Rate Of Pathologic Upgrade Research Articles

Development and External Validation of Multiparametric MRI-Derived Nomogram to Predict Risk of Pathologic Upgrade in Patients on Active Surveillance for Prostate Cancer.

OBJECTIVE. The aim of this study was to create, develop, and externally validate a nomogram that predicts pathologic upgrade in patients on active surveillance (AS) for prostate cancer using commonly available clinical and multiparametric MRI (mpMRI) factors. MATERIALS AND METHODS. A consecutive sample of 300 patients undergoing AS for prostate cancer at the Keimyung University Dongsan Hospital between 2010 and 2016 was used to develop the nomogram. The validation cohort consisted of 150 patients undergoing active surveillance at Kyungpook National University Hospital between 2013 and 2017. The study outcome was the occurrence of pathologic upgrade in AS patients. The relationship between the clinical and mpMRI factors considered and pathologic upgrade was tested using univariate and multivariate logistic regression analyses. The predictive accuracy of the nomogram was determined using the ROC AUC. RESULTS. The overall rate of pathologic upgrade was 25.0% in the developmental cohort and 22.0% in the validation cohort. Significant variables in the models were age, prostate-specific antigen level, biopsy grade group 2, baseline Prostate Imaging Reporting and Data System (PI-RADS) scores of 4 and 5, positive cores on initial biopsy greater than 1, and biopsy cores with 50% or more tumor involvement. The progression seen on mpMRI of PI-RADS score was significantly associated with pathologic upgrade. The nomogram used to predict the risk of pathologic upgrade had a predictive accuracy of 0.78 in the external validation cohort. CONCLUSION. This study developed and externally validated a nomogram that predicts the risk of pathologic upgrade on the basis of commonly used factors. This nomogram may be used to assist management decision making for patients on AS for prostate cancer.

Is bigger better? Twenty-year institutional experience of atypical ductal hyperplasia discovered by core needle biopsy

ObjectivesThe increasing accuracy of large-bore (11- or 8-gauge) vacuum-assisted core needle biopsies (VACNB) has challenged the commonly-accepted practice that surgery is needed for definitive diagnosis when atypical ductal hyperplasia (ADH) is found on VACNB. This study seeks to demonstrate the impact of increased VACNB caliber on the pathologic upgrade rate of ADH. MethodsPatients diagnosed with isolated ADH by VACNB who subsequently underwent surgical excision at our tertiary medical center were retrospectively studied. Demographics, needle gauge, number of needle passes, and pathology results were analyzed. ResultsFrom June 1996 to June 2016, approximately 3740 VACNBs were performed. 139 patients were diagnosed with isolated ADH on VACNB and underwent surgical excision. 30 patients (22%) were upgraded to ductal carcinoma in-situ or invasive cancer; 17 upgrades (21%) from 11-gauge CNB vs. 13 upgrades (23%) from 8-gauge CNB (p = 0.67). ConclusionIncreasing core needle biopsy size from 11 g to 8 g does not decrease the rate of pathologic upstaging at the time of surgical excision. Surgical excision of ADH is still required for complete diagnosis.

Radial scars/complex sclerosing lesions of the breast: radiologic and clinicopathologic correlation

BackgroundWe investigated the radiologic and clinical findings of radial scar and complex sclerosing lesions, and evaluated the rate of pathologic upgrade and predicting factors.MethodsFrom review of our institution’s database from January 2006 to December 2012, we enrolled 82 radial scars/complex sclerosing lesions in 80 women; 51 by ultrasound guided core needle biopsy, 1 by mammography-guided stereotactic biopsy, and 38 by surgical excision. The initial biopsy pathology revealed that 53 lesions were without high risk lesions and 29 were with high risk lesions. Radiologic, clinical and pathological results were analyzed statistically and upgrade rates were calculated.ResultsOf the 82 lesions, 64 (78.0%) were surgically excised. After surgical excision, two were upgraded to DCIS and two were upgraded to lesions with high risk lesions. The rate of radial scar with high risk lesions was significantly higher in the surgical excision group (11.1% vs. 42.2%, p = 0.015), which also demonstrated larger lesion size (10.7 ± 6.5 vs. 7.1 ± 2.6 mm, p = 0.001). The diagnoses with high risk lesions on final pathological results showed older age (52.9 ± 6.0 years vs. 48.4 ± 6.7 years, p = 0.018).ConclusionsRadial scars with and without high risk lesions showed no statistically significant differences in imaging, and gave relatively low cancer upgrade rates.

