Atypical Lobular Hyperplasia Research Articles

Frequency and outcomes of new or suspicious MRI findings on breast MRI for patients on neoadjuvant therapy.

To assess the frequency and outcomes of indeterminate enhancing findings on breast MRI unrelated to the index primary tumor(s) in patients on neoadjuvant therapy (NAT). This retrospective review identified all diagnostic breast MRIs performed to evaluate response to NAT at our institution between 2017 and 2020. All exams with indeterminate enhancing findings (BI-RADS 3-5) unrelated to the index tumor(s) for which follow-up imaging or tissue diagnosis was recommended were included. Cases lacking a pre-treatment MRI or those with insufficient follow-up were excluded. Imaging of all post-NAT breast MRIs were re-reviewed. The electronic medical record was reviewed to evaluate patient and lesion characteristics and outcomes. Between 2017 and 2020, 614/4042 (15.2%) breast MRIs were performed to evaluate response to NAT. After exclusions, 38 of these exams (6.2%) identified 42 indeterminate enhancing findings unrelated to the index tumor for which follow-up imaging (15 exams) or tissue diagnosis (23 exams) was recommended. Fifteen of 42 (35.7%) of the findings were new compared to the pre-treatment baseline MRI, 8/42 (19.0%) increased and 19/42 (45.2%) were present on pre-treatment MRI. Most findings were contralateral to the index tumor (28, 66.7%). Findings were masses (17, 40.4%), focus (15, 35.7%), and non-mass enhancement (10, 23.8%). Of the 42 findings, 19 (45.2%) underwent percutaneous biopsy, 10 (23.8%) underwent surgical biopsy or mastectomy, and 13 (31%) were followed by imaging. Thirty-seven were benign, 4 were high-risk lesions without upgrade (atypical ductal hyperplasia, atypical lobular hyperplasia, and papillomatosis with atypical ductal hyperplasia), and one (2.4%) was malignant (invasive lobular carcinoma), which was non-mass enhancement present on the pre-treatment MRI. Indeterminate enhancing lesions unrelated to the index tumor(s) on breast MRIs performed to assess response to neoadjuvant chemotherapy are uncommon. When present, these lesions have an extremely low likelihood of malignancy, especially when new compared to the pre-treatment MRI. Because incidental indeterminate enhancing lesions on breast MRI at post-NAT follow-up are rarely malignant, radiologists should be judicious in recommending follow-up or tissue diagnosis for such lesions after NAT.

Subsequent percutaneous breast biopsies after initial atypia diagnosis: The patient burden of long-term follow up

BackgroundBreast atypia increases overall breast cancer risk, potentially necessitating future interventions. This study examines the frequency and outcomes of additional percutaneous biopsies after an atypia diagnosis. MethodsAdult patients with breast atypia (atypical ductal hyperplasia, atypical lobular hyperplasia, lobular carcinoma in situ) at a single institution were reviewed for subsequent core needle biopsies (CNBs) and corresponding malignant outcomes. ResultsAmong 432 patients, median age at diagnosis was 54.8 ​y. Seventy-one (71/432, 16.4 ​%) patients developed a breast malignancy. During a median follow-up of 7.4 ​y, 113 patients underwent 149 additional CNBs. Twenty-six patients (26/113, 23.0 ​%) had >2 additional CNBs. Approximately half (79/149, 53.0 ​%) of all additional CNBs occurred within 5 years after breast atypia diagnosis. ConclusionA considerable number of patients with breast atypia undergo additional percutaneous biopsies, especially within 5 years post-atypia diagnosis. Our study highlights the significant burden of surveillance and the need for tailored follow-up strategies.

Altered cytokeratin 5 expression in breast lobular myoepithelial cells

AimsCytokeratin 5 (CK5) is a surrogate maker of progenitor cells and early glandular and myoepithelial cells (MECs) in the breast, and CK5 expression in breast MECs varies from ducts to...

Digital Mammography (DM) vs. Dynamic Contrast Enhancement-Magnetic Resonance Imaging (DCE-MRI) in Microcalcifications Assessment: A Radiological-Pathological Comparison.

