Management Of High-Risk Breast Lesions Research Articles

Management of High-Risk Breast Lesions: Counterpoint-Time for Personalized Surveillance.

This article does not include an abstract. Please see the accompanying Point by Benjamin C. Calhoun.

Management of High-Risk Breast Lesions: Point-Surveillance Is a Change in Practice Preceding Evidence-Based Standardization.

This article does not include an abstract. Please see the accompanying Counterpoint by Sughra Raza.

Management of high-risk breast lesions diagnosed on core biopsies and experiences from prospective high-risk breast lesion conferences at an academic institution.

The management of high-risk breast lesions diagnosed on image-guided core biopsy remains controversial. We implemented a high-risk breast conference attended by breast pathologists, imagers, and surgeons to prospectively review all contemporary cases in order to provide a consensus recommendation to either surgically excise or follow on imaging at 6-month intervals for a minimum of 2years. Between May, 2015 and June, 2019, 127 high-risk lesions were discussed. Of these 127 cases, 116 had concordant radiology-pathology (rad-path) findings. The remaining 11 patients had discordant rad-path findings. Of the 116 concordant cases, 6 were excluded due to lack of the first imaging follow-up until analysis. Of the remaining 110 patients, 43 had atypical ductal hyperplasia (ADH), 12 had lobular carcinoma in situ (LCIS), 19 had atypical lobular hyperplasia (ALH), 33 had radial scar (RS), 2 had flat epithelial atypia (FEA), and 1 had mucocele-like lesion (ML). We recommended excision for ADH if there were > 2 ADH foci or < 90% of the associated calcifications were removed. For patients with LCIS or ALH, we recommended excision if the LCIS or ALH was associated with microcalcifications or the LCIS was extensive. We recommended excision of RS when < 1/2 of the lesion was biopsied. We recommended all patients with FEA and ML for 6-month follow-up. Following conference-derived consensus for excision, of the 27 ADH excised, 9 were upgraded to invasive carcinoma or ductal carcinoma in situ. Of the six LCIS cases recommended for excision, none were upgraded. Nine excised radial scars revealed no upgrades. Additionally, 3 patients with ADH, 2 with ALH, 1 with LCIS, and 2 with RS underwent voluntary excision, and none were upgraded. All other patients (13 with ADH, 5 LCIS, 17 ALH, 22 RS, 2 FEA and 1 ML) were followed with imaging, and none revealed evidence of disease progression during follow-up (187-1389days). All 11rad-path discordant cases were excised with 2 upgraded to carcinoma. The results of this prospective study indicate that high-risk breastlesions can be successfully triaged to surgery versus observation following establishment of predefined firm guidelines andperformance of rigorous rad-path correlation.

Diagnosis and Management of High-Risk Breast Lesions.

Atypical hyperplasia (AH) and lobular carcinoma in situ (LCIS) are nonmalignant breast lesions that confer a 4- to 10-fold increased risk for breast cancer in women. Often, AH and LCIS are diagnosed through breast biopsy due to a mammographic or palpable finding. Although AH and LCIS are benign breast disease, further management is necessary due to their high-risk nature and premalignant potential. Over the decades, management of AH and LCIS has changed as more is learned about these disease processes. This review explores the studies evaluating the risk for breast cancer in women with AH or LCIS and the clinical management of these lesions, which can include a combination of surgical excision, surveillance, and risk-reduction therapy.

Management of high-risk breast lesions found on mammogram or ultrasound: the value of contrast-enhanced MRI to exclude malignancy

PurposeTo evaluate the performance of magnetic resonance imaging (MRI) to exclude malignancy in biopsy-proven high-risk breast lesions prior to surgical excision. Material and methodsBreast MRIs performed after a core needle biopsy (CNB) yielding high-risk pathology were evaluated for the presence of suspicious enhancement. The diagnostic performance of MRI to exclude malignancy was calculated. ResultsThe average reader sensitivity, specificity, negative predictive value, positive predictive value and accuracy of MRI were 92%, 51%, 98%, 22% and 56%, respectively. ConclusionLack of enhancement on MRI at the site of a high-risk lesion was useful for excluding malignancy.

Can Machine Learning Be Used to Generate a Model to Improve Management of High-Risk Breast Lesions?

Can Machine Learning Be Used to Generate a Model to Improve Management of High-Risk Breast Lesions?

Current Management of High-Risk Breast Lesions

The purpose of this review is to describe recent updates in the management of high-risk breast lesions. We review the various high-risk breast lesions and evaluate the collective literature regarding the rates of upgrade to invasive cancer or ductal carcinoma in situ with excisional biopsy as well as the increased risk for future breast cancer development that a diagnosis of a high-risk breast lesion may portend. For those lesions associated with an increased risk of breast cancer, we discuss the appropriate surveillance regimens as well as risk reduction opportunities available to patients. Recent studies may suggest a role for close imaging observation in certain clinical settings when a benign intraductal papilloma or flat epithelial atypia is identified by core needle breast biopsy. Ongoing prospective clinical trials should reveal valuable data to help answer this question. Clinical management of high-risk breast lesions identified and determined to be concordant after image-guided core needle biopsy varies and prospective data are needed to better guide management decisions. High-risk breast lesions require close radiologic-pathologic correlation when diagnosed by image-guided breast core needle biopsy. Excisional biopsy can exclude a higher-grade lesion such as DCIS or invasive cancer; however, in certain cases, close observation with follow-up may be appropriate. Additionally, women who have certain high-risk lesions such as lobular carcinoma in situ, atypical ductal hyperplasia, or atypical lobular hyperplasia are at an increased risk for the future development of breast cancer and should undergo risk assessment and discussion of risk reduction measures. Ongoing and future prospective trials may provide data to better guide these management decisions and optimize patient care.

