Mucocoele-like Lesion Research Articles

B3 lesion upgrade rates in a tertiary Australian breast centre: a 8-year experience (2012-2019).

B3 breast lesions identified on core needle biopsy have uncertain malignant potential. Traditional management of these lesions has been surgical excision, but there is growing interest in less invasive and more cost-effective alternatives such as vacuum-assisted excisional biopsy (VAEB). Determining the rate of malignant upgrade for B3 lesions is important as it may identify low-risk lesions where VAEB could be considered. A retrospective study was conducted of women undergoing an elective excisional biopsy for a B3 lesion identified on core needle biopsy at a tertiary Australian breast centre. The pre-operative biopsy diagnosis and subsequent excisional biopsy diagnosis were used to calculate the proportion of cases where the diagnosis was upgraded to malignancy. A total of 299 eligible patients were identified. Pre-operative diagnosis of papillary lesion with atypia was associated with the highest upgrade rate (50%, n = 12). The next highest upgrade rates occurred in those with flat epithelial atypia (37.50%, n = 8); atypical ductal hyperplasia (24.71%, n = 85); lobular carcinoma in situ (LCIS)/atypical lobular hyperplasia with calcification (17.65%, n = 17); and papillary lesion without atypia (4.72%, n = 106). Patients with radial scar (n = 51), classical LCIS without calcification (n = 7) and mucocoele-like lesion (n = 8) had a 0% upgrade rate. VAEB may be appropriate for low malignant risk lesions such as papillary lesion without atypia, mucocoele-like lesion and radial scar lesion without atypia. Open-surgical-excisional biopsy remains appropriate for high upgrade lesions such as atypical ductal hyperplasia, papillary lesion with atypia, flat epithelial atypia and classical LCIS with calcification. Long-term prospective randomized multicentre studies and continuing multidisciplinary approach is recommended for future clinical implementation.

Upgrade rate of mucocoele-like lesion diagnosed on breast core biopsy for a local population

Upgrade rate of mucocoele-like lesion diagnosed on breast core biopsy for a local population

Is it feasible to use an automated system to identify gait impairments?

To assess the rate of upgrade in our screening population to determine whether open excision biopsy of mucocoele-like lesions (MLL) is still required.A retrospective review of the breast screening database from 1999–2014 was performed.MLL were identified on core biopsy in 113 women (0.6% of those recalled for a core biopsy). The majority (n=100, 88%) had a localised cluster of calcification prompting screening recall. Eighty-seven percent (n=99) underwent an excision biopsy; there was a 5% upgrade rate to malignancy (all low/intermediate ductal carcinoma in situ [DCIS]) and 15 women (15%) were found to have an additional “B3” lesion. Fourteen women did not undergo excision biopsy; none of these women had a subsequent cancer at an average of 5-years follow-up. Within the follow-up period, five additional cancers were identified, one of these was in the ipsilateral breast and location, albeit 9-years later.This is the largest study of MLL in the literature to date. The present findings show a 5% upgrade rate to DCIS. As long as the current management of low-risk DCIS remains surgical excision, the present results support continued excision of MLLs, either surgically or by vacuum-assisted biopsy.

Mucocoele-like lesions: is surgical excision still necessary?

To assess the rate of upgrade in our screening population to determine whether open excision biopsy of mucocoele-like lesions (MLL) is still required. A retrospective review of the breast screening database from 1999-2014 was performed. MLL were identified on core biopsy in 113 women (0.6% of those recalled for a core biopsy). The majority (n=100, 88%) had a localised cluster of calcification prompting screening recall. Eighty-seven percent (n=99) underwent an excision biopsy; there was a 5% upgrade rate to malignancy (all low/intermediate ductal carcinoma in situ [DCIS]) and 15 women (15%) were found to have an additional "B3" lesion. Fourteen women did not undergo excision biopsy; none of these women had a subsequent cancer at an average of 5-years follow-up. Within the follow-up period, five additional cancers were identified, one of these was in the ipsilateral breast and location, albeit 9-years later. This is the largest study of MLL in the literature to date. The present findings show a 5% upgrade rate to DCIS. As long as the current management of low-risk DCIS remains surgical excision, the present results support continued excision of MLLs, either surgically or by vacuum-assisted biopsy.