The aim of this study was to compare the characteristics of breast microcalcification on digital mammography (DM) with the histological and molecular subtypes of breast cancer and to identify the predictive value of DM and dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) in assessing microcalcifications for radiologic-pathologic correlation. We relied on our prospectively maintained database of suspicious microcalcifications on DM, from which data were retrospectively collected between January 2020 and April 2023. We enrolled 158 patients, all of whom were subjected to biopsy. Additionally, 63 patients underwent breast DCE-MRI. Microcalcifications with a linear branched morphology were correlated with malignancies (p < 0.001), among which an association was highlighted between triple negatives (TNs) and segmental distribution (p < 0.001). Amorphous calcifications were correlated with atypical ductal hyperplasia (ADH) (p = 0.013), coarse heterogeneous (p < 0.001), and fine-pleomorphic (p = 0.008) with atypical lobular hyperplasia (ALH) and fine pleomorphic (p = 0.009) with flat epithelial atypia (FEA). Regarding DCE-MRI, no statistical significance was observed between non-mass lesions and ductal carcinoma in situ (DCIS). Concerning mass lesions, three were identified as DCIS and five as invasive ductal carcinoma (IDC). In conclusion, microcalcifications assessed in DM exhibit promising predictive characteristics concerning breast lesion subtypes, leading to a reduction in diagnostic times and further examination costs, thereby enhancing the clinical management of patients.

Abstract PO5-19-11: A novel portable breast cancer screening method - initial institutional experience

Abstract Background: Breast ultrasound (US) is a remarkable supplementary tool alongside mammography and magnetic resonance imaging (MRI) for the detection of breast lesions. US imaging is a fast, reliable method to identify and localize breast pathology. Innovative technologies that aim to timely identification and prompt diagnosis of suspicious lesions in breast cancer screening remain a clinical need. ATUSA is a B-type rechargeable US, shaped as a wearable device. It uses a linear array of transducers with water acting as a coupling medium that recreates a 3-dimensional image of the scanned breast. The ATUSA portability makes this device a practical breast screening method during a healthcare office visit. We report the initial feasibility of ATUSA to detect breast lesions in an outpatient setting from a trial in progress. Methodology: Interim prospective data from 35 female patients presenting with a mass of equal or greater than 1 cm in size, with a baseline handheld US image and pathology reports that evidenced a cancer diagnosis or a lesion suspicious of malignancy. Breast cancer types included invasive ductal carcinoma (IDC), ductal carcinoma in situ (DCIS) and invasive lobular carcinoma (ILC), invasive mammary carcinoma (IMC) with mixed ductal and lobular features and atypical lobular hyperplasia (ALH). ATUSA and baseline handheld reference US images were cross-referenced from June 2022 to June 2023. Basic demographics, clinical characteristics, mammogram and/or MRI, and pathology reports were included in the analysis. Patients were followed up for a 30-day period to note occurrence of any adverse event (AE). Institutional Review Board (IRB) approved this study (protocol H-42616). Results: The 35 patients had a mean age of 57 years (range: 25 – 79), mean BMI 29.6 kg/m2 (range: 18.1 – 49.3). Mammographic breast density was fibroglandular tissue 15 (42.8%), followed by heterogeneously dense (HD) 13 (3.7%), mixed HD and fibroglandular 1 (2.8%), mildly dense 1 (2.8%), extremely dense 2 (5.7%), and extremely fatty 1 (2.8%). Breast sizes were 1 (2.8 %) A cup, 11 (31.4%) B cups, 1 (2.8%) B – C cups, 5 (14.2%) C cups, 1 (2.8%) C – D cups, 13 (37.1%) D cups, and 3 (8.5%) DD cups. The 35 scanned lesions had a diagnosis (compared with final resected pathology) classified as IDC 18 (51.4 %), DCIS 2 (5.7 %), mixed IDC and DCIS 6 (17.1 %), ILC 3 (8.5 %), IMC with mixed features 2 (5.7 %), IMC with DCIS 1 (2.8 %), ALH 1 (2.8 %), and 2 (5.7 %) benign masses. ATUSA successfully identified 17/35 (48.5 %) lesions from this group as malignant, from which 4 were hard to distinguish due to shadowing artifact and 3 were underestimated in size. A total of 15 (42.8 %) malignant lesions were missed by ATUSA. No AEs related to the ATUSA device were reported. Conclusion: The ATUSA provides the means to produce a good quality US image during a clinic visit or where a facility lacks conventional US imaging. When compared to the handheld US, ATUSA can be safely used in the outpatient setting without the need of trained specialists but requires further development and testing to match conventional breast imaging. Table 1. Basic clinical characteristics &amp; demographics Citation Format: Margarita Riojas-Barrett, Jessica Montalvan, Mary Bajomo, Ivan Marin, Quan Dang Nguyen, Karla A Sepulveda, Elizabeth Bonefas, Alastair Thompson, Stacey Carter. A novel portable breast cancer screening method - initial institutional experience [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO5-19-11.

