Lesions Of Uncertain Malignant Potential Research Articles

EP.TH.803VAE for Breast Lesions of Uncertain Potential (B3) -A Quality Improvement Project

Abstract Aims Breast lesions of uncertain malignant potential (B3) account for 7% breast lesions biopsied. Management has been controversial and challenging for the MDT. Aim of the study was to compare current NHS BSP guidelines with our trust’s practice and the secondary outcome was a shorter patient pathway and cost effectiveness. Methods As per NHS BSP guidelines VAE should be performed for all B3 lesions diagnosed on 14g or vacuum assisted biopsy. We were referring them to other NHS trusts as there were no in-house facilities or doing an excisional biopsy if no resources for VAE available. From September 2019 VAEs started to be done by in-house consultant breast radiologist after getting the appropriate training and instruments. Data was collected from September 2019 to August 2020 for all patients. Results 22 VAEs were performed in one year. Out of those 6 (27.2%) were upgraded to malignancy and needed further surgery, 2 (9%) with atypia had 5 years mammographic surveillance and 14 (63%) were discharged including sclerosing lesions, radial scars, fibrosis and chronic inflammation. The cost of VAE in our hospital is £1330 vs. £2439 for Wire Guided wide local excision. This makes it cost effective. Conclusion We were following the VAE protocol as per NHS BSP guidelines. Despite added workload to radiology VAE is minimally invasive, safe and cost effective alternative to surgery providing thorough MDT discussion has taken place. Greater benefit was provided to patient as all VAEs were performed in radiology department avoiding general Anaesthesia and surgical trauma.

Malignancy Rate and Malignancy Risk Assessment in Different Lesions of Uncertain Malignant Potential in the Breast (B3 Lesions): An Analysis of 192 Cases from a Single Institution

Background: The question of how to deal with B3 lesions is of emerging interest. Methods: In the breast diagnostics of 192 patients between 2009 and 2016, a minimally invasive biopsy revealed a B3 lesion with subsequent resection. This study investigates the malignancy rate of different B3 subgroups and the risk factors that play a role in obtaining a malignant finding. Results: The distribution of B3 lesions after minimally invasive biopsy was as follows: atypical ductal hyperplasia (ADH), 7.3%; flat epithelial atypia (FEA), 7.8%; lobular neoplasia (LN), 7.8%; papilloma (Pa), 49.5%; phylloidal tumour (PT), 8.9%; radial sclerosing scar (RS), 3.1%; mixed findings, 10.4%; and other B3 lesions, 5.2%. Most B3 lesions were detected by stereotactic vacuum-assisted biopsy (44.3%), 36.5% by ultrasound-assisted biopsy, and 19.3% by magnetic resonance imaging-assisted biopsy. Most B3 lesions (55.2%) were verified by surgical resection, whereas 30.7% were downgraded to a benign lesion. About 14.1% of the cases were upgraded to malignant lesions, 9.4% to ductal carcinoma in situ and 4.7% to invasive carcinoma. In relation to individual B3 lesions, the following malignancy rates were found: 28.6% (ADH), 13.3% (FEA), 33.3% (LN), 12.6% (Pa), 5.9% (PT), and 0% (RS). The most important risk factor was increasing age. Postmenopausal status was considered an increased risk for an upgrade (p = 0.015). A known malignancy in the ipsilateral breast was a significant risk factor for a malignant upgrade (p = 0.003). Conclusion: Increasing knowledge about B3 lesions allows us to develop a “lesion-specific” therapy approach in the heterogeneous group of B3 lesions, with follow-up imaging for some lesions with less malignant potential and concordance with imaging or further surgical resection in cases of disconcordance with imaging or higher malignant potential.

Effectiveness of percutaneous vacuum-assisted excision (VAE) of breast lesions of uncertain malignant potential (B3 lesions) as an alternative to open surgical biopsy.