The significance of extracellular mucin in breast fine needle aspiration specimens.

To determine if all breast fine needle aspiration (FNA) specimens with abundant extracellular mucin require excisional biopsy. Fifty cases of breast FNA containing extracellular mucin, reported with a recommendation for biopsy and with histological follow-up were reviewed. Cellular features were noted, and the cases reclassified ignoring the presence of mucin and then correlated with histological outcome. Subsequent histology showed benign changes in 20% (10/50), two cases (4%) of atypical ductal hyperplasia (ADH) and 76% (38/50) to be malignant lesions, including three cases of ductal carcinoma insitu (DCIS). When the FNA cases were reviewed disregarding the presence of mucin, 11 cases were reclassified as benign and one case that contained mucin-like material but no epithelial cells reviewed as non-diagnostic. All cases of invasive mixed and mucinous carcinoma (MC) would have been reported with a recommendation for histological examination. In addition, the three cases each of fibroadenoma (FA) and a benign mucocoele-like lesion (MLL) were correctly identified as benign. However, two cases each of DCIS and ADH would have been reported benign with no recommendation for further histology. Breast FNA specimens with mucinous material may arise from sampling of a range of benign and malignant processes; however, a biopsy should be recommended, even in cases of low cellularity, owing to sampling problems and the frequent co-occurrence of significant lesions. FNA is highly accurate at predicting carcinoma with mucinous differentiation although it is not possible to reliably predict if the lesion represents pure MC or a mixed carcinoma.

Breast core needle biopsy: issues and controversies

Core needle biopsy (CNB) is increasingly being used in the investigation of breast disease whether this is asymptomatic and suspected after screening mammography, or presents symptomatically in the patient. In most cases, the result of the procedure provides a definitive diagnosis or at least provides information that is used to plan the further management of the patient. There are, however, a number of unresolved issues with the use of CNB; for example, with regard to the amount of information that can be reliably derived from CNB or with regard to the management of the patient after some CNB diagnoses. Oestrogen and progesterone receptors and HER2 are reported on both core biopsies and excision specimens, but there continues to be debate over which represents the more appropriate specimen type on which to perform these tests. There are a number of possible diagnoses after CNB for which the management is not straightforward and around which there may be controversy, or just a lack of sufficient evidence to support a definite management plan. These ‘lesions of uncertain malignant potential’ include papillary lesions, fibroepithelial lesions with cellular stroma, mucocoele-like lesions and radial scars. Currently, these are removed surgically but there may be an argument for more conservative management including vacuum-assisted core excision in some cases.

Mucin extravasation in breast core biopsies – clinical significance and outcome correlation

To document the spectrum of lesions associated with mucin extravasation (ME) in breast core biopsy specimens, and to correlate with open surgical excisions. Thirty-nine lesions in 37 women with ME on core biopsies constituted the study group. Fibrocystic change (FC), atypical ductal hyperplasia (ADH) and ductal carcinoma in situ (DCIS) were found in 21 (53.8%), 13 (33.3%) and four (10.3%) core biopsy specimens, respectively, with one (2.6%) consisting only of mucin pools. Except for the latter, all disclosed mucocoele-like lesions (MLL) accompanying ME. Columnar cell lesions (CCL) were frequently observed (84.6%). On open biopsy, three cases underdiagnosed on core biopsy included FC that later disclosed ADH; one ADH lesion on core later upgraded to DCIS; and a case of mucin pools that revealed mucinous carcinoma on excision. The extent of CCL on core biopsy appeared to predict sinister lesions on open excision. For calcified lesions that were completely removed on core biopsy, there were no malignant lesions discovered on open excision that had not already been diagnosed preoperatively. ME and MLL on core biopsy warrant close radiological-pathological correlation. When the entire radiological abnormality has been removed with large core mammotome biopsy specimens, surgery may potentially be avoided in histologically benign lesions, although such an approach requires further validation.