Integration of Pathological Criteria and Immunohistochemical Evaluation for Invasive Lobular Carcinoma Diagnosis: Recommendations From the European Lobular Breast Cancer Consortium

Invasive lobular carcinoma (ILC) is the second most frequent type of breast cancer (BC) and its peculiar morphology is mainly driven by inactivation of CDH1, the gene coding for E-cadherin cell adhesion protein. ILC-specific therapeutic and disease-monitoring approaches are gaining momentum in the clinic, increasing the importance of accurate ILC diagnosis. Several essential and desirable morphologic diagnostic criteria are currently defined by the World Health Organization, the routine use of immunohistochemistry (IHC) for E-cadherin is not recommended. Disagreement in the diagnosis of ILC has been repeatedly reported, but interpathologist agreement increases with the use of E-cadherin IHC. In this study, we aimed to harmonize the pathological diagnosis of ILC by comparing 5 commonly used E-cadherin antibody clones (NCH-38, EP700Y, Clone 36, NCL-L-E-cad [Clone 36B5], and ECH-6). We determined their biochemical specificity for the E-cadherin protein and IHC staining performance according to type and location of mutation on the CDH1 gene. Western blot analysis on mouse cell lines with conditional E-cadherin expression revealed a reduced specificity of EP700Y and NCL-L-E-cad for E-cadherin, with cross-reactivity of Clone 36 to P-cadherin. The use of IHC improved interpathologist agreement for ILC, lobular carcinoma in situ, and atypical lobular hyperplasia. The E-cadherin IHC staining pattern was associated with variant allele frequency and likelihood of nonsense-mediated RNA decay but not with the type or position of CDH1 mutations. Based on these results, we recommend the indication for E-cadherin staining, choice of antibodies, and their interpretation to standardize ILC diagnosis in current pathology practice.

Outcomes of atypical lobular hyperplasia managed by active surveillance or immediate surgery.

Atypical lobular hyperplasia (ALH) is typically diagnosed via needle core biopsy (NCB) and is commonly removed surgically in light of upgrade to malignancy rates of 1%-5%. As studies on radiographic outcomes of ALH managed by active surveillance (AS) are limited, we investigated the upgrade rates of surgically excised ALH as well as radiographic progression during AS. In this retrospective study, 125 patients with 127 ALH lesions diagnosed via NCB at Weill Cornell Medicine from 2015 to 2021 were included. The upgrade rate to cancer was determined for patients who had surgical management ≤6months after biopsy. Among patients with ALH managed by AS, we investigated radiographic progression on 6-month interval imaging. Of 127 ALH lesions, 75% (n=95) were immediately excised and 25% (n=32) were observed under AS. The upgrade rate of immediately excised ALH was 2.1% (n=2; invasive ductal carcinoma [IDC], T1N0 and IDC, and T1Nx). In the AS cohort, no ALH lesions progressed radiographically during the follow-up period of 22.5months (median), with all remaining stable (50%, n=16), resolving (47%, n=15), or decreasing in size (3%, n=1). In this study, NCB-diagnosed ALH had a low upgrade to malignancy rate (2.1%), and no ALH lesions managed by AS progressed radiographically during the follow-up period of 22.5months. These results support AS as the favorable option for patients with pure ALH on biopsy, with surgical excision for lesions that progress on surveillance.