Traditionally B3 breast lesions are treated surgically, but overtreatment is a concern, as the majority have a final benign diagnosis. A national screening program introduced vacuum-assisted excision (VAE) for managing B3 lesions in late 2016. This retrospective study aimed to assess the outcomes associated with this approach. All B3 lesions diagnosed between 01/2017 and 12/2019 were identified at two centres. Information was obtained on the initial biopsy and final histology, and method of VAE image guidance, needle size and number of cores. Lesions were excluded if there was cancer elsewhere in the breast at the time of diagnosis; the lesion was not suitable for VAE due to position in the breast or had B3 pathology for which open biopsy was still required. The final decision to offer VAE was always made at a multidisciplinary meeting (MDM). Risk difference was used to test the significance at p ≤ .05. In total, 258 B3 lesions were diagnosed, 105 (40.7%) met the inclusion criteria and underwent VAE. VAE was performed under X-ray (89/105) or ultrasound guidance (16/105), taking an average of 18.5 cores with the 10-G needle or 10.8 cores with the 7-G needle. Nine cases (8.6%) were upgraded to a malignant diagnosis following VAE. Malignancy was found in 15.5% (9/58) of B3 lesions with epithelial atypia, but in none without atypia (0/47) (p = .004). No new lesions or malignancy has occurred at the site of the VAE with an average mammographic follow-up of 2.2 years. Upgrade to malignancy following VAE was uncommon (8.6%) and associated with atypia in the initial biopsy. VAE is an alternative approach to the management of B3 lesions, reducing open surgical procedures. • Upgrade to malignancy after a vacuum-assisted excision of a B3 breast lesion is uncommon with an 8.6% upgrade rate. • The risk of a malignant diagnosis after a vacuum-assisted excision was significantly higher for B3 lesions with atypia compared to those without (+15.5% difference, p = .004).

Clinical practice guidelines for intraductal papilloma: Chinese Society of breast surgery (CSBrS) practice guidelines 2021.

Clinical practice guidelines for intraductal papilloma: Chinese Society of breast surgery (CSBrS) practice guidelines 2021.

P91 Phyllodes Tumours: Looking for Predictive Features from Multidisciplinary Assessments

IntroductionThe breast triple assessment enables rapid evaluation of breast abnormalities. Lesions are assessed via the assessments based on clinical examination, imaging and histological sampling. Fibroepithelial lesions (FELs) are amongst the most common breast lesions of uncertain malignant potential. They encompass a spectrum of entities ranging from benign fibroadenomas (FA) to malignant phyllodes tumours (PT), with contrasting clinical management approaches. Unfortunately, the distinction between various FELs is often difficult, despite recent diagnostic advances. This is especially so between FAs and PTs. Nevertheless, understanding how to prioritise key characteristics of PTs, both radiologically and histologically may ease this challenge. In our opinion, a multidisciplinary approach including radiological input is probably the most helpful in reaching an accurate diagnosis.MethodsWe, retrospectively studied data from breast lesions which were initially diagnosed pre-operatively as R3/B3 FELs, and those with a final diagnosis of PT on excision. 71 suitable cases were identified from 2009 to 2019. Information was extracted from reports made by specialists at the pre-operative and post-excision stages. Statistical analysis will be applied to quantify the significance of features evaluated.ResultsPreliminary results suggest diagnoses made by pathologists on pre-operative samples correlated well with the eventual final diagnosis made on post-operative specimens. Adequate sampling appears to be a significant factor in influencing the pre-operative core biopsy diagnosis.ConclusionWe anticipate to acquire a comprehensive knowledge of various predictive features of PTs, and the correlation between the key radiological features, thereby allowing accurate pre-operative diagnosis of these interesting and challenging lesions.

Abstract PS7-52: The upgrade risk to (pre-)invasive breast cancer for B3 lesions diagnosed on core needle or vacuum assisted biopsy. A Belgian retrospective study

