Atypical ductal hyperplasia diagnosed at ultrasound guided biopsy of breast mass Poster No.: C-1483 Congress: ECR 2014 Type: Authors: Keywords: DOI: Scientific Exhibit J. Cho, J. Chung, E. S. Cha, J. E. Lee, J. H. Kim, M. Lee; Seoul/ KR Breast, Ultrasound, Biopsy, Neoplasia 10.1594/ecr2014/C-1483 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. www.myesr.org Page 1 of 12
Aims and objectives Percutaneous ultrasound-guided core needle biopsy is increasingly being used as a faster, more comfortable, and less expensive alternative to surgical excision. However, the core needle biopsy finding of atypical ductal hyperplasia (ADH) is less reliable. The rate of underestimation of ADH has been reported to be 11-75% for 14- gauge core needle biopsy. ADH is defined as a ductal hyperplastic lesion that has cellular atypia and structural rigidity suggesting ductal carcinoma in situ (DCIS) but involving only one duct profile or an area less than 2 mm in diameter. Pathologists have considerable interobserver variability in determining whether a lesion is ADH or DCIS. The most common radiologic finding of ADH has been reported as microcalcification with or without a mss. Therefore, most studies of ADH diagnosed at core needle biopsy have been performed with stereotactic technique and there are only a few studies with sonographically guided core biopsy. The purpose of this study was to evaluate the sonographic features of atypical ductal hyperplasia (ADH) diagnosed at ultrasound guided biopsy of breast mass and to determine the features of this lesion can be predict upgrade to malignancy. Methods and materials We retrospectively reviewed the pathologic results of core needle biopsies at our institution from February 2012 through October 2013 and found a total of 27 ADH lesions. Only diagnoses of ADH alone were included; ADH lesions associated with other benign, highrisk, or malignant lesions were excluded. Sonographically guided core needle biopsies were performed by freehand technique with a high resolution sonographic unit and a 7.5 or 12MHz linear array transducer (IU22, Philips; Logic 9, GE Healthcare; Aixplorer, Supersonic imagine). A 14gauge TruCut needle with a 22mm throw (SACN Biopsy Needle, Medical Device Technologies) or an 11-gauge vacuum-assisted device (Mammotome, Ethicon Endo-Surgery)were used. Biopsies were performed by one of 4 radiologists who specializes in interpreting breast images and performing percutaneous breast biopsy with sonographic guidance. The clinical variables were age, personal or family history of breast cancer, and associated symptoms. Procedural variables were biopsy method and the number of core specimens per lesion. Page 2 of 12
For collection of radiologic variables, each image was reviewed retrospectively by one of the four radiologist. The following sonographic features were determined: shape, margin, orientation, lesion boundary, echo pattern, posterior acoustic features, calcification, and sonographic lesion diameter. Statistical comparisons were performed with chisquare or Fisher's exact tests using the SPSS program (version 10.0 for Microsoft Windows, SPSS). For all analyses, results were considered statistically significant at p < 0.05. Results The results of surgical excision of 27 ADH lesions were malignancy in 5 cases (core needle biopsy- 31% (4/13) vs. vacuum assisted biopsy 7%(1/14) rate of underestimation of ADH)(Figure 1-3). The most common sonographic features of ADH showed irregular shape, indistinct margin, hypoechoic lesions with hypervascularity, although, there was no significant differences. Page 3 of 12
Fig. 1: Figure 1-3. A 49-year-old female who has newly developed segmental distributed punctate and round microcalcifications in her right lower central breast. The sonography reveals indistinct irregular slightly hypoechoic lesion with suspicious ductal extension in 6 o'clock direction of right breast, which diagnosed as atypical ductal hyperplasia at sonographically guided 14-gauge core needle biopsy. After surgical Page 4 of 12
excision mass was turned out to be 1x0.8 cm extent of ductal carcinoma in situ with microcalcifications in benign ducts. References: Ewha womens university mockdong hospital - Seoul/KR Fig. 2: Figure 1-3. A 49-year-old female who has newly developed segmental distributed punctate and round microcalcifications in her right lower central breast. The sonography reveals indistinct irregular slightly hypoechoic lesion with suspicious ductal Page 5 of 12