Progress in atypical lobular hyperplasia: Striking a balance between active surveillance and minimally invasive interventions.

Progress in atypical lobular hyperplasia: Striking a balance between active surveillance and minimally invasive interventions.

Atypia Involving Fibroadenomas: Outcomes and Upgrade Rates.

Fibroadenomas (FAs) involved by atypia are rare. Consensus guidelines for management of FAs involved by atypia when diagnosed on image-guided biopsy do not exist because of limited data reporting surgical upgrade rates to ductal carcinoma in situ (DCIS) or invasive malignancy. Therefore, these lesions commonly undergo surgical excision. This single-institution retrospective study identified cases of FAs involved by atypical ductal hyperplasia (ADH), atypical lobular hyperplasia (ALH), and/or lobular carcinoma in situ (LCIS) diagnosed on image-guided biopsy between January 2014 and April 2023 to determine upgrade rates. Cases with incidental atypia adjacent to but not involving FAs were excluded. Among 1736 FAs diagnosed on image-guided biopsy, 32 cases (1.8%) were FAs involved by atypia including 43.8% (14/32) ALH, 28.1% (9/32) ADH, 18.8% (6/32) LCIS, 6.3% (2/32) LCIS + ALH, and 3.1% (1/32) unspecified atypia. The most common imaging finding was a mass. Most cases, 81.3% (26/32), underwent subsequent surgical excisional biopsy. A single case of ADH involving and adjacent to an FA was upgraded to FA involved by low-grade DCIS on excision for an overall surgical upgrade rate of 3.8%. There were no cases upgraded to invasive malignancy. For those omitting surgical excision, there was no subsequent malignancy diagnosis at the FA biopsy site over a mean follow-up of 73 months. Cases of radiologic-pathologic concordant FAs involved by atypia have a low upgrade rate of 3.8% and should undergo multidisciplinary review. Larger multi-institutional analysis is needed to determine whether guidelines for excision of atypia should apply to atypia involving FAs.

Preoperative multimodal ultrasonic imaging in a case of Peutz-Jeghers syndrome complicated by atypical lobular endocervical glandular hyperplasia: a case report and literature review

BackgroundPeutz-Jeghers syndrome (PJS), an autosomal dominant multiple cancerous disorder, is clinically characterized by mucocutaneous macules and multiple gastrointestinal hamartomatous polyps. Gastric-type endocervical adenocarcinoma (G-EAC), a special subtype of cervical adenocarcinoma with non-specific symptoms and signs, is known to occur in approximately 11% of female patients with PJS.Case presentationHere, we report a case of PJS in a 24-year-old female with multiple mucocutaneous black macules who complained of vaginal discharge and menorrhagia. Moreover, we first described the multimodal ultrasonographical manifestations of PJS-correlated G-EAC. The three-dimensional reconstructed view of G-EAC on 3D realisticVue exhibited a distinctive “cosmos pattern” resembling features on magnetic resonance imaging, and the contrast-enhanced ultrasound displayed a “quick-up and slow-down” pattern of the solid components inside the mixed cervical echoes. We reported the multimodal ultrasonographical characteristics of a case of PJS-related G-EAC, as well as reviewed PJS-related literature and medical imaging features and clinical characteristics of G-EAC to provide insight into the feasibility and potential of utilizing multimodal ultrasonography for the diagnosis of G-EAC.ConclusionsMultimodal ultrasound can visualize morphological features, solid components inside, and blood supplies of the G-EAC lesion and distinguish the G-EAC lesion from normal adjacent tissues. This facilitates preoperative diagnosis and staging of PJS-related G-EAC, thereby aiding subsequent health and reproductive management for patients with PJS.