Fine needle aspiration cytology in young women with breast cancer diagnostic difficulties

Breast carcinoma is the most common malignancy in women worldwide. Though fine needle aspiration cytology (FNAC) plays an important role in preoperative diagnosis, there may be diagnostic delays in affected young women due to a lower index of suspicion. The files of the Departments of Pathology, Singapore General Hospital, Singapore, and Prince of Wales Hospital, Hong Kong, were searched for cases of breast carcinoma in women aged 35 years or less. Those with prior FNA procedures comprised our study group. The FNA smears were reviewed and classified into five categories: inadequate, benign, equivocal, suspicious, malignant. The findings were correlated with subsequent histology. Thirty-four women aged 35 years and below underwent 35 FNACs, with one woman having bilateral FNA procedures. Upon review, one (2.9%) was classified as inadequate, one (2.9%) benign, five (14.3%) equivocal, five (14.3%) suspicious, 21 (60%) malignant and slides were not available for review for two (5.6%) cases. For six benign and equivocal cytological diagnoses, subsequent histology disclosed pure ductal carcinoma in situ (DCIS, 1 case), mucocoele-like lesions with DCIS (2 cases), invasive and in situ ductal carcinoma with neuroendocrine features (1 case) and two cases of invasive ductal carcinoma. Diagnostic difficulties in cytological interpretation of aspirates from breast carcinoma in young women may lead to unwanted delays, which occurred in six (17.6%) of 34 women in our series. Low grade cancers posing a pitfall in cytological diagnosis have to be considered.

Surgical excision is warranted following a core biopsy diagnosis of mucocoele-like lesion of the breast.

Mucocoele-like lesions (MLLs) of the breast are unusual lesions in which mucin-filled ducts or cysts are accompanied by extrusion of mucin into surrounding stroma. A possible diagnosis of MLL may be suggested by the finding of mucin-filled ducts or cysts and/or stromal mucin in a core biopsy sample. Whether such findings should prompt immediate open diagnostic biopsy to exclude malignancy is currently uncertain, although this represents current practice in our institution. In this study we have reviewed 11 cases of possible MLL on core biopsy correlating both pathological and radiological findings in order to determine the risks of associated malignancy and whether excision is the most appropriate management option. Eleven cases of possible MLL presenting via the Breast Screening and Assessment Unit in Leeds since April 1999 were identified by review of pathological records. Histological slides, mammograms and ultrasound images were reviewed. Ten of the 11 had undergone open surgical biopsy for diagnosis. Three of the 10 (30%) proved to derive from malignant lesions. Two were ductal carcinoma in situ (DCIS) and one was an invasive mucinous carcinoma. All three cases had an associated atypical epithelial proliferation which, in a surgical excision, would be classified as atypical ductal hyperplasia (ADH) at least, as well as mucin in the core biopsy sample. The majority of possible MLLs presented radiologically as coarse calcification, but two of four (50%) which had a radiological mass subsequently proved malignant. Seven cases were without atypia on the core and all subsequently proved benign. Three of these, however, were associated with ADH on the excision biopsy. Surgical excision is warranted following a core biopsy suggestion of possible MLL when mucin-filled ducts or cysts and stromal mucin have been seen. The risk of malignancy is high when the core biopsy also contains an atypical epithelial proliferation (100% in our series) and also when there is an associated radiological mass lesion. In cases without atypia on the core a significant proportion of cases (43%) are associated with ADH on excision.

Atypical ductal hyperplasia and atypia of uncertain significance in core biopsies from mammographically detected lesions: correlation with excision diagnosis

