Excision Follow-up Research Articles

Is Surgical Excision of Focal Atypical Ductal Hyperplasia Warranted? Experience at a Tertiary Care Center.

The core-needle biopsy (CNB) diagnosis of atypical ductal hyperplasia (ADH) generally mandates follow-up excision, but controversy exists on whether small foci of ADH require surgical management. This study evaluated the upgrade rate at excision of focal ADH (fADH), defined as 1 focus spanning ≤2mm. We retrospectively identified in-house CNBs with ADH as the highest-risk lesion obtained between January 2013 and December 2017. A radiologist assessed radiologic-pathologic concordance. All CNB slides were reviewed by two breast pathologists, and ADH was classified as fADH and nonfocal ADH based on extent. Only cases with follow-up excision were included. The slides of excision specimens with upgrade were reviewed. The final study cohort consisted of 208 radiologic-pathologic concordant CNBs, including 98 fADH and 110 nonfocal ADH. The imaging targets were calcifications (n=157), a mass (n=15), nonmass enhancement (n=27), and mass enhancement (n=9). Excision of fADH yielded seven (7%) upgrades (5 ductal carcinoma in situ (DCIS), 2 invasive carcinoma) versus 24 (22%) upgrades (16 DCIS, 8 invasive carcinoma) at excision of nonfocal ADH (p=0.01). Both invasive carcinomas found at excision of fADH were subcentimeter tubular carcinomas away from the biopsy site and deemed incidental. Our data show a significantly lower upgrade rate at excision of focal ADH than nonfocal ADH. This information can be valuable if nonsurgical management of patients with radiologic-pathologic concordant CNB diagnosis of focal ADH is being considered.

Mass-forming ductal carcinoma in situ: An ultrasonographic and histopathologic correlation study

Ultrasound (US) guided core needle biopsy (CNB) for mass lesions resulting in a diagnosis of ductal carcinoma in situ (DCIS) is often considered radiologically discordant and generates surgical planning difficulty. One hundred cases of US-guided CNB for mass lesions diagnosed as DCIS were collected from 2013 to 2021. Histological features were reviewed and correlated with radiology and surgical excision findings. Thirty (30%) were high-grade (HG), and seventy (70%) were low- to intermediate-grade. Seventy-one (71%) cases had a histological correlate of a mass-forming lesion, including 26 (26%) were associated with benign mass-forming lesions (category 1) such as papilloma, complex sclerosing lesion/radial scar, fibroadenoma, sclerosing adenosis, and ruptured cyst; 23 (23%) were HG with solid pattern, comedo necrosis, and stromal desmoplasia (category 2); and 22 (22%) had predominantly papillary architecture (category 3). Twenty-nine (29%) were discordant with no histologic correlate of a mass lesion (category 4). Follow-up excisions were available in 79 cases. Invasive carcinoma was identified in 14 cases (18%), of which 8 were from the radiologically discordant category (35%), 3 (17%) associated with HG DCIS with desmoplasia, 2 (10%) associated with benign mass lesion and 1(5%) was predominantly papillary architecture. US-guided CNB for mass-forming lesions with a DCIS diagnosis on CNB can be grouped into four categories. Radiology-pathology correlation is essential. This categorization emphasized rad-path correlation and had a clear difference in upgrade rate on follow-up excision. Rad-path discordant biopsy cases were more likely to be associated with a missed invasive carcinoma (p < 0.05).