Mucocelelike Lesions in the Breast: Radiologic and Clinicopathologic Correlations With Upgrade Rate.

The purpose of this article is to investigate the radiologic and clinicopathologic findings of mucocelelike lesions (MLLs) and the rate of pathologic upgrade with factors predicting it. We reviewed our institution's database from January 2006 to December 2012 and enrolled 89 women with 89 MLLs. The pathologic findings from the initial biopsies identified 71 lesions without and 18 lesions with associated high-risk lesions. Images were reviewed according to the BI-RADS lexicon. Clinical and pathologic results were analyzed statistically, and upgrade rates were calculated. Of the 89 lesions, 67 (75.3%) underwent surgical excision and 22 (24.7%) did not. After surgical excision (n = 67), one lesion was upgraded to mucinous carcinoma, three were upgraded to ductal carcinoma in situ, and 16 were upgraded to MLLs with associated high-risk lesions (29.9% total upgrade rate; 20/67). A statistically significant higher percentage of MLLs with associated high-risk lesions was observed in the surgical excision group (94.4% vs 70.4%; p = 0.036). The final pathologic diagnosis revealed larger lesions (16.4 ± 9.1 vs 12.6 ± 6.8 mm; p = 0.024) and younger patients in the high-risk group (46.9 ± 7.7 vs 50.6 ± 9.1 years; p = 0.049). Although no significant differences were observed in the imaging findings, including the BI-RADS category, upgraded lesions were seen as a mass with calcification as a predominant feature. This study revealed no significant differences in imaging findings or BI-RADS category between high-risk and non-high-risk breast MLLs. However, we confirmed that high-risk lesions typically are seen as larger masses with calcifications.

Radial Scar at Percutaneous Breast Biopsy That Does Not Require Surgery

Surgical excision is currently recommended after pathologic radial scar is found on breast core needle biopsy because surgical upgrade to carcinoma is not uncommon. The goal of our study was to identify the true pathologic upgrade rate for a "pure" radial scar, those without associated proliferative lesion, based on indication for biopsy, biopsy type, and needle size. The pathology database of Continuum Health Partners was searched for the terms radial scar and radial sclerosing lesion, from January 2007 to December 2015. From review of 1,513 pathology reports, 292 cases of core biopsies without malignancy were identified. Age, indication for biopsy, type of biopsy, and excisional pathology were obtained. Data were then analyzed using SPSS. Two hundred nineteen (75%) of the 292 core biopsies showed pure radial scar without associated proliferative lesion, and 161 (74%) of these patients had surgical excision. Only 1 of these patients had disease that was upgraded to ductal carcinoma in situ-a 2-mm focus located 5 mm away from the radial scar biopsy cavity. This patient also had residual calcifications on mammography after the stereotactic biopsy. Six additional malignant upgrades were found in patients who had radial scar associated with atypical ductal hyperplasia (n= 5) or lobular neoplasia (n= 1) on needle biopsy. Surgical excision is unnecessary when radial scar is found at percutaneous needle biopsy without an associated proliferative lesion. Surgical excision is still indicated when radial scar is associated with atypical ductal hyperplasia or lobular neoplasia.

Comparing magnetic resonance imaging/ultrasound-fusion biopsy and systemic 12-core transrectal ultrasound biopsy for whole gland pathology.

