Excisional biopsy or long term follow-up results in breast high-risk lesions diagnosed at core needle biopsy

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1 Excisional biopsy or long term follow-up results in breast high-risk lesions diagnosed at core needle biopsy Poster No.: C-2515 Congress: ECR 2015 Type: Authors: Scientific Exhibit Ö. S. Okcu 1, A. Oktay 1, F. Can 2, I. G. Bilgen 3 ; 1 Izmir/TR, 2 Kutahya/TR, 3 Bornova/TR Keywords: DOI: Pathology, Neoplasia, Cancer, Vacuum assisted biopsy, Surgery, Ultrasound, MR, Mammography, Breast /ecr2015/C-2515 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 18

2 Aims and objectives This study aims to retrospectively assess the results of surgical excision versus longterm imaging follow-up of high-risk breast lesions after the diagnosis on core-needle biopsy (CNB) and to discuss the results in association with the review of the literature. High-risk breast lesions are rare, borderline lesions with a potential of malignancy. Coreneedle biopsy is the primary diagnostic tool to reveal them (1). These lesions include atypical ductal hyperplasia (ADH), lobular neoplasia (LN), papillary lesions, radial scars and columnar cell lesions (CCL). There are not clear guidelines for management of these lesions. We aim to share our protocol and results regarding the management of these lesions. Page 2 of 18

3 Methods and materials The radiologic and surgical records of 391 patients who underwent image-guided percutaneous biopsy from January 2008 to September 2014 were reviewed. 33 patients with a biopsy-proven high-risk breast lesion in the absence of ductal carcinoma in situ (DCIS) or invasive breast carcinoma in the samples obtained, were included in the study. Patients >40 years-old had mammography and whole-breast ultrasound (US) while only US was performed for patients younger.for the mammographic examination, two-view standard mammograms (and additional projections when necessary) were obtained using a film-screen unit or a full-field digital unit. The choice of imaging guidance (US or stereotactic) and biopsy technique (trucut or vacuum-assisted biopsy) was made according to the lesion's visibility. Biopsies were performed by three attending radiologists with 5-20 years of experience in breast imaging. US-guided trucut biopsy was performed in 256 patients (65.47%) and stereotactic vacuum-assisted biopsy was performed in 135 patients (34.52%). US-guided biopsy was performed by an an automated biopsy gun with a 14-gauge needle obtaining three to six samples. Stereotactic biopsy was performed mainly for calcifications by 9-gauge vacuumassisted device and a digital prone table obtaining ten to eighteen samples. According to our protocol, some of the patients underwent an excisional biopsy while the rest were scheduled for a long-term imaging follow-up of 6 months' intervals. Follow-up was performed by the modality which detected the lesion. Page 3 of 18

4 Results All 33 patients included in the study were female with a mean age of 53 years (range 25 to 77 years). High-risk lesions diagnosed in these cases were ADH in 16 (4.09%), intraductal papilloma in 12 (3.06%), CCL in 4 (1.02 %) and LN in 1 (0.25%) as showed on Figure 1. Fig. 1 References: EGE UNIVERSITY HOSPITAL - Izmir/TR 21 patients (63.6 %) proceeded to excisional biopsy. 10 of them (47.6 %)upgraded to malignancy afterwards while 11 (52.3%) remained to be benign (Fig.2). 9 of the 10 malignancy-upgraded lesions were diagnosed as DCIS/IDC. The last one upgraded to LN. Of 11 lesions which did not upgrade to malignancy, 7 were diagnosed as papilloma, 2 were as CCL and 2 were as FBD. Page 4 of 18

5 Fig. 2 References: EGE UNIVERSITY HOSPITAL - Izmir/TR Of 12 patients scheduled for imaging follow-up, 4 (12.1 %) were lost to follow-up. These were ADH in 2 patients and CCL in 2 patients. 1 of CCL patients was diagnosed with IDC, 3 years later. 8 patients (24.2 %) were followed-up for an average of 26 months either with mammography or US depending on which modality detected the lesion. Lesion stability was confirmed in 7 patients (2 patients with CCL,4 patients with papilloma and 1 patient with ADH). Only 1 patient in this group was operated on the sixth month of follow-up, due to rapid growth and the final diagnosis was benign papilloma. These findings are summarized on Figure 3. Page 5 of 18

6 Fig. 3 References: EGE UNIVERSITY HOSPITAL - Izmir/TR We found underestimation rates 28.5 % for ADH, 4.7 % for CCL, 4.7 % for LN and 9.5 % for papilloma as shown on Figure 4. Page 6 of 18

7 Fig. 4 References: EGE UNIVERSITY HOSPITAL - Izmir/TR Page 7 of 18

8 Images for this section: Fig. 5: A cluster of faint microcalcifications on the outer quadrant of left breast. Stereotactic vacuum-assisted biopsy was performed. EGE UNIVERSITY HOSPITAL - Izmir/TR Page 8 of 18

9 Fig. 6: Specimen graphy after VAB demonstrating some calcifications.they had a diagnosis of CCL and remained stable after 21 months' imaging follow-up. EGE UNIVERSITY HOSPITAL - Izmir/TR Page 9 of 18

10 Fig. 7: VAB was performed for this nonuniform microcalcifications on inner quadrant of left breast. EGE UNIVERSITY HOSPITAL - Izmir/TR Page 10 of 18

11 Fig. 8: Specimen mammograms first after VAB and then after excisional biopsy.the patient was diagnosed to have ADH.And due to our protocol,patient had an excisional biopsy which resulted as CCL only. EGE UNIVERSITY HOSPITAL - Izmir/TR Page 11 of 18