To assess: (1) the prevalence of reporting of atypical ductal hyperplasia (ADH) and intraductal atypia of uncertain significance (AUS) in a series of core biopsies from mammographically detected lesions, (2) the proportion of cases where excision revealed breast carcinoma, and (3) whether any diagnoses should be revised on review. Breast core biopsy reports from the Sir Charles Gairdner Hospital Breast Assessment Centre for the years 1999-2000 were retrieved. Slides from cases reported as ADH or AUS were reviewed as well as slides from the excision biopsies. There were 1048 core biopsies from 911 women. Breast carcinoma was diagnosed in 197 samples (18.8%) including 88 with invasive carcinoma (8.4%), 109 with ductal carcinoma in situ (DCIS) (10.4%). Three biopsies (0.3%) 'suspicious' of invasive carcinoma proved to be so. Of 52 samples (5.0%) with a diagnosis of ADH or AUS, 46 were excised, showing seven invasive carcinomas, 15 DCIS, 11 ADH, two lobular carcinoma in situ (LCIS), nine fibrocystic change (FCC), one mucocoele-like lesion and one fibroadenoma. The 22 malignancies represented 47.8% of the excised lesions. On review, seven of the 52 original core diagnoses were downgraded to benign hyperplasia. Five underwent excision, revealing two FCC, one complex sclerosing lesion, and two incidental lesions unrelated to the mammographic abnormality, including a microscopic tubular carcinoma and a focus of LCIS. In one case reviewed as unsatisfactory, excision showed invasive carcinoma. Lesions of particular interest included a case of high-grade DCIS with local regression in the core biopsy (so-called 'bumt out DCIS'), and one case diagnosed on excision as micropapillary ADH, where the review diagnosis was micropapillary DCIS. ADH and AUS were reported in 5.0% of biopsies. There was a high rate of carcinoma (47.8%) in subsequent excisions. Very few diagnoses were revised on review. Current protocols for excision of lesions with a 14-gauge core biopsy diagnosis of ADH/AUS appear justified. Literature review suggests that vacuum-assisted core sampling with 11-gauge needles will not remove the need for excision. Further study of local regression of DCIS and micropapillary lesions will be worthwhile.

Mammary mucinous lesions: congeners, prevalence and important pathological associations.

A retrospective histopathological study was undertaken to determine the prevalence of mucin filled ducts and their associated mucinous proliferation in 962 breast cancers and 335 benign lesions. A total of 38 (3%) cases with mucin filled ducts was identified and 27 (2%) of these showed mucin extravasation into the adjacent stroma, changes characteristic of mucocoele-like lesions. This constitutes the largest series reported to date. Of the mucocoele-like lesions 12 were prototypic screen-detected cases: 11 of which were mammographically detected on account of suspicious microcalcification and eight cases (67%) exhibited mucinous atypical ductal hyperplasia without overt malignancy. A further 12 mucocoele-like lesions were incidental findings in screen-detected (11) and symptomatic (one) cancers, the majority of which were invasive ductal carcinomas of no special type. In six of these cases (50%), mucinous atypical ductal hyperplasia or ductal carcinoma in situ was present. Thirty mucinous carcinomas constituted 3% of all cancers and three cases had associated mucocoele-like lesions. Mucinous atypical ductal hyperplasia or ductal carcinoma in situ was also associated with 11 cases of mucinous carcinoma. In six mucinous carcinomas, amorphous microcalcification with a similar appearance to that of benign mucocoele-like lesions was identified in the mucin, suggesting a possible link between the two lesions. Mucin-filled ducts or mucocoele-like lesions were almost twice as frequent in screen-detected as in symptomatic lesions. The presence of mucinous atypical ductal hyperplasia in screen-detected mucocoele-like lesions, a decade earlier than the peak of mucinous carcinoma, is a possible risk factor for subsequent invasive malignancy. Mucin-filled ducts, mucocoele-like lesions, mucinous atypical ductal hyperplasia or ductal carcinoma in situ and mucinous carcinoma may represent different stages of the same disease process. Our findings suggest that patients with mucin-filled ducts of mucocoele-like lesions merit close follow-up.

Mucocoele-like lesions detected by the mammographic presence of suspicious clustered microcalcifications

Abstract Six impalpable mucocoele-like lesions of the breast were detected by mammographic screening of 16000 women over a 15-month period in the Avon (Bristol) Breast Screening Programme as a result of suspicious clustered microcalcifications. The clusters measured between 5 mm and 50 mm. Five contained a small cluster between 5 mm and 15 mm, but one exhibited bizarre calcifications and soft-tissue densities over an area of 50 mm; two adjacent clusters displayed a crescentic (‘tea-cup’) morphology in some of the individual microcalcifications. Their mammographic appearances were pleomorphic. In this period calcified mucocoele-like lesions were detected both in a cohort of approximately 4500 women aged 50–52 years called for prevalent-round screening, and 11500 women involved in incident-round screening. However, not all mucocoele-like lesions are associated with mammographic microcalcification, and not all mucocoele-like lesions detected by microcalcification are associated with high-risk or frankly neoplastic lesions.