Atypical Ductal Hyperplasia and Lobular In Situ Neoplasm: High-Risk Lesions Challenging Breast Cancer Prevention.

This retrospective study investigates the histopathological outcomes, upgrade rates, and disease-free survival (DFS) of high-risk breast lesions, including atypical ductal hyperplasia (ADH or DIN1b) and lobular in situ neoplasms (LIN), following Vacuum-Assisted Breast Biopsy (VABB) and surgical excision. The study addresses the challenge posed by these lesions due to their association with synchronous or adjacent Breast Cancer (BC) and increased future BC risk. The research, comprising 320 patients who underwent stereotactic VABB, focuses on 246 individuals with a diagnosis of ADH (120) or LIN (126) observed at follow-up. Pathological assessments, categorized by the UK B-coding system, were conducted, and biopsy samples were compared with corresponding excision specimens to determine upgrade rates for in situ or invasive carcinoma. Surgical excision was consistently performed for diagnosed ADH or LIN. Finally, patient follow-ups were assessed and compared between LIN and ADH groups to identify recurrence signs, defined as histologically confirmed breast lesions on either the same or opposite side. The results reveal that 176 (71.5%) patients showed no upgrade post-surgery, with ADH exhibiting a higher upgrade rate to in situ pathology than LIN1 (Atypical Lobular Hyperplasia, ALH)/LIN2 (Low-Grade Lobular in situ Carcinoma, LCIS) (38% vs. 20%, respectively, p-value = 0.002). Considering only patients without upgrade, DFS at 10 years was 77%, 64%, and 72% for ADH, LIN1, and LIN2 patients, respectively (p-value = 0.92). The study underscores the importance of a multidisciplinary approach, recognizing the evolving role of VABB. It emphasizes the need for careful follow-up, particularly for lobular lesions, offering valuable insights for clinicians navigating the complex landscape of high-risk breast lesions. The findings advocate for heightened awareness and vigilance in managing these lesions, contributing to the ongoing refinement of clinical strategies in BC care.

Huddled and Preternatural- Atypical Lobular Hyperplasia

Atypical lobular hyperplasia manifests as a clonal proliferation of dis-cohesive epithelial cells emerging from terminal duct lobular units. Neoplasm appears reminiscent of lobular carcinoma in situ (LCIS) although cellular quantification is reduced. Characteristically, the incidentally discovered lesion is associated with dysfunction or decimation of E-cadherin. Additionally designated as lobular intraepithelial neoplastic 1 (LIN1), tumefaction exemplifies a female preponderance. Typically, adult subjects are implicated. Tumefaction is commonly encountered within the fifth decade although no age of disease emergence is exempt. Atypical lobular hyperplasia is detected within&lt;1% of core needle biopsies adopted for evaluating BI-RADS 4 lesions [1,2]. Atypical lobular hyperplasia may incriminate bilateral breasts wherein specific lesion localization is absent. Tumefaction exhibits loss of chromosome 16qand deletion of CDH1 genes with loss of function of E-cadherin, a Tran’s membrane cell adhesion molecule. Alternatively, altered function of E-cadherin may occur. Exceptionally, various adhesion proteins are implicated wherein E-cadherin molecule appears stable [1,2]. Characteristically, atypical lobular hyperplasia is a diploid neoplasm. Tumefaction exhibits loss of heterozygosis (LOH) at chromosome 16q. A subset of neoplasms demonstrates methylation of CDH1 gene. Several tumefaction express loss of chromosome 22q and 16p, gain of chromosome 2p11.2, 5q32- 33.1 (CSF1R), 6q, 11q13 or 14q32.33.

Mucocele-like Lesion: To Excise or Not to Excise?