Detailed Morphologic Evaluation of Breast Papillary Lesions on Core Biopsy Is Critical for Accurate Classification and Clinical Management: The Experience of an Academic Institute

BackgroundDistinguishing between a breast intraductal papilloma and a papillary lesion with atypia or malignancy can be very challenging on core biopsy. There has been a long ongoing debate over whether or not it is necessary for breast papillary lesions diagnosed on core biopsies to be surgically excised, and the upgrading rate after excision varies. Method and/or ResultThis study was carried out in a subspecialized academic pathology department, with well-formed criteria established among the faculty for the categorization of breast papillary lesions, with emphasis on the morphology evaluation of cellular features. A total of 320 breast core biopsies with follow-up excisions were identified. Of these, 286 cases had concordant results between the biopsy and excision, giving a concordance rate of 89.4%, with 98% concordance (143/146) in benign papilloma, 100% (111/111) in papillary carcinoma, and 51% (32/63) in papilloma with atypia. Of the upgraded cases, two were upgraded from benign to atypical, 11 from atypia to malignancy, and only one from benign to malignant. The overall average upgrading rate was 4.4% (14/320), with the critical upgrading (from benign to atypia or malignancy) rate of 0.94% (3/320). Downgrading was only identified in the group of papilloma with atypia, with 20 of 63 cases downgraded to benign papilloma on excision. ConclusionOur study indicates that surgical excision may not be necessary for all papillary lesions after detailed evaluation of the morphology on core biopsies. Assessing the morphological features of the epithelial cells is critical for the accurate classification and clinical management of papillary lesions.

Morphologic subtypes of lobular carcinoma in situ diagnosed on core needle biopsy: clinicopathologic features and findings at follow-up excision.

Lobular carcinoma in situ (LCIS) is currently classified as classic (CLCIS), florid (FLCIS), and pleomorphic (PLCIS). Given the rarity of FLCIS and PLCIS, information on their clinico-pathologic features and biologic potential remains limited. We evaluated the upgrade rates at excision of FLCIS and PLCIS diagnosed on inhouse core needle biopsy (CNB) and their clinical presentation and follow-up. Over a period of 11 and a half years, there were a total of 36 inhouse CNBs with pure PLCIS (n = 8), FLCIS (n = 24), or LCIS with pleomorphic features (LCIS-PF) (n = 4). The upgrade rates to invasive carcinoma or ductal carcinoma in situ (DCIS) were 25% for PLCIS (2/8), 17% for FLCIS (4/24), and 0% for LCIS-PF (0/4). The overall upgrade rate of PLCIS and FLCIS combined was 19% (6/32). All but one case (not upgraded at excision) were radiologic-pathologic concordant. Apocrine features, previously reported only in PLCIS, were also noted in FLCIS. HER2 overexpression was seen in 13% of cases. This study highlights the more aggressive biologic features of PLCIS and FLCIS compared to CLCIS and supports surgical management for these lesions.

Does the Two-Tier System Accurately Predict Progression of Endometrial Hyperplasia to Endometrial Carcinoma in High-Risk Populations? A Retrospective Study in a Safety-Net Hospital

Abstract Introduction/Objective In 2014, the WHO simplified the classification of endometrial hyperplasia (EH) into a two-tier system: endometrial hyperplasia without atypia/benign endometrial hyperplasia (BEH) and atypical endometrial hyperplasia (AEH)/endometrioid intraepithelial neoplasia (EIN), as opposed to the 1994 WHO 4-tier scheme. We conducted this study to assess the diagnostic validity of the two-tier scheme in predicting upgrade to endometrioid adenocarcinoma (EA) in our high-risk patient population. Methods Retrospective review from Aug 2009 to August 2019 revealed 144 cases of EH diagnosed on biopsy. The cases were reclassified using the 2014 two-tier scheme to 81 BEH and 63 AEH. The excisional diagnoses, if available, were compared with the initial biopsy results. Results At hysterectomy, 22 AEH (50%) were diagnosed as benign, with no residual AEH, 15 cases were upgraded to EA (34.1%), and 7 had residual AEH (15.9%). Endometrial polyp was identified in 29 cases out of 63 AEH, 24 of which had a follow-up excision. Among those, 6 were upgrade to EA (25%), significantly lower than the upgrade rate of AEH without polyp (45%) (p=0.0344). Conclusion In our high-risk patient population, the likelihood of upgrade to EA at excision of a biopsy-diagnosed AEH is significantly higher than BEH and is in line with what was reported in the literature for other populations. Patients with endometrial polyps were less likely to progress to EA. Our study demonstrated the diagnostic validity of the two- tiered classification in high-risk population and supports the emphasis on cytological atypia.