12 Fig. 9: Two different cluster of microcalcifications on outer quadrant of the right breast.they were accepted as suspicious for malignancy because of their morphology.the diagnosis of LCIS on VAB turned out to be ILC after excisional biopsy. EGE UNIVERSITY HOSPITAL - Izmir/TR Page 12 of 18

13 Fig. 10: Specimen graphy after VAB. EGE UNIVERSITY HOSPITAL - Izmir/TR Page 13 of 18

14 Fig. 11: US assisted trucut biopsy of a BIRADS 4 nodule. It had a diagnosis of intraductal papilloma with atypia. An excisional biopsy was planned which resulted as CCL. EGE UNIVERSITY HOSPITAL - Izmir/TR Fig. 12: This lesion was diagnosed as ADH by trucut biopsy. Excisional biopsy, afterwards did not reveal more than FBD. EGE UNIVERSITY HOSPITAL - Izmir/TR Page 14 of 18

15 Fig. 13: Trucut biopsy of this ill-defined lesion revealed ADH.This lesion upgraded to lowgrade DCIS after excisional biopsy. EGE UNIVERSITY HOSPITAL - Izmir/TR Page 15 of 18

16 Conclusion It looks like, there is a consensus in the literature regarding the management of some high-risk lesions (e.g. ADH) diagnosed at CNB as to surgically excise, based on the risk of underestimation of malignancy, while for others (e.g. CCL,LN) definitive decisions are not yet defined as to excise or to follow-up radiologically (2,3,4,5,6,7). ADH has been assigned as a moderately increased risk for development of both ipsilateral and contralateral breast cancer. Besides, it may coexist with DCIS and/or invasive carcinoma. The rate of underestimation of carcinoma, on core-needle biopsy, is reported as high as 87 in the literature (2,3). This was 31.3 % in a large study conducted on ADH by Deshaias et al. as comparable to our rate of 28.5 %. These facts warrant a follow-up excision. Though we recommended excision for all of our ADH patients, only 2 out of 16 patients preferred long-term follow-up instead and remained stable. CCL term includes a wide variety of intraductal alterations of epithelial cells. Lately, it's believed to be an early precursor of malignancy due its strong association with ADH. We had one patient with CCL,turned out to be DCIS on subsequent excision with an up-grade rate of 4.7 %. This rate was identifed as % in other studies (2,4). We think that our rate seems higher probably because we had only 4 CCL patients. And the other CCL patient in our study who was lost to follow-up, returned with a diagnosis of IDC three years after. This,we think,is a good example of the high-risk of upgrading to carcinoma of CCL. The term lobular neoplasia (LN) includes lobular carcinoma in situ (LCIS) and atypical lobular hyperplasia (ALH). There are not yet clear guidelines in the management of isolated LCIS or ALH on a CNB. Up-grading rate changes from 1% to 46 % in different studies (1). Our rate was similar (4.7 %) with the rate we obtained for CCL, as we only had 1 patient with LN. The recommendations in the literature in regard to follow-up or excise these lesions are quite variable as are for CCL. Liberman et al. conducted a large study with benign papillomas with a malignancy upgrade rate, reported as 0 % for asymptomatic patients. A similar result was reported by Bennett et al. with no upgrade to malignancy. We had 2 patients out of 12 who were underestimated before excisional biopsy. We believe that close imaging follow-up is reasonable for CCL and papilloma without atypia and LN, if radiology-pathology concordance is obtained. Our 7 patients out of 8 were stable after an average of 26 months' imaging follow-up. 4 of them were papilloma, 2 were CCL and 2 were ADH as mentioned. Another important point is that the patients scheduled for follow-up should be easy to keep in touch. Page 16 of 18

17 In the literature, some factors are accepted to be associated with upgrading rate to carcinoma such as size of biopsy needle, sampling method,number of samples and coexistence with other high-risk lesions. We did not analyse these in our study due to small sample size. There aren't still universally recognized criteria to identify patients for safe clinical-only follow-up without surgical excision of the lesions.the significance of imaging-pathologic correlation should also be kept in mind (5,6,7,8). More prospective trials conducted on the spesific and predictive features of high-risk breast lesions with larger series of patients are needed, to be able to guide the patients in the appropriate way.individualized treatment options should also be offered for this population. Page 17 of 18

18 References 1.O'Neil M, Madan R, Tawfik O.W. et al. Lobular carcinoma in situ/atypical lobular hyperplasia on breast needle biopsies: does it warrant surgical excisional biopsy? A study of 27 cases. Annals of Diagnostic Pathology 2010;14: Kunju L.P, Kleer C.G.Significance of flat epithelial atypia on mammotome core needle biopsy: should it be excised?.human Pathology 2007 ; 38: Deshaies I, Provencher L, Jacob S et.al.factors associated with upgrading to malignancy at surgery of atypical ductal hyperplasia diagnosed on core biopsy. The Breast 2011; 20 : Seo M, Chang J.M, Kim W.H et.al.columnar Cell Lesions Without Atypia Initially Diagnosed on Breast Needle Biopsies:Is Imaging Follow-Up Enough?.AJR 2013; 201: Georgian-Smith D, Lawton T.J.Variations in Physician Recommendations for Surgery After Diagnosis of a High-Risk Lesion on Breast Core Needle Biopsy.AJR 2012; 198: Krishnamurthy S,Bevers T,Kuerer H.et al.multidisciplinary Considerations in the Management of High-Risk Breast Lesions.AJR 2012; 198: Javitt M.C.Diagnosis and Management of High-Risk Breast Lesions: Aristotle's Dilemma.AJR 2012 ; 198 : Lawton T.J.Excision of High-Risk Breast Lesions on Needle Biopsy: Is There a Standard of Core?AJR 2009 ;192 :268. Page 18 of 18