Abstract Introduction/Objective Mucocele-like lesions (MLLs) are characterized by cystically dilated, mucin-filled ducts, usually associated with rupture and extravasation of mucin into the stroma. The epithelium lining the ducts may be attenuated or show a spectrum of proliferative changes ranging from hyperplasia to atypical hyperplasia to ductal carcinoma in situ (DCIS). Our study aims to evaluate the necessity of excision of pure MLL without atypia diagnosed on core needle biopsy (CNB). Methods/Case Report We retrospectively identified all subsequent in-house CNBs obtained between January 2017- August 2022 with MLLs. We reviewed all CNB slides with the diagnosis containing a “mucocele-like lesion” and assessed radiologic-pathologic concordance. An upgrade was defined as invasive carcinoma and/or DCIS in the excision. The excision slides of all upgraded cases were re-reviewed. Out of ~16000 consecutive CNBs in the study period, 69 CNBs from 69 patients yielded MLL alone, MLL with atypia, or MLL with carcinoma. We excluded 43 CNBs (7 patients with prior/concurrent carcinoma and 36 without excision). The final cohort consisted of 25 CNBs (14 with pure mucocele-like lesions and 11 MLLs with atypia). The CNB targeted mammographic calcifications in 42 cases, and 4 sonographic mass. Results (if a Case Study enter NA) Subsequent excision or clinical follow-up was available for 14 pure MLLs—of which one was upgraded. Five excisions showed atypia (4 atypical ductal hyperplasias (ADH) and one atypical lobular hyperplasia (ALH)). Excisions of 11 MLL with atypia yielded 1 case upgraded to DCIS (9.09%, 1/11) and seven excisions showed atypia (5 ADH, 1 ALH, and 1 flat epithelial atypia). DCIS in an upgraded case was in an area with biopsy site changes. There was no upgrade to invasive carcinoma in either group. Among the 36 MLLs excluded from the study due to not having excision available for review, twelve were followed up with interval radiology and showed either stable lesions or no residual calcifications. Conclusion There was one case with upgrade of pure MLLs in our series. Clinicoradiological surveillance can be considered in a patient without prior/current carcinoma in pathological-radiological concordant CNB diagnosis of pure MLL.

European guidelines for the diagnosis, treatment and follow-up of breast lesions with uncertain malignant potential (B3 lesions) developed jointly by EUSOMA, EUSOBI, ESP (BWG) and ESSO

IntroductionBreast lesions of uncertain malignant potential (B3) include atypical ductal and lobular hyperplasias, lobular carcinoma in situ, flat epithelial atypia, papillary lesions, radial scars and fibroepithelial lesions as well as other rare miscellaneous lesions. They are challenging to categorise histologically, requiring specialist training and multidisciplinary input. They may coexist with in situ or invasive breast cancer (BC) and increase the risk of subsequent BC development. Management should focus on adequate classification and management whilst avoiding overtreatment. The aim of these guidelines is to provide updated information regarding the diagnosis and management of B3 lesions, according to updated literature review evidence. MethodsThese guidelines provide practical recommendations which can be applied in clinical practice which include recommendation grade and level of evidence. All sections were written according to an updated literature review and discussed at a consensus meeting. Critical appraisal by the expert writing committee adhered to the 23 items in the international Appraisal of Guidelines, Research and Evaluation (AGREE) tool. ResultsRecommendations for further management after core-needle biopsy (CNB) or vacuum-assisted biopsy (VAB) diagnosis of a B3 lesion reported in this guideline, vary depending on the presence of atypia, size of lesion, sampling size, and patient preferences. After CNB or VAB, the option of vacuum-assisted excision or surgical excision should be evaluated by a multidisciplinary team and shared decision-making with the patient is crucial for personalizing further treatment. De-escalation of surgical intervention for B3 breast lesions is ongoing, and the inclusion of vacuum-assisted excision (VAE) will decrease the need for surgical intervention in further approaches. Communication with patients may be different according to histological diagnosis, presence or absence of atypia, or risk of upgrade due to discordant imaging. Written information resources to help patients understand these issues alongside with verbal communication is recommended. Lifestyle interventions have a significant impact on BC incidence so lifestyle interventions need to be suggested to women at increased BC risk as a result of a diagnosis of a B3 lesion. ConclusionsThese guidelines provide a state-of-the-art overview of the diagnosis, management and prognosis of B3 lesions in modern multidisciplinary breast practice.