Histology-Independent Signature Distinguishes Kikuchi-Fujimoto Disease/Systemic Lupus Erythematosus-Associated Lymphadenitis From Benign and Malignant Lymphadenopathies.

Kikuchi-Fujimoto disease (KFD) and systemic lupus erythematosus (SLE) are benign entities with histologic features that raise concern about malignancy and infection. We searched for a histology-independent KFD/SLE signature relying on only immunophenotype and basic clinical characteristics. A histology-independent KFD/SLE signature was generated using 975 excised lymph nodes with flow immunophenotyping, including 16 cases of KFD/SLE. This signature was then evaluated in 1,198 fine-needle aspiration (FNA) specimens. The top flow cytometry discriminant for KFD/SLE was uniform CD38+ expression on CD19+ events. Immunohistochemistry demonstrated nodules of IgD+, IgM- B cells surrounding necrotizing and activated T-cell areas. A signature combining 6 flow cytometry criteria with age and sample site had a positive predictive value of 88% for KFD/SLE, which had a prevalence of 1.6%. All 4 signature-positive FNA cases with follow-up excision were KFD/SLE. At a second institution, 4 of 5 KFD/SLE cases passed the top discriminant. A flow cytometry signature combined with age and biopsy site identifies KFD/SLE independent of histology, suggesting a shared immune composition and independently confirming that KFD/SLE represents a distinct entity. Unexpectedly, an IgD+CD38+ small B-cell population is a distinctive feature of KFD/SLE, suggesting a possible pathologic role for anergic/autoreactive B cells.

Outcomes of benign intraductal papillomas diagnosed on core biopsy: a review of 104 cases with subsequent excision from a single institution.

A diagnosis of papilloma with atypia on core biopsy (CB) requires excision, as the risk of associated malignancy is high (average 36.9%). The management of benign intraductal papillomas (IP) diagnosed on CB is controversial due to varying upgradation rates (0-29%, average 7%) reported on excision. Our aim was tostudy the clinical, radiological, and pathological features associated with benign IP upgradation at our institution. An electronic data base search (keyword papilloma), from Jan. 2000-Aug. 2015 identified 258 CBs. After exclusions, 104 CBs of benign IPs with subsequent excisions from 101 females were reviewed. The clinical, radiological, and pathological features between IPs that had upgrades (defined as malignancy or atypical ductal hyperplasia) and non-upgraded IPs were compared using descriptive statistics. Studies of benign IP on CB with at least 50 follow-up excisions published between 2008 and 2016 were analyzed. Residual IP was present in 83.6% (87/104) of reviewed excisions. There were six upgrades (5.6%) (4 to malignancy (3.8%) and 2 to atypical ductal hyperplasia).Upgrades were associated with mass on imaging with a trend to significance (p = .05). Two cases with malignant upgrade had a history of contralateral cancer. An analysis of 25 published studies showed an average malignant upgrade of 5.7% (182/3164). The majority of benign IP are not upgraded on excision; thus, not all need to be excised. Those that may warrant excision are those with prior history of carcinoma, those with a mass on imaging, and/or suboptimal or imaging-discordant CB sampling.

Feasibility of the Less Is More Approach in Treating Low-Risk Ductal Carcinoma In Situ Diagnosed on Core Needle Biopsy: Ten-Year Review of Ductal Carcinoma In Situ Upgraded to Invasion at Surgery.

