What to do with B3 lesions at needle biopsy

Abstract

Evaluation of breast lesions using core needle biopsies (CNB) under stereotactic or ultrasound or MR guidance is a well-established practice [1–3]. This diagnostic approach is able to provide excellent results and to guide the management of the majority of patients with breast lesions [1–3]. However, CNB diagnosis of a group of non-malignant lesions, called “B3” or “high-risk” lesions, poses several dilemmas in terms of subsequent patient management. The diagnosis of B3 lesions accounts for as many as 9% of all imaging-guided CNB [3–6]. These lesions include lobular neoplasia (LN)(lobular carcinoma in situ, atypical lobular hyperplasia), atypical ductal hyperplasia (ADH), papilloma, radial scar, fibroepithelial lesions, mucocele-like lesions and columnar cells lesions. CNB diagnosis of these lesions is considered unreliable because it can result in underestimation of the histopathologic finding at surgical excision. The reported risk of associated malignancy at surgical excision varies widely (0–35%), and is higher for LN and ADH, compared to other B3 lesions [4–8]. Because of this variability, there is no consensus as to how to treat patients who receive CNB diagnosis of B3 lesions: imaging follow-up or surgical excision [9,10]. These management differences might translate into thousands of patients undergoing unnecessary surgical procedures or an equal number of patients with delays in diagnosis of malignancy, depending on the recommendations. Several papers have investigated the role of conventional imaging in the management of B3 lesions, but published data are contradictory and non-conclusive [11–15]. In addition, most of these studies are small, single-institution, retrospective and have inherent built-in selection bias.