Abstract Introduction: Flat epithelial atypia (FEA), classical lobular neoplasia (LN), papillary lesions (PL), radial scars (RS) and atypical ductal hyperplasia (ADH) are lesions of uncertain malignant potential in the breast, which are described as B3 lesions in the B classification system of the European Working Group for Breast Cancer Screening Pathology. Current standard for management of B3 lesions on core needle biopsy (CNB) or vacuum assisted biopsy (VAB), is wide local excision (WE). However, recent consensus-based guidelines no longer recommend WE for all such lesions, but propose surveillance following CNB or VAB to be sufficient in some cases. In the absence of a Belgian guideline on the treatment of B3 lesions, this study was conducted to identify which B3 lesions have the lowest likelihood for breast malignancy and could therefore be spared from WE. Methods: Using data from the Belgian Cancer Registry (BCR), all patients with a new diagnosis of a B3 lesion on CNB or VAB between 2013-2016 and who had a histological follow up with VAB or WE after CNB or WE after VAB were included. Histological follow-up was retrieved from BCR and limited to 12 months following diagnosis. Histology was compared between the first- and follow-up investigation to determine the upgrade risk to ductal carcinoma in situ (DCIS) or invasive breast cancer (IC) according to the type of B3 lesion. Patients with synchronous (pre-) invasive lesions were excluded. Results: Between 2013-2016 there were 812 B3 lesions available for upgrade analysis after initial diagnosis. After CNB 551 lesions had WE or VAB as follow up and after VAB 261 lesions had WE. After primary diagnosis on CNB, the total upgrade risk was 19,0%. There was histological agreement in 57,9% and no B3 lesion or upgrade was reported in 21,8%. Per B3 lesion subtype the upgrade risk to DCIS - IC after diagnosis on CNB was: ADH 17,1%-12,4%, FEA 21,1% - 18,4%, LN 18,9% -21,6%, RS 14,3% - 11,4%, and PL 7,2% - 3,2%. After initial diagnosis on VAB the total upgrade risk was 14,9%. There was histological agreement in 52,9% and no B3 lesion or upgrade was found in 31,4%. Per B3 subtype the upgrade risk to DCIS - IC after diagnosis on VAB was: ADH 17,3%- 2,7%, FEA 11,7%- 5,9%, LN 0,0% - 4,3%, PL 10,4% - 2,1%. We found no upgrade for RS. (Table 1). Conclusions: In a series of B3 lesions with a histological follow-up, we notice that overall upgrade risk is higher for lesions detected on CNB than on VAB: 19,0% vs. 14,9%. The majority of lesions showed histological agreement between initial B3 diagnosis and histological follow-up: 57,9% after CNB and 53,5% after VAB. More investigation is needed to make a proper risk assessment as to which B3 lesions can be followed with regular surveillance. Also, further prospective research is needed to get a better understanding of associated risk factors for upgrade, upgrade risk and lifetime risk of developing breast cancer after diagnosis of a B3 lesion. Table 1: Upgrade risk per B3 subtype after diagnosis on CNB or VABSubtypeNumberCNB followed by VAB or WEDCISICTotal Upgrade riskCNBNumberVAB followed by WEDCISICUpgrade riskVAB followed by WEADH10517,1%12,4%29,5%11017,3%2,7%20,0%FEA3821,1%18,4%39,5%5111,7%5,9%17,6%LN3718,9%21,6%40,5%460%4,3%4,3%PL3367,2%3,2%10,4%4810,4%2,1%12,5%RS3514,3%11,4%25,7%60%0%0%Total551261Upgrade105/55119,0%39/26114,9%B3 lesion319/55157,9%138/26152,9%No B3 lesion120/55121,8%82/26131,4%Result not available7/5511,3%2/2610,8% Citation Format: Nynke Willers, Patrick Neven, Giuseppe Floris, Cecile Colpaert, Eva Oldenburger, Sileny Han, Chantal Van Ongeval, Ann Smeets, Francois Duhoux, Hans Wildiers, Petra Denolf, Isabel De Brabander, Nancy Van Damme, Harlinde De Schutter. The upgrade risk to (pre-)invasive breast cancer for B3 lesions diagnosed on core needle or vacuum assisted biopsy. A Belgian retrospective study [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS7-52.

