Management Of High-Risk Lesions Research Articles

Upgrading Rate and Associated Factors of High-Risk Breast Lesions from Imaging Guided Breast Biopsy in King Chulalongkorn Memorial Hospital

Objective: To determine the underestimate rate of high-risk lesions from imaging guided breast biopsy to be malignancy from subsequent surgical excision in King Chulalongkorn Memorial Hospital and to determine the factor associated to imaging characteristics and geographic data. Materials and Methods: A retrospective review of 79 high-risk breast lesions of 78 patients who underwent imaging guided breast biopsy studies between January 1, 2010, and August 31, 2020, on women, aged 30 years or older in King Chulalongkorn Memorial Hospital. The upgrading rate of the high-risk lesions were calculated. Radiologic findings were analyzed by SPSS version 26. Results: Seventy-nine lesions were divided into three groups with 24 lesions of atypical ductal hyperplasia (ADH), 50 lesions of the papillary lesion, and five lesions of the complex sclerosing lesion. The authors found that the upgrade rate was about 58% in the ADH group, 28% in the papillary lesion group, and 20% in the complex sclerosing lesion group. Moreover, the authors found an increased upgrade rate among patient 50 years or older (43%) as compared with fourteen patients age under 50 years (32%). However, there was no statistically significant difference in radiologic findings or factors associated with upgrading rate to malignancy under subsequent surgical excision. Conclusion: Upgrading rate of high-risk lesions including ADH, papillary lesions, and complex sclerosing lesion were high in each lesion and the upgrade rate increased slightly in patient 50 years or older. However, there was no demonstrable radiologic manifestation or factor associated with upgrading to malignancy at subsequent surgical excision. Hence, radiologic-pathologic correlation or multidisciplinary discussion will be important roles in management of high-risk lesions. Keywords: Breast; High risk lesion; Atypical ductal hyperplasia (ADH); Papillary lesions; Radial scar; Complex sclerosing lesion

Retrospective statistical analysis on the diagnostic value of ductography based on lesion pathology in patients presenting with nipple discharge.

To compare sensitivities and specificities of ductography to noninvasive imaging studies in determining the cause of nipple discharge and assess the value of ductography on the basis of pathologic results. In this retrospective review of women with nipple discharge who underwent ductography between January 1, 2005 and October 30, 2015, at our institution, we compared ductography with noninvasive imaging results (mammography, ultrasound, MRI) to determine its relative diagnostic sensitivity, specificity, and relative accuracy. Diagnosis was defined from pathology results, clinical notes, and minimum of 1-year follow-up monitoring. The primary endpoints include accuracy, sensitivity, specificity, positive predictive value, and negative predictive value. The analyses were carried out in different configurations to compare results by the following pathologic categories: cancer, high-risk lesion, intraductal papilloma (IP) without atypia, and benign pathology and/or normal imaging results. In patients with breast cancer, ductography and noninvasive breast imaging had similar sensitivities. In patients with a high-risk lesion, ductography was significantly more sensitive than noninvasive imaging modalities. In patients with intraductal papilloma without atypia, ductography was more sensitive than noninvasive imaging, but the difference was of only borderline significance. For women with benign pathology and/or normal imaging, noninvasive imaging showed a significantly higher specificity than ductography. In the absence of standard diagnostic algorithm for patients presenting with nipple discharge, the clinician has numerous options to choose a diagnostic approach that will yield the most accurate information with the least disruption to the patient. Our results indicate the value of ductography compared to value of noninvasive imaging modalities when cancer is suspected and when high risk lesion is suspected. While we show the sensitivity of ductography is similar to noninvasive imaging modalities in the setting of cancer, the sensitivity of ductography is statistically valuable for diagnosing high-risk lesions. Our hope is that this study will emphasize more research and more understanding in clinical utility and management of high-risk lesions, leading to patient-focused algorithm for diagnosing the etiology of abnormal nipple discharge.

Use of Doppler Probe in Nonvariceal Upper-Gastrointestinal Bleeding Is Less Costly and More Effective Than Standard of Care

Upper gastrointestinal bleeding is a common emergency and rebleeding is associated with an increased risk of death. Proper assessment of high-risk lesions and appropriate endoscopic hemostasis are required for the best outcomes. The endoscopic Doppler probe examination (DPE) allows for a more complete assessment of the stigmata of hemorrhage, providing better evaluation of the need for endoscopic hemostasis and determination of its completeness. We aimed to evaluate whether use of the DPE provides an additional advantage in cost and effectiveness compared with traditional endoscopic visual assessment (TEA) of high-risk stigmata in patients with nonvariceal upper gastrointestinal bleeding. We drew a decision tree representing the choice between DPE and TEA approaches for patients undergoing an index endoscopy for active nonvariceal upper gastrointestinal bleeding. Clinical probabilities were retrieved from randomized controlled trial data. Costs were expressed in 2017 US dollars. A third-party payer perspective was adopted. We performed deterministic and probabilistic sensitivity analyses. The adopted time horizon was 30 days after the index endoscopy. We found that DPE is a dominant strategy over the TEA, in that DPE is more efficacious (92.6% of patients avoiding rebleeding vs 78.6% for TEA) and less expensive ($8502 vs $9104 for TEA). The economic dominance of DPE over TEA was robust to sensitivity analyses across all assumptions of the model when varied among ranges spanning 30% of their respective baseline values. In a cost-effectiveness analysis, we found DPE to be an economically dominant strategy to TEA (the traditional approach) in the management of high-risk lesions in patients with nonvariceal upper gastrointestinal bleeding. DPE was less costly and more effective.

The Imaging Appearance and Management of High-Risk Lesions of the Breast

The Imaging Appearance and Management of High-Risk Lesions of the Breast

The Imaging Appearance and Management of High-Risk Lesions of the Breast

The Imaging Appearance and Management of High-Risk Lesions of the Breast

Imaging Features and Management of High-Risk Lesions on Contrast-Enhanced Dynamic Breast MRI

Women at high risk for breast cancer and women with newly diagnosed breast cancer often undergo breast MRI. With the increasing availability of MRI-guided biopsy, high-risk lesions are not infrequently encountered. These high-risk lesions include atypical ductal hyperplasia, lobular carcinoma in situ, atypical lobular hyperplasia, papilloma, radial scar, and flat epithelial cell atypia. The management of these lesions is controversial and is often extended to high-risk lesions detected on mammography and ultrasound, with surgical excision usually recommended. The increasing use of MRI for suspicious lesions necessitates review of the imaging characteristics, frequency, and surgical outcome of high-risk lesions identified at MRI. This article addresses the frequency of high-risk lesions detected on breast MRI according to the current literature and discusses MRI features of high-risk lesions, including morphologic and enhancement kinetic characteristics. The surgical outcome for high-risk lesions identified at MRI-guided biopsy will be discussed. Finally, appropriate management guidelines for high-risk lesions identified on MRI-guided biopsy will be determined. To our knowledge, no studies to date show definitive and specific characteristics for high-risk lesions. Underestimation of malignancy on MRI-guided biopsy currently warrants surgical management for all high-risk lesions. There is a need for prospective larger power studies.

Medical Management of High-Risk Lesions

Medical Management of High-Risk Lesions