Upgrade rates of high-risk breast lesions diagnosed on core needle biopsy: a single-institution experience and literature review

Optimal management of high-risk breast lesions detected by mammogram yielding atypical ductal hyperplasia, flat epithelial atypia, atypical lobular hyperplasia, lobular carcinoma in situ, and radial scar without atypia on core needle biopsy is controversial. This is a single-institution retrospective review of 5750 core needle biopsy cases seen over 14.5 years, including 249 (4.3%), 72 (1.3%), 50 (0.9%), 37 (0.6%), and 54 (0.9%) cases of atypical ductal hyperplasia, flat epithelial atypia, atypical lobular hyperplasia, lobular carcinoma in situ, and radial scar without atypia, respectively. Patient age, radiologic characteristics, needle gauge, and excision diagnoses were recorded. Of 462 high-risk cases analyzed, 333 (72%) underwent excision. Upgrade rate to ductal carcinoma in situ, pleomorphic carcinoma in situ, or invasive mammary carcinoma was 18% for atypical ductal hyperplasia, 11% for flat epithelial atypia, 9% for atypical lobular hyperplasia, 28% for lobular carcinoma in situ, and 16% for radial scar. Carcinoma diagnosed on excision was more likely to be in situ than invasive, and if invasive, more likely to be low grade than high grade. Overall, cases that were benign (vs high risk or carcinoma) on excision were less likely to have residual calcifications after biopsy (17% vs 27%, P=0.013), and more likely to have a smaller mass size (<1 cm) (82% vs 50%, P=0.001). On subgroup analysis, atypical ductal hyperplasia cases that were benign (vs high risk or carcinoma) on excision were more likely to have smaller mass size (<1 cm) (P=0.025). Lobular neoplasia diagnosed incidentally (vs targeted) on core needle biopsy was less likely to upgrade on excision (5% vs 39%, P=0.002). A comprehensive literature review was performed, identifying 116 studies reporting high-risk lesion upgrade rates, and our upgrade rates were similar to those of more recent larger studies. Careful radiological–pathological correlation is needed to identify high-risk lesion subgroups that may not need excision.

Current Multidisciplinary Management of High-Risk Breast Lesions

For years, surgical excision has been the standard of care for women with proliferative lesions such as atypical hyperplasia or lobular carcinoma in situ identified on needle biopsy because of concern of co-existing occult cancer. However, emerging evidence has suggested a more personalized approach of identifying women for whom surgical excision may be appropriate. A number of variables have been shown to be associated with an increased risk of a pathologic upgrade; this affords the opportunity for selective surgical excision. All women with these proliferative lesions, whether diagnosed on needle biopsy or surgical excision, are at increased risk of future breast cancers and derive significant risk reduction with endocrine therapy. Unless contraindicated, all women with atypical hyperplasia and lobular carcinoma in situ should be started on preventive therapy.

Current management of lesions associated with an increased risk of breast cancer.

High-risk breast lesions, which comprise benign lesions and in situ carcinomas (lobular carcinoma in situ and ductal carcinoma in situ), are clinically, morphologically, and biologically heterogeneous and are associated with an increased risk of invasive breast cancer development, albeit to varying degrees. Recognition and proactive management of such lesions can help to prevent progression to invasive disease, and might, therefore, reduce breast cancer incidence, morbidity, and mortality. However, this opportunity comes with the possibility of overdiagnosis and overtreatment, necessitating risk-based intervention. Notably, despite the progress in defining the molecular changes associated with carcinogenesis, alterations identifying the individuals with high-risk lesions that will progress to invasive carcinoma remain to be identified. Thus, until reproducible clinicopathological or molecular features predicting an individual's risk of breast cancer are found, management strategies must be defined by population-level risks as determined by models such as the Gail or IBIS models, as well as patient attitudes toward the risks and benefits of interventions. Herein, we review the contemporary approaches to diagnosis and management of high-risk breast lesions. Progress in this area will ultimately be dependent on the ability to individualize risk prediction through better definition of the key drivers in the carcinogenic process.

Multidisciplinary Considerations in the Management of High-Risk Breast Lesions

The purpose of this review is to discuss the controversy and lack of consensus in the management of high-risk breast lesions, including flat epithelial atypia, atypical ductal hyperplasia, lobular neoplasia, radial scar, papillary lesions, and mucocelelike lesions, after diagnosis with core needle biopsy. A single uniform approach may not be appropriate for the management of all high-risk breast lesions. A multidisciplinary team may offer individualized treatment options for patients.

Management of High-Risk Breast Lesions

Breast lesions with certain types of “benign” pathology on core breast biopsy pose a management dilemma. Although the lesion is not considered malignant by core biopsy, specific benign pathologies can be upgraded to carcinoma after surgical excision. These benign pathologies include atypical ductal hyperplasia, atypical lobular hyperplasia, lobular carcinoma in situ, papillary lesions, and radial scar. Core biopsy of these lesions can underestimate malignancy; therefore, these lesions are regarded as nonmalignant but high risk. The literature is controversial regarding the appropriate treatment of patients who have nonmalignant but high-risk diagnoses, especially for less commonly encountered pathologies. The core biopsy medical literature comprises, for the most part, single-institution retrospective reviews with insufficient numbers of these uncommon high-risk lesions to provide meaningful practice guidance. The authors reviewed the current medical literature from January 1999 through December 2009 in American Journal of Roentgenology (AJR) and Radiology discussing core-needle biopsy of these lesions in an attempt to determine the feasibility of developing a comprehensive management strategy of these high-risk but nonmalignant lesions.

Management of High-Risk Breast Lesions

Contemporary Diagnostic Radiology: October 15, 2010 - Volume 33 - Issue 21 - p 6 doi: 10.1097/01.CDR.0000389782.50431.ce