- Ductal carcinoma in situ (DCIS) represents 20% of screen-detected breast cancers. The likelihood that certain types of DCIS are slow growing and may never progress to invasion suggests that our current standards of treating DCIS could result in overtreatment. The LORIS (LOw RISk DCIS) and LORD (LOw Risk DCIS) trials address these concerns by randomizing patients with low-risk DCIS to either active surveillance or conventional treatment. - To determine the upgrade rate of DCIS diagnosed on core needle biopsy to invasive carcinoma at surgery and to evaluate the safety of managing low-risk DCIS with surveillance alone, by characterizing the pathologic and clinical features of upgraded cases and applying criteria of the LORD and LORIS trials to these cases. - A 10-year retrospective analysis of DCIS on core needle biopsy with subsequent surgery. - We identified 1271 cases of DCIS on core needle biopsy: 200 (16%) low grade, 649 (51%) intermediate grade, and 422 (33%) high grade. Of the 1271 cases, we found an 8% upgrade rate to invasive carcinoma (n = 105). Nineteen of the 105 upgraded cases (18%) had positive lymph nodes. Low-grade DCIS was least likely to upgrade to invasion, comprising 10% (10 of 105) of upgraded cases. Three of the 105 upgraded cases (3%) met criteria for the LORD trial, and all were low-grade DCIS on core needle biopsy with favorable biology on follow-up. - There is a clear risk of upgrade to invasion on follow-up excision; however, applying strict criteria of the LORD trial effectively decreases the likelihood of a missed invasive component or missed aggressive pathologic features.

Correlation between invasive mammary carcinoma grade and size in ultrasound-guided core needle biopsy and subsequent surgical excision.

The purpose of this study was to correlate the histologic grade, mitotic rate and size of invasive mammary carcinomas (IMC) on ultrasound (US) core needle biopsy (CNB) and the follow-up excision (FUE). The underestimation and overestimation of the grades by CNB were 11% and 8%. CNBs were more specific for grade 3 tumors. Tumors >10mm by US examination showed greater concordance in grades. The size in the FUE was the best determinant of pT followed by US examination. The extent of IMC on CNB was larger than FUE in 8% resulting in pT upstaging in 3% of cases.

Lobular neoplasia diagnosed on breast Core biopsy: frequency of carcinoma on excision and implications for management.

The appropriate follow-up and treatment for patients with a core biopsy diagnosis of lobular neoplasia (atypical lobular hyperplasia or lobular carcinoma in situ) remains controversial. Several studies have attempted to address this issue, with recommendations ranging from close clinical follow-up or surveillance to mandatory surgical excision in all cases. We report the findings at our institution, where virtually every core needle biopsy diagnosis of lobular neoplasia results in follow-up excision. The goal of the study was to identify potential predictors of upgrade to a more significant lesion. We identified 76 patients over a 15-year period with a core biopsy diagnosis of pure lobular neoplasia and no other high-risk lesions. Subsequent surgical excision identified 10 cases (13%) that were upgraded to carcinoma. Upgrade diagnoses included invasive ductal carcinoma (n=1), invasive lobular carcinoma (n=4), ductal carcinoma in situ (n=3), and pleomorphic lobular carcinoma in situ (n=2). All 10 upgraded cases had imaging findings suspicious for malignancy including irregular masses, asymmetric densities, or pleomorphic calcifications. Of the 10 upgraded cases, 7 were diagnosed as lobular carcinoma in situ on core biopsy. The data support a role for radiologic-pathologic correlation in the evaluation of suspicious breast lesions and suggest that the extent of lobular neoplasia in core biopsy specimens may be an indicator of the likelihood of upgrade to carcinoma.

Surgical follow-up results for apocrine adenosis and atypical apocrine adenosis diagnosed on breast core biopsy.

Apocrine adenosis (AA) and atypical apocrine adenosis (AAA) are uncommon findings in breast biopsies that may be misinterpreted as carcinoma. The clinical significance and risk implications of AAA diagnosed on core biopsy are not well established. This study aimed to determine the frequency of carcinoma on follow-up excision in patients with a diagnosis of AA or AAA on core biopsy. Forty-one breast core biopsies of AA (n=29) and AAA (n=12) were identified during a study period of 12 years. Of the 41 core biopsies with AA or AAA, 10 biopsies showed coexisting/concurrent atypical hyperplasia or carcinoma. In the absence of coexisting/concurrent atypical hyperplasia or carcinoma in core biopsy, none of the follow-up excision specimens after a diagnosis of AA or AAA showed ductal carcinoma in situ or invasive carcinoma. In conclusion, AA or AAA by itself is an uncommon core biopsy diagnosis that may not require surgical excision.