A risk stratification algorithm for lesions of uncertain malignant potential diagnosed by vacuum-assisted breast biopsy (VABB) of mammographic microcalcifications

PurposeTo investigate a risk stratification strategy for lesions of uncertain malignant potential (B3) diagnosed by vacuum-assisted breast biopsy (VABB) of mammographic microcalcifications. MethodsPatients who underwent VABB for microcalcification-only lesions with a diagnosis of B3 and subsequent surgery were included in this retrospective, IRB-approved study. Seventy-six B3-lesions (final histology: 66 benign, 10 malignant) were included (Tr). Data on B3 lesion type and presence of atypia, microcalcification characteristics (BI-RADS), removal at biopsy and concomitant lesions were collected. After univariate analysis (Chi-square test), data were combined into a risk stratification algorithm by using a ten-fold, cross-validated Classification and Regression Tree analysis (CRT). The algorithm was tested on a testing dataset (Te) of 23 B3-lesions (six malignant, 17 benign). ResultsMalignancy was more frequent in women with a concomitant cancer (P < 0.001) and highly suspicious microcalcifications (P < 0.001). The CRT algorithm retained three characteristics: morphology; presence of atypia; presence of concomitant cancer. The algorithm identified 25/76 (32.9 %,Tr) and 6/23 (26.1 %,Te) lesions at low risk of malignancy. No malignant cases were identified at surgery (0/31). There were 3/76 (3.9 %,Tr) and 1/23 (4.3 %,Te) lesions assigned as high-risk by the algorithm and confirmed at surgery (4/4). In the remaining lesions (48/76, 63.1 %,Tr; 16/23, 69.6 %,Te), malignancy rates varied between 9% and 88.4 %; thus, surgery could not have been avoided. ConclusionWe constructed and tested a risk stratification algorithm for B3 microcalcifications, including clinical, imaging, and pathological features, to assign probabilities of malignancy, which has the potential to reduce unnecessary surgeries.

Lesiones mamarias borderline: categorización diagnóstica y manejo

IntroductionA finding of lesions with indeterminate radiological characteristics and their subsequent management is one of the main challenges in breast disease. The same is true of lesions histologically considered to be of uncertain malignant potential. Diagnostic classification systems help to classify these lesions, but little is known about the agreement between radiological and histological categories. The aim of this study was to assess the diagnostic agreement between BIRADS-3 lesions and the B3 histological category, as well as to review current recommendations on their management. Material and methodWe conducted a retrospective observational study of breast biopsies performed in BIRADS-3 radiological lesions over a 5-year period and gathered clinical-pathological and follow-up data. ResultsWe included 267 BIRADS-3 lesions that underwent core needle biopsy, of which 12 were malignant tumours (4.49%), 10 were lesions of uncertain malignant potential (3.75%) and the remainder were histologically classified as benign. ConclusionThe BIRADS-3 radiological category and B3 histological diagnosis are not equivalent. Given the nearly 10% of malignant or borderline lesions showing indeterminate radiological characteristics in this study, we recommend that the indication for biopsy be considered whenever there is any clinical and/or radiological discordance in patients with images classified as BIRADS-3.

527 Poster - A review of subsequent breast cancers detected on mammographic surveillance following Vacuum Assisted Excision for lesions of uncertain malignant potential (B3) with atypia

Background: There is a spectrum of lesions that fall into the category of ‘uncertain malignant potential’ (B3). These lesions are often associated with atypia, insitu or invasive carcinoma. Therefore, once these lesions are discovered on biopsy, it necessitates the need to ensure adequate sampling to exclude focal carcinoma. Vacuum Assisted Excision (VAE) has become the management of choice of B3 lesions <3 cm which meet criteria as set out by NHSBSP B3 guidelines. Because B3 lesions with atypia confer a risk for a future breast cancer, it is important to ensure mammographic follow up following VAE to allow early diagnosis of a potential subsequent cancer. Our departmental protocol for surveillance of VAE/Vacuum Assisted Core Biopsy histology demonstrating atypia is annual mammography for 5 years, followed by return to routine biennial screening thereafter.

