Management of B3 lesions
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1 Management of B3 lesions Pathological view Abeer Shaaban Queen Elizabeth Hospital Birmingham
2 FEA AIDP B3 lesions In situ Lobular neoplasia Papilloma Radial scar Fibroaepithelial lesion Mucocoele like lesion Other: spindle cell lesions, apocrine atypia
3 B3 category Includes lesions of variable significance. Includes lesions with and without atypia. Risk of upgrade increases in the presence of atypia. Requires further sampling: surgery/other.
4 Factors affecting frequency & upgrade Patient population: screening vs symptomatic Method of biopsy: NCB vs VAB (gauge of needle) Type of B3 lesion Presentation: calcs/mass Presence of atypia
5 Screen detected vs symptomatic No difference in distribution of lesions Upgrade 17% (screen detected) and 20% (symptomatic)
6 Atypia vs no atypia
7 Papillary lesions Without atypia: 3.8% Noyak et al % Youk et al 2011 (age, size) With atypia 33% (vs 3%) McGhan et al 2013 Mucocoele - like lesion Without atypia 4% With atypia 21% Rakha et al, Histopathology 2013
8 49 cases of radial scar without atypia In 9 cases (18.3%): atypia on surgical excision. Conclusion: diagnosis of RS without atypia does not exclude malignancy. Further sampling by VAB or surgical excision is required
9 Rakha et al 2014
10 Type of B3 lesion/combination of lesions
11 Upgrade rate Columnar cell change: 1.5% CCC with atypia: 9% ADH with CCC: 20%
12 Flat epithelial atypia with and without atypical ductal hyperplasia: to re-excise or not. Results of a 5-year prospective study N=3948 core biopsies 145 FEA and 58 FEA +ADH Upgrade rate: 3.2 and 18.6% Conclusion: pure FEA has a very low association with carcinoma and these patients may benefit from close clinical and mammographic follow up, while combined FEA/ADH may be excised Uzoaru et al Virchows Archives 2012
13 1025 core biopsies Two UK regions: West Midlands and South Central region Final histology : 25% malignant
14 Lesion PPV (%) Pure ADH 50.4 LCIS 15 ALH 24.2 LN (unspecified) 25 LN+ADH 61.5 LN+CSL/RS 60 Papilloma with atypia 36.7 Papillomawithout 12.9 atypia RS with atypia 39.2 RS without atypia 8.9
15 Authors FEA FEA + AIDP AIDP Rakha et al 14% (1/7) 29% (2/7) 40% (6/15) Lee et al 14% (1/7) 29% (9/31) 37% (11/30) Chivukula et al 14% (5/35) 16% (31/190) 11% (5/45) Kunju & Kleer et al 21% (3/14) 11% (4/38) 38% (3/8) Kumaroswamy et al 22% (2/9) - 50% (6/12) Rajan et al 19% (7/37) 29% (5/17) 53% (17/32)
16 Conventional core vs 1 st line VAB
17 22 Italian centres 3107 B3 VAB diagnoses 1644 (54.2%) underwent surgical excision Overall PPV: 21.2 %
18 VAB upgrade Lesion PPV (%) Pure ADH 27.3 FEA 12.7 ALH 24.2 LIN 22 RS 10.6 All B3 21.2
19 Are B3 patients being over treated?
20 The majority of patients with B3 diagnosis (75%) will have a benign histology on further sampling. Is surgical excision necessary?
21 Aim to adequately sample to rule out coexistent cancer Follow up
22 Addressing Over-diagnosis /Over-treatment LORIS: The Low Risk DCIS Trial
23 Current state Management is inconsistent across screening units. Increasing use of VAB Over-treatment is a recognised issue Local guidelines: Leeds pathway, London QARC
24 Advantages of 2 nd line VAB For patients Targeted sampling: less tissue removed. Outpatient procedure, well tolerated by patients. Avoid complication of anaesthesia and surgery No scarring, easier further imaging and assessment. Rapid turnaround of results.
25 Advantages of 2 nd line VAB For MDT Improved pre-operative diagnosis rate. Reduced benign surgical biopsy rate. Planning therapeutic surgery for cancer patients. Reducing the risk of over-diagnosis/overtreatment
26 Reduction in benign diagnostic surgery From Dr S Rajan
27 B3 Guidelines Group Remit To undertake review of the literature on lesions categorised as B3 To come up with guideline document for a practical approach to management of these for the NHS BSP.
28 Proposed plan Review the literature on the upgrade rate of each of lesions categorised as B3, of uncertain malignant potential. Consider if these upgrade rates are influenced by presentation (screendetected vs symptomatic vs incidental)
29 Explore how radiological and histological diagnostic features may influence management approach. Consider any present guideline/publications. Propose safe and nationally applicable approaches to the different lesions. Write a document for publication through NHS BSP and circulate to Big 18s for feedback/ratification.
30 Composition of the B3 group Chair: Prof Sarah Pinder Radiologists: Nisha Sharma, Louise Wilkinson Surgeons: Simon pain, Desai Anil, Ashu Gandhi Pathologists: Sarah Pinder, Andrew Lee, Abeer Shaaban
31 Approach Management recommendations lesion by lesion. Use of diagrams/flow charts General principles: radiological/pathological concordance
32 14g core/first line VAB : diagnostic sampling Guidance on second line VAB adequate sampling Advice on follow up
33 Pathological issues Complete excision of lesion by VAB biopsy (false positive)
34 Comment on: Marker clip reaction Evidence of previous biopsy Calcification/type of lesion in current biopsy Review original core/mammotome
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36
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38 Sizing of lesion: e.g AIDP Pragmatic approach Largest size on any biopsy provided
39 Difficult interpretation of some lesions if piecemeal: Papilloma with atypia, fibroepithelial lesions, spindle cell lesions
40 Consistency in pathological diagnosis Low reproducibility in diagnosing some B3 lesions as FEA, AIDP. Discussion with colleagues, courses
41 Extensive calcification Sampling two ends of the lesion by 1 st line VAB Follow by 2 nd line VAB
42 Incidental small RS/Papilloma Lee et al 2011 examined incidental microscopic papillomas (n=18) and radial scars (n=17). If no atypia and the lesion is fully represented on core/vab, categorise as B2. If not sure is completely excised, code as B3 and discuss at MDT meeting. If confirmed wholly excised, no further action is needed
43 Summary Current management of B3 lesions is not uniform and likely to represent overtreatment. The majority of lesions are benign on excision. Radiological-pathological correlation is essential for planning management.
44 There is increasing use of VAB for further sampling as alternative to diagnostic surgery. Guidelines for B3 management are being developed.
45 THANK YOU
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