extension in 6 o'clock direction of right breast, which diagnosed as atypical ductal hyperplasia at sonographically guided 14-gauge core needle biopsy. After surgical excision mass was turned out to be 1x0.8 cm extent of ductal carcinoma in situ with microcalcifications in benign ducts. References: Ewha womens university mockdong hospital - Seoul/KR Fig. 3: Figure 1-3. A 49-year-old female who has newly developed segmental distributed punctate and round microcalcifications in her right lower central breast. The sonography reveals indistinct irregular slightly hypoechoic lesion with suspicious ductal extension in 6 o'clock direction of right breast, which diagnosed as atypical ductal hyperplasia at sonographically guided 14-gauge core needle biopsy. After surgical excision mass was turned out to be 1x0.8 cm extent of ductal carcinoma in situ with microcalcifications in benign ducts. References: Ewha womens university mockdong hospital - Seoul/KR Twenty-two lesions out of 27 ADH lesions diagnosed by core needle or vaccum assisted biopsy were confirmed as intraductal papilloma, ADH, or ADH with other benign lesions such as FCC(Figure 4). Page 6 of 12
Fig. 4: Figure 4. A 30-year-old woman with palpable lump in her right upper inner breast. The sonography reveals a oval hypoechoic mass with gentle lobulation. Diagnosis of atypical ductal hyperplasia was confirmed by sonographically guided 14- gauge core needle biopsy and surgical excision References: Ewha womens university mockdong hospital - Seoul/KR Images for this section: Page 7 of 12
Fig. 1: Figure 1-3. A 49-year-old female who has newly developed segmental distributed punctate and round microcalcifications in her right lower central breast. The sonography reveals indistinct irregular slightly hypoechoic lesion with suspicious ductal extension in 6 o'clock direction of right breast, which diagnosed as atypical ductal hyperplasia at sonographically guided 14-gauge core needle biopsy. After surgical excision mass was Page 8 of 12
turned out to be 1x0.8 cm extent of ductal carcinoma in situ with microcalcifications in benign ducts. Fig. 2: Figure 1-3. A 49-year-old female who has newly developed segmental distributed punctate and round microcalcifications in her right lower central breast. The sonography reveals indistinct irregular slightly hypoechoic lesion with suspicious ductal extension Page 9 of 12
in 6 o'clock direction of right breast, which diagnosed as atypical ductal hyperplasia at sonographically guided 14-gauge core needle biopsy. After surgical excision mass was turned out to be 1x0.8 cm extent of ductal carcinoma in situ with microcalcifications in benign ducts. Fig. 3: Figure 1-3. A 49-year-old female who has newly developed segmental distributed punctate and round microcalcifications in her right lower central breast. The sonography reveals indistinct irregular slightly hypoechoic lesion with suspicious ductal extension in 6 o'clock direction of right breast, which diagnosed as atypical ductal hyperplasia at sonographically guided 14-gauge core needle biopsy. After surgical excision mass was turned out to be 1x0.8 cm extent of ductal carcinoma in situ with microcalcifications in benign ducts. Page 10 of 12
Fig. 4: Figure 4. A 30-year-old woman with palpable lump in her right upper inner breast. The sonography reveals a oval hypoechoic mass with gentle lobulation. Diagnosis of atypical ductal hyperplasia was confirmed by sonographically guided 14-gauge core needle biopsy and surgical excision Page 11 of 12
Conclusion ADH diagnosed at ultrasound guided biopsy has a high underestimation rate, especially with 14-gauge core needle biopsy. Surgical excision should be recommended when ADH diagnosed at ultrasound guided biopsy of breast mass. Personal information References 1. Parker SH, Jobe WE, Dennis MA, et al. US-guided automated large-core breast biopsy. Radiology 1993; 187:507-511 2. Liberman L, Feng TL, Dershaw DD, Morris EA, Abramson AF. Ultrasound-guided core breast biopsy: utility and cost-effectiveness. Radiology 1998; 208:717-723 3. Smith DN, Darling ML, Meyer JE, et al. The utility of ultrasonographically guided largecore needle biopsy: results from 500 consecutive breast biopsies. J Ultrasound Med 2001; 20:43-49 4. Tavassoli FA, Norris HJ. A comparison of the results of long-term follow-up for atypical intraductal hyperplasia and intraductal hyperplasia of the breast. Cancer 1990; 65:518-529 5. Darling ML, Smith DN, Lester SC, et al. Atypical ductal hyperplasia and ductal carcinoma in situ as revealed by largecore needle breast biopsy: results of surgical excision. AJR 2000; 175:1341-1346 6. Grady I, Gorsuch H, WilburnBailey S. Ultrasoundguided, vacuum assisted, percutaneous excision of breast lesions: an accurate technique in the diagnosis of atypical ductal hyperplasia. J Am Coll Surg 2005; 201:14-17 7. Ko E, Han W, Lee JW, et al. Scoring system for predicting malignancy in patients diagnosed with atypical ductal hyperplasia at ultrasoundguided core needle biopsy. Breast Cancer Res Treat 2008; 112:189-195 Page 12 of 12