Role of vacuum assisted excision in minimising overtreatment of ductal atypias

PurposeB3 lesions are indeterminate lesions of uncertain malignant potential. They include lesions with and without epithelial atypia. Those with atypia include atypical intraductal epithelial proliferation (AIDEP)/atypical ductal hyperplasia (ADH) and flat epithelial atypia (FEA). They are traditionally managed with surgery. Vacuum assisted excision (VAE) allows larger samples to be obtained using a vacuum assisted biopsy (VAB) device, which equates to a surgical biopsy. We propose that VAE and mammographic surveillance is a safe alternative to surgery in managing the ductal atypias; (AIDEP/ADH and FEA). MethodRetrospective analysis of prospectively collected data on B3 lesions (April 2009 - March 2016) from consecutive breast screening patients diagnosed with AIDEP/ADH or FEA on initial diagnostic core biopsy. Mammographic abnormality, breast density, size, management pathway and upgrade to cancer and types of cancer were also collected during the treatment pathway and 5 year surveillance period (April 2009 - April 2019). Results273 cases of ductal atypia were identified. 187/273 (68.5 %) cases were managed with VAE only as no upgrade to malignancy and then 5 year mammographic surveillance. 34/273 (12.5 %) cases had a VAE diagnosing malignancy. 24/273 (8.8 %) cases had a VAE and then a surgical biopsy due to radiological or pathological concern, 8/24 upgraded to malignancy. 22/273 (8%) cases had a surgical diagnostic biopsy, 9/22 (41 %) cases were upgraded to malignancy.In total 51/273 (19 %) cases were diagnosed with cancer on the new pathway (13 invasive (all ER positive and Her2 negative) and 38 non-invasive, (34 ductal carcinoma in situ (DCIS) and 4 cases of lobular carcinoma in situ (LCIS)). While 17/273 (6.2 %) cases developed malignancy (12 invasive (all HER2 negative) and 4 DCIS and 1 LCIS) during the 5 year surveillance period. ConclusionsVAE is a safe alternative to surgery in managing ductal atypias. 187/273 (68.5 %) women avoided surgery. While 34/51 cancers (66.7 %) were diagnosed preoperatively using VAE, allowing the women to have a single therapeutic procedure.

Lesions of uncertain malignant potential of the breast (B3) on vacuum-assisted biopsy for microcalcifications: Predictors of malignancy

PurposeTo investigate clinical, radiologic and pathologic features of B3 lesions diagnosed on VABB targeting microcalcifications, for identifying predictors of malignancy. MethodThis retrospective multi-centre study included consecutive VABBs performed over a 10-year period on suspicious microcalcifications not associated with other radiological signs diagnosed as B3 on histology from VABB, with outcomes ascertained by surgical excision. Clinical, demographic, radiological and histological (B3 subcategory) data were collected. For statistical analysis (univariate and binary logistic regression), the primary outcome variable was the upgrade rate to malignancy after surgery. Predictors of upgrade to malignancy were identified from clinical, demographic, radiological and pathological variables (including B3 subcategory). ResultsAmongst 447 VABBs, there were 57(12.7 %) upgrades to malignancy at surgical histology (36 DCIS and 21 invasive cancer). At univariate analysis, variables significantly associated with increased risk of upgrade to malignancy were age>55 years (p = 0.01), lesion size>10 mm (p < 0.0001), BI-RADS 4b-c and 5 (p = 0.0001), and fine pleomorphic morphology (p = 0.002) of microcalcifications. Binary logistic regression confirmed as significant independent risk factors age, lesion size and BI-RADS category (p = 0.02, 0.02 and 0.0006 respectively).Amongst subcategories of B3 lesions, lobular neoplasia was significantly(p = 0.04) associated with upgrade, confirmed as an independent risk factor [p = 0.03, OR = 2.3(1.1−4.7)]. Flat epithelial atypia was significantly(p = 0.004) associated with reduced odds of upgrade, but binary logistic regression showed only borderline association [p = 0.052, OR = 0.4(0.2–1.01)]. ConclusionsAcross B3 lesions diagnosed on histology from VABB of suspicious microcalcifications, older age, size>10 mm, BI-RADS category≥ 4b on imaging, and lobular neoplasia were risk factors for upgrade to malignancy. This information can be used to discuss patients’ tailored management options.

