B3 lesions: A Practical Approach. Dr Nisha Sharma

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Bryan Riley
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1 B3 lesions: A Practical Approach Dr Nisha Sharma

2 B3 lesions NHS BSP 6.7% (3.3%-12.6%) of diagnostic core biopsies will be categorised as B3 El Sayed et al (2008) 8 centres in UK and B3 ranged from 2.3 to 7.9% with a PPV between 14.3%-28.3% Diagnostic variation between pathologists/institutions

3 Why classify as B3? Lesions of uncertain malignant potential Heterogeneous group Core biopsy may not represent the worst part of the lesion adjacent malignancy Some are non-obligate precursor for malignancy Some associated with increased risk of developing breast cancer

4 Traditional management B3 lesions on core biopsy warrant further sampling Traditionally managed with surgical excision Day case procedure Wire localisation General anaesthetic Surgical scar If upgrade to cancer then often second operation required

5 Vacuum assisted biopsy

6 Vacuum assisted Excision

7 New pathway Looks at vacuum assisted biopsy replacing surgical diagnostic biopsy for the management of B3 lesions

8 New pathway Initial biopsy can be 14G or VAB If lesion unifocal and <30mm one area for biopsy If lesion multifocal or >30mm then biopsy two separate areas that would aid surgical planning If B3 diagnosis discussion at MDM Refer all for vacuum assisted excision if technically feasible except papillomas with atypia and fibroepithelial lesions

9 New pathway Vacuum assisted excision is replacing the surgical diagnostic biopsy Aim to remove 4g of tissue. X-ray sample if for calcification Marker placement advised Post biopsy mammogram To comment on marker position Lesion been sampled If lesion <15mm has it been excised

10 New pathway Radiology report needs to state the needle gauge and number of cores and number of cores with calcifications Adequacy of sampling MDM discussion If Radiological/pathological concern then surgical diagnostic biopsy If representative sampling and no further concerns then follow up as per local protocol Beast screening 5 year mammographic follow up Take into account family history and risk

11 Challenges faced Cost Lack of guidance Upgrade to malignancy

12 Cost Is VAE part of the second stage screening or is it now part of the symptomatic service? Currently difficulty in getting commissioners to fund In our institution we refer all B3 lesions to surgeons but perform VAE and code as appropriate

13 Cost The interventional radiology best practice tariffs are being removed and replaced with proposed HRG codes 2017/2018 The BSBR are working with the Expert Working Group on costing. Proposed that vacuum assisted percutaneous excision of benign lesions will have a HRG code Work in progress Part of the NHS BSP specification then should get commissioner funding

14 National Guidance on managing B3 lesions Produced guidance on management of B3 lesions Circulated to all the groups Big 18 and ABS Appendix in the updated 2016 assessment guidelines Submitted for publication in a peer review journal Endorsed by the Big 18, BSBR, ABS Part of the 2017/2018 NHS BSP specification

15 B3 guidance in the NHS BSP assessment guidance 2016

16 Upgrade to malignancy Fear of missing cancer prompts surgical excision Upgrade rate varies from 9.9%-35.1%

17 Upgrade to malignancy B1 B2 B3 B4 NONE TOTAL WITH B5 BIOPSY 2001/02 15% 13% 21% 25% 27% /03 14% 11% 28% 33% 14% /04 11% 10% 33% 35% 12% /05 7% 9% 42% 33% 9% /06 6% 5% 48% 33% 8% /07 5% 6% 48% 34% 7% /08 5% 7% 50% 31% 7% /09 4% 4% 53% 33% 6% /10 4% 6% 54% 31% 5% /11 3% 5% 58% 31% 3% /12 3% 3% 64% 28% 3% /13 1% 4% 65% 27% 3% /14 1% 4% 66% 27% 2% /15 1% 3% 66% 29% 1% 571

18 B3 upgraded to B5a Low Intermediate High Not assessable Unknown Total non invasive with B3 2001/02 60% 18% 6% 15% /03 63% 15% 6% 17% /04 66% 20% 6% 8% /05 73% 15% 7% 5% /06 63% 21% 8% 8% /07 31% 24% 20% 19% 6% /08 32% 21% 20% 9% 18% /09 28% 29% 14% 14% 16% /10 29% 27% 15% 13% 16% /11 28% 27% 15% 29% 1% /12 23% 26% 16% 34% 0% /13 28% 23% 13% 34% 3% /14 26% 25% 13% 34% 1% /15 29% 27% 12% 32% 0% 297

19 B3 lesions upgrade to invasive Grade 1 Grade 2 Grade 3 Not assessable Unknown Total invasive with B3 2001/02 60% 23% 4% 8% 5% /03 56% 28% 7% 4% 5% /04 56% 33% 5% 4% 2% /05 55% 32% 4% 5% 3% /06 50% 37% 4% 6% 3% /07 55% 37% 2% 2% 4% /08 39% 46% 7% 2% 6% /09 54% 43% 1% 3% 0% /10 54% 41% 3% 1% 1% /11 48% 41% 4% 4% 4% /12 51% 36% 4% 6% 4% /13 49% 40% 5% 5% 1% /14 51% 39% 4% 4% 1% /15 45% 46% 3% 5% 1% 74

20 Upgrade to malignancy When the malignant biopsies are reviewed it can be seen that 79% of the B3 lesions are upgraded to DCIS and 20% to invasive cancers. 56% of the cases are LG or IG DCIS, with HGDCIS accounting for 12%. In 32% it was not assessable likely because the grade was not stated in the pathology report or too small to grade. 66% belong to the excellent or good prognostic group in the Nottingham Prognostic Index score.

21 Summary Change in management of B3 lesions is warranted This will be made possible with the development of guidelines and better costing infra structure We need to improve our pre-operative upgrade of B3 lesions to malignancy and support the innovative trials like LORIS and Sloane We need to reduce number of women having a benign surgical biopsy Improve data collection of B3 lesions to enable evidence based practice Planning to make this a new Radiology Key Performance Indicator for the Breast Surgical Audit in 2018

22 THANK YOU

Management of B3 lesions

Management of B3 lesions Pathological view Abeer Shaaban Queen Elizabeth Hospital Birmingham FEA AIDP B3 lesions In situ Lobular neoplasia Papilloma Radial scar Fibroaepithelial lesion Mucocoele like lesion