Surgical excision outcome after radial scar without atypical proliferative lesion on breast core needle biopsy: a single institutional analysis.

Radial scar (RS) has been recognized as a risk factor for developing breast cancer, and excision is recommended for patients with RS identified on core needle biopsy (CNB). However, recent literatures suggest that the increased risk may be caused by concurrent proliferative lesions on the biopsy, rather than radial scar itself. In this study, we investigated the follow-up excision (FUE) results for patients with RS on CNB with no history of a prior or a concurrent breast cancer or atypical proliferative lesions (APLs). A total of 113 RS cases including 32 cases with APLs or carcinoma and 81 cases without APLs on CNB were included in this study. Forty cases (49%) without APLs had FUE. No significant difference in radiologic and clinical findings was identified between cases with FUEs and cases without FUEs. Of the 40 cases with FUE, 9 cases (22.5%) were upgraded including 3 atypical ductal hyperplasias, 4 lobular neoplasias, 1 flat epithelial atypia, and 1 atypical apocrine adenosis. However, no case was upgraded to invasive carcinoma or ductal carcinoma in situ. All cases with mammotome CNBs were not upgraded. Our data suggest that conservative follow-up with imaging rather than surgical excisions may be more appropriate for patients with only RS on biopsy, especially for patients with mammotome CNBs.

Pathologic findings of follow-up surgical excision for radial scar on breast core needle biopsy

The data regarding radial scar (RS) as a risk factor for breast cancer are conflicting, and it is unclear whether an excision is warranted for patients with RS identified on core needle biopsy (CNB). In this study, we investigated the follow-up excisional results for patients with RS on CNB with no history of or concurrent breast cancer or atypical proliferative lesions. The study cohort was composed of 403 such cases, and follow-up excision (FUE) was performed in 220 (54.6%). There was no significant difference in the radiologic findings in cases with and without FUE. Of the 220 cases with FUE, only 2 (0.9%) were upgraded to malignancy (1 invasive carcinoma and 1 ductal carcinoma in situ), whereas 44 cases (20.0%) were upgraded to atypical ductal hyperplasia and 13 cases (5.9%) to lobular neoplasia. Upgrades were associated with greater age but not with any other variable. This is one of the largest studies to evaluate excisional findings in patients with RS identified on CNB but no history of or concurrent breast cancer or atypical proliferative lesions, and the extremely low malignancy-upgrade rate indicates that conservative follow-up with imaging rather than surgical excisions may be more appropriate for these patients.

Actinic Keratosis, Transected: What Lies Beneath?

Evaluation of superficial transected shave biopsies of squamous neoplasms often presents a diagnostic dilemma for the dermatopathologist because of the lack of complete visualization of the base of the epidermis. Fear of "missing" an invasive carcinoma must be balanced with avoidance of overdiagnosis of precancerous actinic keratosis (AK), especially on cosmetically sensitive areas such as the face. If a concern exists that a more invasive component may be present, a diagnosis of AK transected at the base (AKT) will often be rendered to alert the dermatologist of this concern. Because of lack of objective data regarding the malignant transformation of this diagnosis, the method of treatment is often based on the clinical appearance of the residual lesion or the lesion is rebiopsied to establish a more definitive diagnosis, costing patient and physician time and increasing health care costs. This study aims to provide objective data regarding (1) how often dermatologists are resampling these lesions and (2) how accurately an AKT diagnosis identifies patient risk for a more aggressive lesion, to establish whether there is a benefit in providing more tissue for the initial biopsy. We performed a retrospective study examining 274 biopsies with a diagnosis of AKT. We found only 27% had follow-up rebiopsy or excision. Of these 73 cases, 63% showed residual AK and 20% showed a more serious lesion, which warrants more aggressive treatment. Because the health care culture slowly shifts to metric-driven medicine and value-based payment, providing objective data for the progression of diagnosis, such as AKT, will be important (1) to aid the clinician in taking adequate tissue samples for diagnosis to make adequately informed management decisions, (2) to reduce the conversion of AK to squamous cell carcinoma, the resultant depth of squamous cell invasion, and the patient's risk of metastases to improve the patient's long-term outcomes, and (3) to decrease the overall cost of the patient's health care by improving the patient's long-term outcomes.