Conjunctival nevi and melanoma: multiparametric immunohistochemical analysis, including p16, SOX10, HMB45, and Ki-67

The role of p16 in the diagnosis and prognosis of conjunctival melanocytic lesions in the context of other clinical and immunohistochemical parameters has not been systematically explored. This study was conducted to determine whether p16 is a useful parameter in the diagnosis and prognosis of conjunctival melanocytic nevi and melanoma, either independently or as a component of immunohistochemical panels. Sixty-one patients underwent 61 biopsies for conjunctival melanocytic lesions between 2014 and 2018. Pathologic diagnoses were melanoma (n=25, 41%), nevus (n=21, 34%), and conjunctival melanocytic lesion of uncertain malignant potential (n=15, 25%). The biopsies were assessed for expression of p16, SOX10, HMB45, and Ki-67. In a multivariable model, the parameters most predictive of melanoma versus nevus were diffuse HMB45 staining (odds ratio [OR]=45, confidence interval [CI]=4.4-457, P=.02] and p16 nuclear H-score≤115 (OR=9.5, CI=1.2-77; P=.04). There was no association of p16 expression with melanoma thickness. Next-generation sequencing identified no CDKN2A mutations or copy number alterations in 12 conjunctival melanomas, including the tumors with absent p16 expression. This study demonstrates that p16 immunohistochemical stain is useful in distinguishing conjunctival melanocytic nevi from melanoma, particularly in combination with HMB45. P16 expression does not appear to correlate with CDKN2A status and melanoma thickness.

A ten-year, single-center experience: Concordance between breast core needle biopsy/vacuum-assisted biopsy and postoperative histopathology in B3 and B5a cases.

PurposeTo determine the concordance rate between core needle biopsy/vacuum-assisted biopsy (CNB/VAB) and postoperative histopathology in B3 (lesions of uncertain malignant potential) and B5a (in situ) lesions found on mammograms or ultrasound.Material and methods2,029 consecutive biopsies performed over 10 years for patients who underwent mammograms or ultrasounds. For CNB 14G needle and for VAB 8G/10G needles were used. In all biopsies, we identified the age, BI-RADS®, histopathological biopsy results, B-category, nuclear grade for DCIS and postoperative histopathology results in B3 and B5a cases from the biopsy.ResultsThe B-categories from CNB/VAB were as follows: B2 42.2 percent (n = 856), B3 4.5 percent (n = 91), B5a 5.7 percent (n = 115), and B5b 47.6 percent (n = 967). In the B3-category, 72/91 patients underwent surgical excision, with a concordance rate of 83.3 percent (n = 60/72) and a discordance rate of 16.7 percent (n = 12/72) to postoperative histopathology. From the discordant cases, 67.7 percent (n = 8/12) showed DCIS and 32.3 percent (n = 4/12) showed invasive breast cancer. The BIRADS of the discordant cases was 4b in 41.7 percent (n = 5/12) and 5 in 58.3 percent (n = 7/12). The PPVs for malignancy of B3 lesions were 0.21, with no statistical significance between subgroups. In the B5a-category, 101 of 115 patients underwent surgery in our hospital, with a concordance rate of 80.2 percent (n = 81/101) and a discordance rate of 19.8 percent (n = 20/101) to postoperative histopathology. From the discordant cases, 55 percent (n = 11/20) showed invasive breast carcinoma of no special type (NST).ConclusionOur concordance rate for B3 (83.3 percent) and B5a (80.2 percent) lesions in the biopsies to postoperative histopathology is matching to previously published literature. Surgical excision is our recommendation for lesions biopsied with a B3 category in the histopathology and a BIRADS category of (4b, 4c and 5). The PPVs for malignancy of B3 lesions showed no statistical significance between subgroups. Also, the nuclear grade of DCIS was not statistically significant in terms of upgrade into invasive breast cancer.

Over expression of CDK4 and MDM2 in a patient with recurrent ALK-negative mediastinal inflammatory myofibroblastic tumor