Update on Lobular Neoplasia.

Lobular neoplasia (LN) is a histopathologic entity that encompasses both lobular carcinoma in situ (LCIS) and atypical lobular hyperplasia (ALH). Management of LN is known to be variable and institutionally dependent. The variability in approach after a diagnosis of LN at percutaneous breast biopsy derives in part from heterogeneity in the literature, resulting in a range of reported upgrade rates to malignancy after initial identification at percutaneous biopsy, and also from historical shifts in understanding of the natural history of LN. It has become increasingly recognized that not all LN is the same and that distinct variants of LN such as pleomorphic LCIS and florid LCIS have distinct natural histories and distinct likelihoods of upgrade to malignancy. In addition, it is also increasingly understood that appropriate management of LN relies on scrupulous radiologic-pathologic correlation. This review details the imaging features and histopathologic nature of ALH, classic-type LCIS, and the LCIS variants; addresses changes in the historical understanding of this entity contributing to confusion regarding its management; and discusses the importance of performing radiologic-pathologic correlation after percutaneous biopsy to help guide appropriate management steps when LN is encountered. In addition to the short-term implications of an LN diagnosis in terms of upgrade and surgical outcomes, the long-term implications of an LN diagnosis regarding risk of developing a later breast cancer are examined. ©RSNA, 2023 Quiz questions for this article are available through the Online Learning Center.

Management of screening-detected lobular neoplasia in the era of digital breast tomosynthesis: A preliminary study

PurposeThe purpose of this study is to determine upgrade rates of lobular neoplasia detected by screening digital breast tomosynthesis (DBT) and to determine imaging and clinicopathological features that may influence risk of upgrade. MethodsMedical records were reviewed of consecutive women who presented with screening DBT-detected atypical lobular hyperplasia (ALH) and/or lobular carcinoma in situ (LCIS) from January 1, 2013, to June 30, 2020. Included patients underwent needle biopsy and had surgery or at least two-year imaging follow-up. Imaging and clinicopathological features were compared between upgraded and nonupgraded cases of lobular neoplasia using the Pearson's chi-squared test and the Wilcoxon signed-rank test. ResultsDuring the study period, 107 women (mean age 55 years, range 40–88 years) with 110 cases of ALH and/or LCIS underwent surgery (80.9%, n = 89) or at least two-year imaging follow-up (19.1%, n = 21). The overall upgrade rate to cancer was 5.5% (6/110), and the upgrade rate to invasive cancer was 3.6% (4/110). The upgrade rate of ALH to cancer was 4.1% (3/74), whereas the upgrade rate of LCIS to cancer was 9.4% (3/32) (p = .28). The upgrade rate of cases presenting as calcifications was 4.2% (3/71), whereas the upgrade rates of cases presenting as noncalcified findings was 7.7% (3/39) (p = .44). ConclusionsThe upgrade rate of screening DBT-detected lobular neoplasia is less than 6%. Surveillance rather than surgery can be considered for lobular neoplasia, particularly in patients with ALH and in those with screening-detected calcifications leading to the diagnosis.

Recommendations for the Screening of Breast Cancer of the Brazilian College of Radiology and Diagnostic Imaging, Brazilian Society of Mastology and Brazilian Federation of Gynecology and Obstetrics Association.

To present the update of the recommendations of the Brazilian College of Radiology and Diagnostic Imaging, the Brazilian Society of Mastology and the Brazilian Federation of Associations of Gynecology and Obstetrics for breast cancer screening in Brazil. Scientific evidence published in Medline, EMBASE, Cochrane Library, EBSCO, CINAHL and Lilacs databases between January 2012 and July 2022 was searched. Recommendations were based on this evidence by consensus of the expert committee of the three entities. Annual mammography screening is recommended for women at usual risk aged 40-74 years. Above 75 years, it should be reserved for those with a life expectancy greater than seven years. Women at higher than usual risk, including those with dense breasts, with a personal history of atypical lobular hyperplasia, classic lobular carcinoma in situ, atypical ductal hyperplasia, treatment for breast cancer or chest irradiation before age 30, or even, carriers of a genetic mutation or with a strong family history, benefit from complementary screening, and should be considered individually. Tomosynthesis is a form of mammography and should be considered in screening whenever accessible and available.

