausal status were significantly associated with upgrade (P<0.05). In imaging factors, MRI background parenchymal enhancement (BPE), signs of MRI and ultrasound were significantly correlated with upgrade (P<0.05). Patients with negative MRI or ultrasound manifestations had lower upgrade rates (P<0.01). For HR-II, only BPE showed a significant difference between groups (P=0.001). Multifactorial analysis of all HRLs showed that age and BPE were independent predictors of upgrade (P<0.01). The areas under the ROC cure (AUCs) for predicting upgrade in mammography, ultrasound, and MRI were 0.606, 0.590, and 0.913, respectively, indicating that MRI diagnosis was significantly better than mammography and ultrasound (P<0.001). Conclusions: HRLs with AH had a higher rate of upgrade and increased ER expression. Among three imaging modes, MRI was more effective than ultrasound and mammography in diagnosing the upgrade of HRLs. Older age and moderate to marked BPE can indicate malignant upgrade. MRI can provide a certain value for the diagnosis and follow-up of HRLs.

Intraradiological pathology-calibrated electrical impedance spectroscopy in the evaluation of excision-required breast lesions.

PURPOSE: Evaluating a real-time complementary bioelectrical diagnostic device based on electrical impedance spectroscopy (EIS) for improving breast imaging-reporting and data system (BI-RADS) scoring accuracy, especially in high-risk or borderline breast diseases. The primary purpose is to characterize breast tumors based on their dielectric properties. Early detection of high-risk lesions and increasing the accuracy of tumor sampling and pathological diagnosis are secondary objectives of the study. METHODS: The tumor detection probe (TDP) was first applied to the mouse model for electrical safety evaluations by electrical current measurement. Then it was utilized for characterization of 138 human palpable breast lesions that were to undergo core needle biopsy (CNB), vacuum-assisted biopsy (VAB), or fine needle aspiration (FNA) on the surgeon's requests. Impedance phase slope (IPS) in frequency ranges of 100- 500 kHz and impedance magnitude in f = 1 kHz were extracted as the classification parameters. Consistency of radiological and pathological declarations for the excisional recommendation was then compared with the IPS values. RESULTS: Considering pathological results as the gold standard, meaningful correlations between IPS and pathophysiological status of lesions recommended for excision (such as atypical ductal hyperplasia, papillary lesions, complex sclerosing adenosis, and fibroadenoma) were observed (p < 0.0001). These pathophysiological properties may include cell size, membrane permeability, packing density, adenosis, cytoplasm structure, etc. Benign breast lesions showed IPS values greater than 0, while high-risk proliferative, precancerous, or cancerous lesions had negative IPS values. Statistical analysis showed 95% sensitivity with area under the curve (AUC) equal to 0.92. CONCLUSION: Borderline breast diseases and high-risk lesions that should be excised according to standard guidelines can be diagnosed with TDP before any sampling process. It is an important outcome for high-risk lesions that are radiologically underestimated to BI-RADS3, specifically in younger patients with dense breast masses that present challenges in mammographic and sonographic evaluations. Also, the lowest IPS value detects the most pathologic portions of the tumor for increasing sampling accuracy in large tumors. SIGNIFICANCE: Precise detection of high-risk breast masses, which may be declared BI-RADS3 instead of BI-RADS4a.

Upgrade of high-risk breast lesions detected on mammography in the Breast Cancer Surveillance Consortium.

BACKGROUND: Upgrade rates of high-risk breast lesions after screening mammography were examined. METHODS: The Breast Cancer Surveillance Consortium registry was used to identify all Breast Imaging Reporting and Data System category 4 assessments followed by needle biopsies with high-risk lesions. Follow-up was performed for all women. RESULTS: High-risk lesions were found in 957 needle biopsies, with excision documented in 53%. Most (n = 685) were atypical ductal hyperplasia (ADH), 173 were lobular neoplasia, and 99 were papillary lesions. Upgrade to cancer varied with type of lesion (18% in ADH, 10% in lobular neoplasia, and 2% in papillary lesions). In premenopausal women with ADH, upgrade was associated with family history. Cancers associated with ADH were mostly (82%) ductal carcinoma in situ, and those associated with lobular neoplasia were mostly (56%) invasive. During a further 2 years of follow-up, cancer was documented in 1% of women with follow-up surgery and in 3% with no surgery. CONCLUSIONS: Despite low rates of surgery, low rates of cancer were documented during follow-up. Benign papillary lesions diagnosed on Breast Imaging Reporting and Data System category 4 mammograms among asymptomatic women do not justify surgical excision.

[Breast surgeon role in the management of high-risk breast lesions]. / Quelle prise en charge chirurgicale pour "les lésions à haut risque" de cancer du sein?

Diagnostics of high-risk breast lesions have increased these last years with the augmentation of breast percutaneous biopsies. They are lesions that confer an enlarged risk of breast cancer, either because of an increased probability of finding cancer after open surgery, a possible evolution toward in situ or invasive cancer, or because of an increased probability of developing breast cancer over the long term. Much progress has been made these last years in their histological diagnostic, classification and pathogenesis. Nevertheless, no consensus exists to date on the management of these "high-risk" lesions. In particular, surgical indications and follow-up modalities remain controversial for each histological type. In this review, the principal factors that could impact surgical decision and long-term follow-up are discussed with areas of controversy highlighted.