Rationale:The diagnosis of anaplastic lymphoma kinase (ALK)-negative inflammatory myofibroblastic tumors (IMT) remains challenging because of their morphological resemblance with spindle cell sarcoma with myofibroblastic characteristics.Patient concerns:A 69-year-old female patient presented with loco-regional recurrent IMT several times within 8 years after primary treatment and neck lymph node metastasis 3.5 years after last recurrence.Diagnosis:The primary, recurrence, and lymph node metastasis lesions were diagnosed as ALK-negative IMTs based on the histopathological features.Interventions:Biopsy samples were obtained during repeated surgeries and evaluated for genomic alterations during first and recurrent presentations. The evaluation was done using pathway-driven massive parallel sequencing, and genomic alterations between primary and recurrent tumors were compared.Outcomes:Copy number gains and overexpression of mouse double minute 2 homolog (MDM2) and cyclin dependent kinase 4 (CDK4) were observed in the primary lesion, and additional gene amplification of Discoidin Domain Receptor Tyrosine Kinase 2 (DDR2), Succinate Dehydrogenase Complex II subunit C (SDHC), and thyroid stimulating hormone receptor (TSHR) Q720H were found in the recurrent tumors. Metastases to the neck lymph node were observed 3.5 years after recurrence.Lessons:Our results indicated genetic evolution in a microscopically benign condition and highlighted the importance of molecular characterization of fibro-inflammatory lesions of uncertain malignant potential.

Milan Interobserver Reproducibility Study (MIRST): Milan System 2018

Prior to the 2018 publication of the Milan System for Reporting Salivary Gland Cytopathology (MSRSGC), a Web-based interobserver study was performed to evaluate MSRSGC reporting categories, identify cytomorphologic features that represent poor sources of agreement, and establish a baseline for future studies. Study participants evaluated 75 images chosen from the MSRSGC image set, prior to the release of the Milan Atlas. Images spanned all diagnostic categories including typical and borderline cytomorphology. Participant demographics were collected on level of training, practice patterns, and experience. A total of 647 persons attempted access to the survey. Of these, 555 correctly answered the qualifying questions. Participants included: 16.5% ASCP Certified Cytotechnologists, 2.8% Specialist Cytotechnologists, 5.8% IAC Certified individuals, 14.3% Anatomic (AP) Certified Pathologists, 38.9% AP and Cytopathology Certified Pathologists, and 15.3% pathology trainees. Length of participant practice varied from 0 to 54 years. In our sample, 43.4% of participants came from academic centers, 17.6% from private hospitals; and 13.3% from commercial/private laboratories. Overall, 42% of respondents agreed with the reference interpretations of salivary gland lesions. The best agreement was seen in cytopathology certified pathologists. Among the MSRSGC categories, best agreement was found in Neoplasm-Benign (58.9%) and Non-Diagnostic (49.2%) categories, followed by Malignant (48.4%). The agreement rates for Salivary Gland Lesion of Uncertain Malignant Potential (SUMP) and Suspicious For Malignancy (SFM) were 23.6% and 22.7%, respectively. Similar to the reproducibility studies conducted for gynecologic and urinary cytopathology, the most important factor in diagnostic reproducibility was a priori classification of image difficulty, although people with higher certifications performed better.

Management and Outcomes of Lesions of Uncertain Malignant Potential (B3) Identified on Screening Mammography.

Background: Excision is currently recommended for all B3 lesions in Ireland. Reported rates of upgrade vary widely in the literature. The aim of this study was to determine the rate of upgrade of various screening-detected high risk breast lesions diagnosed by CNB in a cohort of Irish women.

Relative apparent diffusion coefficient (rADC) in breast lesions of uncertain malignant potential (B3 lesions) and pathologically proven breast carcinoma (B5 lesions) following breast biopsy

PurposeTo assess relative apparent diffusion coefficient (rADC) and ADC in B3 and B5 lesions in premenopausal female patients, added to standard morpho-dynamic breast contrast-enhanced MRI. Methods104 patients with histologically confirmed B3 (N1 = 52) and matched B5 lesions (N2 = 52), were examined on MRI (1.5 T, full diagnostic protocol, diffusion weighted imaging – b50, b850) in a retrospective analysis following the IRB approval: Atypical ductal hyperplasia (ADH, n1 = 20), Flat epithelial atypia (FEA, n2 = 11), Classic lobular neoplasia (CLN, n3 = 8), Papillary lesion (PL, n4 = 6) and Phyllodes tumor (PT, n5 = 7). rADC and ADC were computed for each lesion. The two-tailed Mann-Whitney U test was used for comparison with B5 lesions. ResultsMean rADC value for B3 lesions, (N1 = 52): 0.81+/-0.08 mm2/s x 10-3 and B5 lesions, (N2 = 52): 0.58+/-0.07 mm2/s x 10-3 is statistically different (p < 0.00001). Mean rADC values [mm2/s x 10-3], per entity in B3 are: ADH, 0.82+/-0.06; FEA, 0.75+/-0.03; CLN, 0.73+/-0.03; PL, 0.94+/-0.02; PT 0.86+/-0.05. ConclusionsAlthough morpho-dynamic features of borderline and malignant lesions may overlap, the initial results in this research, suggest the highly significant difference in both ADC and rADC between B3 and B5 lesions. Larger trials are needed to confirm the initial data.

