3/27/2017. Disclosure of Relevant Financial Relationships. Papilloma???

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1 Management of Papillary Lesions Diagnosed at Rad Path Concordant Core Biopsy (CNB) Disclosure of Relevant Financial Relationships USCAP requires that all planners (Education Committee) in a position to influence or control the content of CME disclose any relevant financial relationship WITH COMMERCIAL INTERESTS which they or their spouse/partner have, or have had, within the past 12 months, which relates to the content of this educational activity and creates a conflict of interest. Edi Brogi MD PhD Attending Pathologist Director of Breast Pathology ISBP meeting March 5, 2017 Evaluation of a papillary lesion RULE OUT EPITHELIAL ATYPIA Management of Papillary Lesions Diagnosed at Rad Path Concordant CNB Papilloma??? Atypical papilloma EXCISION Papillary DCIS EXCISION Papillary Carcinoma EXCISION Evaluate epithelial proliferation between two adjacent fibrovascular cores as if within a duct space No atypia Atypia Evaluation of papillary proliferations Pathologist s expertise upgrade rate to atypia/ at EXC of benign papilloma at CNB breast pathologists 16.3% upgrade non breast pathologists 26.3% upgrade Jakate et al. Am J Surg Pathol 2012 Use of IHC to rule out ADH or DCIS ER Strong and diffuse ER(+) and CK5/6( ) CK5/6 support the diagnosis of ADH/ DCIS ADH5 cocktail In an analysis of 204 benign papillary proliferations, IHC increased the identification of atypia/ in CNB material, and reduced the rate of upgrade to at EXC (7.4% vs 4.7%) Koo JS et al. Breast Cancer Res Treat

2 Factors affecting upgrade at EXC of papilloma w/o atypia at CNB Upgrade at EXC of papilloma w/o atypia Vacuum Assisted Biopsy (VAB) vs 14G CNB Type and size of the imaging target lesion Ca2+ MRI or non Fragmented vs non fragmented cores Fragmentation more common for larger and more complex lesions The nature of the epithelium may be more difficult to evaluate in a fragmented specimen Complete removal by CNB Small papillomas and/or vacuum assisted CNB Seely J The Breast Journal 2015 Upgrade rates to or atypia in F/U EXC # at EXC Ahmadiyeh (3%) 0 1 (3%) NS none Swapp none Hong (6%) 5 (2%) 9 (4%) NS age >54 y; size >1 cm Kim (2.6%) 2 (0.8%) 4(1.8%) 8 (5.6%) none Nakhlis (6.6%) 1 (2.2%) 2 (4.4%) NS palpable Upgrade rates to or atypia in F/U EXC # at EXC Ahmadiyeh (3%) 0 1 (3%) NS none Swapp none Hong (6%) 5 (2%) 9 (4%) NS age >54 y; size >1 cm Kim (2.6%) 2 (0.8%) 4(1.8%) 8 (5.6%) none Nakhlis (6.6%) 1 (2.2%) 2 (4.4%) NS palpable Upgrade rates to or atypia in F/U EXC # at EXC Ahmadiyeh (3%) 0 1 (3%) NS none Swapp none Hong (6%) 5 (2%) 9 (4%) NS age >54 y; size >1 cm Kim (2.6%) 2 (0.8%) 4(1.8%) 8 (5.6%) none Nakhlis (6.6%) 1 (2.2%) 2 (4.4%) NS palpable Upgrade rates to or atypia in F/U EXC # at EXC Ahmadiyeh (3%) 0 1 (3%) NS none Swapp none Hong (6%) 5 (2%) 9 (4%) NS age >54 y; size >1 cm Kim (2.6%) 2 (0.8%) 4(1.8%) 8 (5.6%) none Nakhlis (6.6%) 1 (2.2%) 2 (4.4%) NS palpable 2

3 papilloma w/o atypia at CNB: MSKCC Study MSKCC in house CNBs obtained All CNB modalities CNB dx: papilloma or papillary lesion EXCLUDED: atypia, DCIS and/or invasive All imaging studies and slides of CNB and EXC specimens re reviewed Rad path concordance reassessed for all cases MSKCC Study 196 rad path concordant CNB DX papilloma w/o atypia 171/196 (87%) cases with F/U EXC 25/196 (13%) cases stable F/U 4 (2.3 %) cases with UPGRADE 167/171 (97.7%) cases with NO UPGRADE Clinical characteristics of patients with upgrade Clinical characteristics of patients with upgrade Age (years) Age (years) Personal Hx BrCa No Yes Yes Yes laterality - Ipsilateral Ipsilateral Ipsilateral time - 2 yrs prior Concurrent Concurrent histology - IDC IDC IDC Personal Hx BrCa No Yes Yes Yes laterality - Ipsilateral Ipsilateral Ipsilateral time - 2 yrs prior Concurrent Concurrent histology - IDC IDC IDC Patient undergoing excision for concurrent ; consider excision of papilloma non- Ca2+ non- Ca2+ Size of Size of Distance of DCIS involves ILC: 8mm Distance of DCIS involves IDP 3

4 non- Ca2+ non- Ca2+ Size of Size of Distance of DCIS involves IDP Distance of Type of UPGRADE DCIS in IDP TRUE Papilloma size wide range At present, no lowest size cutoff for the DX of papilloma Some studies: no EXC for imaging target size up to 1 cm or 1.5 cm lobule Morphologic mimics of micropapilloma at CNB (Micro)papilloma completely excised at rad path concordant CNB ISION myoepithelial hyperplasia papillary usual ductal hyperplasia 4

5 CNB Dx of papillary lesion w/o atypia Guidelines for management of high risk lesions American Society of Breast Surgeons The decision to excise a papillary lesion without atypia needs to be individualized based on risk, including such criteria as size; symptomatology, including palpability and presence of nipple discharge; and breast cancer risk factors. Those not excised should be followed closely with imaging. Palpability alone is not an absolute indication for excision. Papillary lesions Excision OR clinical and imaging F/U Excise palpable lesions and those with atypia, benign papillary lesions can be followed Patient Management following CNB Dx of papilloma without No excision required Rad path concordant findings No clinical symptoms Routine radiologic F/U planned (micro)papilloma completely removed by CNB Excision Recommended Rad path discordant findings Patient is symptomatic (nipple discharge/ palpable ) Patient undergoing surgery for breast cancer Guidelines for management of high risk lesions Am Society of Breast Surgeons Lesion Recommendation Exceptions/ Notes ADH LCIS/ ALH EXC EXC or observation with clinical and imaging F/U Small volume ADH if completely excised on CNB may be observed based on risk factor assessment and multidisciplinary input Excision is necessary if pathology is discordant, limited sampling, or other high lesion present Pleomorphic LCIS EXC Similar for necrosis and other non classical lesions Pure FEA or CCH Observation with clinical and imaging F/U EXC if concurrent ADH Papillary lesions EXC or clinical and EXC palpable lesions and those with atypia imaging F/U, benign papillomas can be followed CSLs EXC Small, adequately sampled CLSs may be observed Fibroadenoma EXC or clinical observation FEL with concern for phyllodes Mucocele like lesion EXC EXC or F/U Concerning features include stroma mitoses, overgrowth, pleomorphism, fragmentation, adipose tissue infiltration or other path concerns Benign MLLs can be observed if atypia would not alter pt management Fibromatosis Wide local EXC High risk local recurrence PASH Clinical observation 5