Management of flat epithelial atypia on breast core biopsy may be individualized based on correlation with imaging studies

Flat epithelial atypia of the breast commonly co-exists with atypical ductal hyperplasia, lobular neoplasia, and indolent forms of invasive carcinomas such as tubular carcinoma. Most patients with pure flat epithelial atypia on core biopsy undergo surgical excision to evaluate for carcinoma in the adjacent breast tissue. Studies to date have reported varying upgrade rates with most recommending follow-up excision. These studies have often lacked detailed radiographic correlation, central review by breast pathologists and information regarding the biology of the carcinomas identified upon excision. In this study, we report the frequency of upgrade to invasive carcinoma or ductal carcinoma in situ in excision specimens following a diagnosis of pure flat epithelial atypia on core biopsy. Radiographic correlation is performed for each case and grade/receptor status of detected carcinomas is reported. Seventy-three (73) core biopsies containing pure flat epithelial atypia were identified from our files, meeting inclusion criteria for the study. In the subsequent excision biopsies, five (7%) cases contained invasive carcinoma or ductal carcinoma in situ and seventeen (23%) contained atypical ductal hyperplasia or lobular neoplasia. All of the ductal carcinoma in situ cases with estrogen receptor results were estrogen receptor positive and intermediate grade. The invasive tumors were small (pT1a) hormone receptor-positive, HER2-negative, low-grade invasive ductal or tubular carcinomas with negative sentinel lymph-node biopsies. No upgrades were identified in the 14 patients who had all of their calcifications removed by the stereotactic core biopsy. Our rate of upgrade to carcinoma, once cases with discordant imaging are excluded, is at the lower end of the range reported in the literature. Given the low upgrade rate and indolent nature of the carcinomas associated with flat epithelial atypia, case management may be individualized based on clinical and radiographic findings. Excision may not be necessary for patients without remaining calcifications following core biopsy.

The utility of MYC and FLT4 in the diagnosis and treatment of postradiation atypical vascular lesion and angiosarcoma of the breast.

Atypical vascular lesions (AVLs) and angiosarcomas (ASs) are well-recognized complications of radiotherapy for breast cancer. Early diagnosis may be challenging, particularly on small biopsies, and the treatment options are limited. Recently, MYC and sometimes FLT4 gene amplification has been reported in AS, but not in AVL, and FLT4 may be a target for therapy. We evaluated the MYC/FLT4 status in AVL and AS by immunohistochemistry (IHC) and fluorescence in situ hybridization (FISH), determined its utility in differentiating these 2 entities in small biopsies, and ascertained the value of FLT4 as a potential marker for targeted therapy. Thirty-five vascular neoplasms were reviewed from 21 breast cancer patients who received radiotherapy (AVL, n = 18; AS, n = 17). MYC expression by IHC and/or gene amplification by FISH were identified in 13 (77%) of 17 ASs, but none of the AVL cases. Four patients had biopsies with follow-up excisions, of which 1 showed the morphology of an AVL on biopsy and AS on excision, both positive for MYC. Of 17 ASs, 3 (18%) showed strong and diffuse 3+ cytoplasmic FLT4 staining by IHC and FLT4 gene amplification by FISH. All 3 cases were coamplified for the MYC gene. Focal and weak FLT4 cytoplasmic immunoreactivity was present in 2 (12%) of 17 AVL cases and 12 (70%) of 17 AS cases. Although MYC is a valuable ancillary tool in distinguishing AS from AVL, FLT4 IHC may be used to screen for patients with FLT4 gene amplification who might benefit from targeted therapy, as only diffuse strong FLT4 immunoreactivity correlated with FLT4 gene amplification.