Ultrafast ultrasound breast scanning for improved image quality and functional information in 3-D

With an automated breast volume scanner (ABVS), a volumetric breast image can be constructed. Clinical studies show high sensitivity but also high recall-rates due to the detection of many lesions of uncertain malignant potential. It is known that breast lesions have different mechanical properties with respect to its surrounding tissue. Consequently, imaging the biomechanics of a breast might improve diagnosis in this disease. First, we improved the image quality by taking full advantage of the ultrafast acquisition and by applying dedicated signal processing techniques. Next, by imaging biomechanics we increased the specificity since compared to benign lesions, malignant lesions are often stiffer, and more grown into the surrounding tissue (firmly bonded). We extended conventional 2-D strain imaging to full 3-D (shear) strain imaging by combining automated breast volume scanning with ultrafast plane wave imaging (10 000 frames/s). Validation studies in breast phantoms revealed that lesions could be differentiated based on strain and shear strain imaging. Decreased strain values were found in stiff lesions and firmly bonded lesions demonstrated low shear strain values. Initial acquisitions in patients demonstrated decreasing strain values with increasing severity of the disease. Additionally, we developed an ultrasensitive 3-D Doppler method to detect neo-vascularization that might be present around malignant lesions. In conclusion, imaging the biomechanical properties in 3-D improves diagnosis breast cancer.With an automated breast volume scanner (ABVS), a volumetric breast image can be constructed. Clinical studies show high sensitivity but also high recall-rates due to the detection of many lesions of uncertain malignant potential. It is known that breast lesions have different mechanical properties with respect to its surrounding tissue. Consequently, imaging the biomechanics of a breast might improve diagnosis in this disease. First, we improved the image quality by taking full advantage of the ultrafast acquisition and by applying dedicated signal processing techniques. Next, by imaging biomechanics we increased the specificity since compared to benign lesions, malignant lesions are often stiffer, and more grown into the surrounding tissue (firmly bonded). We extended conventional 2-D strain imaging to full 3-D (shear) strain imaging by combining automated breast volume scanning with ultrafast plane wave imaging (10 000 frames/s). Validation studies in breast phantoms revealed that lesions could be diff...

Risk of breast cancer following detection of breast lesions of uncertain malignant potential: a 23-year retrospective review

Risk of breast cancer following detection of breast lesions of uncertain malignant potential: a 23-year retrospective review

Heterogeneous risk profiles among B3 breast lesions of uncertain malignant potential.

Most cases of breast lesions of uncertain malignant potential (B3) undergo surgical intervention. We aimed to analyze the outcome of B3 lesion subtypes in a large series of screen-detected cases. We screened 2,986 core needle biopsies to classify B3 lesions. Positive predictive values (PPVs) for malignancy were calculated for a comprehensive risk characterization according to clinicopathologic and morphologic variables. B3 lesions comprised 35% atypical ductal hyperplasia (PPV = 20%), 16.7% flat epithelial atypia (PPV = 12%), 22.7% lobular neoplasia (PPV = 16.2%), 9% papillary lesion (PPV = 18.5%), 8.6% phyllodes tumor (PPV = 3.8%), and 8% radial scars (PPV = 4.1%) based on histopathologic diagnosis. Upgrade rates were 15.9% for calcifications, 13.7% for mass lesions, and 16.7% for architectural deformities, with 8.3% of malignant lesions classified as ductal carcinoma in situ and 6.7% as invasive cancers (PPV = 15%). B3 lesions entail a heterogeneous risk of malignancy, and careful radiologic-pathologic correlation is required for optimal treatment.