No Cancer Occurrences in 10-year Follow-up after Prophylactic Nipple-sparing Mastectomy.

Patients receiving prophylactic NSM at a single institution from 2006 to 2019 were included in a retrospective nature. Patient demographics, genetic mutations, operative details, and specimen pathology were recorded, and all postoperative patient visits and documentation were screened for cancer occurrence. Descriptive statics were performed where appropriate. Two hundred eighty-four prophylactic NSMs were performed on 228 patients with a median follow-up of 120.5 ± 15.7 months. Roughly, a third of patients had a known genetic mutation, with 21% BRCA1 and 12% BRCA2. The majority (73%) of prophylactic specimens had no abnormal pathology. The most commonly observed pathologies were atypical lobular hyperplasia (10%) and ductal carcinoma in situ (7%). Cancer was identified in 10% of specimens, with only one case of lymphovascular invasion. Thus far, there have been no incidences of locoregional breast cancer occurrence in this cohort. The long-term breast cancer occurrence rate in this cohort of prophylactic NSM patients at the time of this study is negligible. Despite this, continued surveillance of these patients is necessary until lifetime risk of occurrence following NSM has been established.

98. Incidental Findings of Malignant and Pre-malignant Lesions in Gender-Affirming Mastectomies: A Retrospective Review with Recommendations for Post-operative Management

INTRODUCTION: Gender-affirming mastectomy is the most common gender-affirming operation performed in the United States. Given expanding insurance coverage and access, there are increasing reports of incidental pathologic findings of breast cancer and high-risk lesions on routine surgical specimens. While these incidental findings have been described in the literature, there is little guidance regarding treatment and subsequent follow-up. In this retrospective review, we describe our incidental findings with a focus on post-operative treatment and ongoing surveillance. METHODS: A retrospective review of gender-affirming mastectomy patients from 2007 to 2022 at a single institution was performed to identify the incidence of abnormal perioperative breast tissue pathology. For patients with atypical or malignant lesions, a case series was performed to evaluate demographics, personal and family history of cancer, genetic risk factors, mammography, smoking history, medical comorbidities, reproductive health history, testosterone use, oncologic treatment course, and ongoing surveillance. RESULTS: Four hundred and sixty-six patients over a fifteen-year period underwent gender-affirming mastectomy with tissue submitted for pathologic evaluation. Incidental atypical or malignant lesions were identified in nine patients (1.9%). Individual treatment and surveillance plans varied. All patients with malignant pathology (one with invasive ductal carcinoma (IDC) and two with ductal carcinoma in situ (DCIS)) were referred to surgical oncology at our institution. The patient with IDC underwent axillary workup with imaging and active treatment with chemotherapy. Two patients with DCIS did not require axillary staging, radiation, or chemotherapy, and are undergoing active surveillance. Among the patients with atypical findings (four with atypical ductal hyperplasia (ADH), two with atypical lobular hyperplasia (ALH)), there was variation in referral and treatment plans. Surveillance recommendations ranged from monthly self-exams and annual clinical exams to no recorded surveillance recommendations. CONCLUSION: In this retrospective review, the overall incidence of high risk and malignant lesions is low. While we found there was consistent treatment offered to patients with malignant findings, there was variation in follow-up and surveillance recommendations for atypical lesions. As we perform gender-affirming mastectomy with increasing pace, it is essential to understand breast cancer risk, treatment, and long-term screening. Further studies are needed for accurately characterizing risk to inform surgical decision making, patient counseling for treatment and surveillance, and long-term screening guidelines.

AB147. SOH23ABS_178. Atypical lobular hyperplasia in a fibroadenoma a case report

AB147. SOH23ABS_178. Atypical lobular hyperplasia in a fibroadenoma a case report