Radial scar/complex sclerosing lesions: a clinicopathologic correlation study from a single institution.

Radial scars (RSs) or complex sclerosing lesions (CSLs) of the breast are benign radiologic and histologic entities. With the introduction of population-based screening programs, their incidence has increased to 0.03% to 0.09% of all core needle biopsies (CNBs). They can pose diagnostic difficulty because their radiologic and histologic appearances mimic carcinoma. We retrospectively searched for and reviewed all cases of RS/CSL diagnosed on image-guided CNB from January 1, 1994, to August 31, 2013, at a single institution. We also assessed the pathologic reports from excisional biopsies to identify cases upstaged to atypia or neoplasm. After exclusions, 100 CNBs were identified from 97 women, which showed RS/CSL without concomitant atypia. Mean age of the women was 52.9 years. Thirty-five women (38/100 CNBs, 38%) had follow-up excision. The median size of the excised RS/CSLs was 1.2 cm; 69% were larger than 1.0 cm. Almost all excised cases (92%) showed radiologic and pathologic concordance, and 79% were designated as suspicious for malignancy (Breast Imaging Reporting and Data System level 4). The most common findings of 38 follow-up excisional biopsies were residual RS (22 [58%]), atypical lobular hyperplasia (5 [13%]), and no residual lesion (5 [13%]). Eleven excisional biopsies (29%) were upstaged to invasive or in situ carcinoma or to atypical hyperplasia. Follow-up excisional biopsy is warranted for RS/CSLs, specifically those larger than 1.0 cm with worrisome radiographic findings or with radiologic and pathologic discordance. Approximately 29% of cases were upstaged to in situ or invasive carcinomas or other high-risk lesions in our study.

Significant histologic features differentiating cellular fibroadenoma from phyllodes tumor on core needle biopsy specimens.

Cellular fibroepithelial lesions (CFELs) are a heterogeneous group of tumors encompassing cellular fibroadenoma (CFA) and phyllodes tumor (PT). Distinction between the two is challenging on core needle biopsy (CNB) specimens. The objective of this study was to evaluate histologic features that can help distinguish PT from CFA on CNB specimens. Records of all patients diagnosed with CFELs on CNB specimens with follow-up excision between January 2002 and December 2012 were retrieved. Histopathologic stromal features were evaluated on CNB specimens, including mitoses per 10 high-power fields (hpf), overgrowth, increased cellularity, fragmentation, adipose tissue infiltration, heterogeneity, subepithelial condensation, and nuclear pleomorphism. Twenty-seven (42.2%) of 64 were diagnosed as PT (24 benign PTs and three borderline PTs) and 37 (57.8%) as CFA on excision. All features except for increased stromal cellularity were statistically significant. The average number of histologic features seen in PT and CFA was 3.9 and 1.4, respectively (odds ratio [OR], 7.27; 95% confidence interval [CI], 2.44-21.69; P = .0004). The average number of mitoses per 10 hpf was 3.0 for PT compared with 0.8 for CFA (OR, 2.14; 95% CI, 1.18-3.86; P = .01). The presence of mitoses (three or more) and/or total histologic features of three or more on CNB specimens were the most helpful features in predicting PT on excision.

Abstract P1-02-08: Papillary lesions of the breast on core biopsies: Should routine surgical excision be performed?

Abstract Background: The optimal management of papillary lesions, particularly benign papillomas, detected on core needle biopsies remains debatable. The purpose of this study was to determine the risk of upgrade to malignancy of core biopsy diagnosed papillary lesions on the subsequent surgical excision. Methods: Following institutional ethics review board approval, the pathology database was searched for all papillary lesions diagnosed on core needle biopsies from Jun 2005 to June 2010. The papillary lesions were histologically categorized as benign, atypical, suspicious for malignancy and definite for malignancy. The core biopsy findings were compared with the follow-up excision biopsy material to identify any upgrade to malignancy (i.e. ductal carcinoma in situ or invasive carcinoma). The presence of any associated significant risk lesions such as atypical ductal hyperplasia (ADH) and lobular neoplasia (LN) were also recorded. Results: A total of 113 papillary lesions were diagnosed on core needle biopsies of 98 patients, with a mean age of 57 years. A median of 5 cores of breast tissue were obtained per papillary lesion. Of these papillary lesions, 73 were benign, 25 atypical, 8 suspicious for malignancy and 7 definite for malignancy. The overall excision rate was 83%. Of the 58 benign papillary lesions excised, only one (1.7%) showed malignancy (3mm ductal carcinoma in situ) - of interest, the papillary lesion per se was confirmed benign on excision, while an adjacent focus of flat epithelial atypia was present in the initial core biopsy. Nine papillomas were associated with adjacent ADH and/or LN on excision and the rest of the excisions (n = 48) showed no residual papillary lesion or benign papillomas. Among the 24 excised atypical papillary lesions, the positive predictive value (PPV) for malignancy was 42% (10 in situ papillary carcinomas, 4 of these associated with invasive carcinoma). The remaining excisions disclosed ADH and/or LN (n = 3) or benign breast tissue/papillomas (n = 11). None of the 4 papillary lesions with the apocrine atypia were malignant on excision. Of the 5 excised papillary lesions which were suspicious for malignancy on the cores, all showed malignancy (5 in situ carcinomas; 2 associated with invasive carcinoma) on open surgical biopsy. The PPV for malignancy of the 7 core biopsy diagnosed malignant papillary lesions was 100%. Conclusions: Papillary lesions diagnosed as atypical or suspicious for malignancy on core needle biopsies should be completely excised to exclude malignancy. Our findings suggest, however, that routine surgical excision may not be necessary for core biopsy detected benign papillomas which are not associated with atypia. Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P1-02-08.

Management of Papillary Lesions of the Breast: Can Larger Core Needle Biopsy Samples Identify Patients Who May Avoid Surgical Excision?

The ability to distinguish benign from atypical/malignant papillary lesions on core needle biopsy is limited by the representative nature of the biopsy method, thus follow-up excision is usually recommended. We aimed to determine if larger samples of tissue obtained by core needle biopsy can more reliably predict the true benign nature of a papilloma. We reviewed the pathology slides and medical records of 51 patients who were diagnosed with benign papillomas on core needle biopsy from 2000 to 2010, who subsequently underwent surgical excision. The characteristics of the core needle biopsy that were associated with retention of benign histology on excision were determined and analyzed. Atypical ductal hyperplasia and carcinoma were identified in 5.8 % (3/51) and 5.8 % (3/51) of papillary lesions, respectively, when excised. Patients whose lesions were diagnosed as benign on excision were significantly distinguished by the area (mm(2)) of tissue sampled by core needle biopsy (mean ± standard deviation (SD): 101.5 ± 106.5) compared with those with atypia or carcinoma on excision (mean ± SD: 41.7 ± 24.0, P = 0.003). All biopsies performed with 12-gauge or larger needles retained benign features on excision. Core needle biopsy tissue samples consisting of ≥7 cores, or measuring >96 mm(2) in aggregate, had a negative predictive value for atypia/malignancy of 100 %. Larger tissue samples significantly improved the predictive value of benign histology on core needle biopsy. A papilloma sampled by a 12-gauge or larger needle, ≥7 cores, or >96 mm(2) retained its benign features upon excision.