84 Background: Historically, pathologic findings from standard 12-core prostate biopsies are upgraded in 25 to 33% of patients after radical prostatectomy (RP). MRI/US fusion prostate biopsy has been shown to upgrade prostate cancer compared to standard 12-core biopsy in 32% of patients. MRI/US fusion biopsy may offer a more accurate representation of whole gland pathology. We evaluate the rate of pathologic upgrade in standard 12-core biopsy and MRI/US fusion biopsy when compared with whole gland pathology from RP. Methods: Patients who underwent random prostate biopsy, fusion biopsy and subsequently RP for prostate cancer from 2012 to 2013 were included. Pathology was reviewed by a single pathologist. The cohort was divided into clinically significant high-grade (Gleason score 4+3 or higher) and clinically insignificant low-grade (Gleason score 3+4 or lower) sub cohorts. Pathological upgrade was defined as any increase in Gleason sum or primary Gleason score. McNemar’s test was used to compare the proportion of patients who were upgraded from random biopsy to RP versus the proportion that were upgraded from fusion biopsy to RP. Results: Sixty eight patients underwent 12-core and fusion prostate biopsy then subsequently RP. Mean prostate-specific antigen was 9.2ng/ml. There are total of 43 patients with clinically insignificant low-grade and 25 patients with clinically significant high-grade. Fusion biopsy upgraded 19 patients (28%) compared to 12-core biopsy, eight of these patients had negative 12-core biopsy. Pathology on the RP specimen upgraded 18 of the 12-core results (26%) compare to only eight fusion biopsy results (11%). (p =0.0095) 14 patients (20%) who had clinically insignificant low-grade disease on 12-core biopsy were upgraded to clinically significant high-grade on RP. Only two patients (3%) with clinically insignificant low-grade from fusion biopsy were upgraded on RP. (p< 0.0005) Conclusions: Prostate cancer detected on MRI/US fusion prostate biopsy has significantly lower rates of pathologic upgrade than standard 12-core biopsy when both were compared to prostatectomy specimens. MRI/US fusion biopsy may represent whole gland pathology more accurately compared to 12-core biopsy.

Pathologic Upgrade Rates on Subsequent Excision When Lobular Carcinoma In Situ Is the Primary Diagnosis in the Needle Core Biopsy With Special Attention to the Radiographic Target

Lobular carcinoma in situ (LCIS) as the primary pathologic diagnosis in a needle core biopsy is an infrequent finding, and the management of patients in this setting is controversial. To determine the rate of pathologic upgrade (defined as the presence of a clinically more-significant lesion in the subsequent excision) in patients with a primary pathologic diagnosis of LCIS in the needle core biopsy. Patients with a primary diagnosis of LCIS in a needle core biopsy who underwent subsequent excision were identified. Core biopsies containing a concurrent high-risk lesion and cases with radiologic-pathologic discordance were excluded. The presence of selected microscopic features in the needle core biopsy was correlated with pathologic upgrade. Microscopic findings were correlated with the radiographic target in the needle core biopsy. Sixty-one women with primary LCIS in their needle core biopsy showed a 10% pathologic upgrade rate. The percentage of cores involved by LCIS was significantly associated with pathologic upgrade (P= .04), whereas the remaining measured parameters were not. When LCIS represented the radiographic target, the pathologic upgrade rate was 18%, whereas when it was an incidental finding, the pathologic upgrade rate was 4%. It may be reasonable for patients with primary, yet incidental, LCIS on needle core biopsy to be managed in a nonsurgical fashion. Larger studies are needed to confirm our findings.

Breast Lesions of Uncertain Malignant Potential: A Challenge for Surgeons

Objective and background: The need for surgical resection of breast lesions of uncertain malignant potential diagnosed by core-needle biopsy (CNB) is not well established. Our study sought to determine the incidence of these lesions at CNB and to find the rate of pathologic upgrade at surgery. and during clinical follow-up. Method: A retrospective review of CNBs performed at our hospital covering the period from November 1999 to December 2008 was undertaken. In those patients diagnosed with lobular neoplasia (atypical lobular neoplasia (ALH) and lobular carcinoma in situ (LCIS)), atypical ductal hyperplasia (ADH) and radial scar (RS) the rates of pathologic upgrade at subsequent surgery were determined. Results: 9325 breast CNBs were performed during the period under review. There were 36 diagnoses of ALH (0.4%), 20 of LCIS (0.2%), 110 of ADH (1.2%) and 60 of RS (0.6%). Regarding lobular neoplasia, ALH surgical resection was performed with subsequent pathologic upgrade in only 1/31 patients (3.2%). 85% of LCIS diagnoses were followed by surgical resection with pathologic upgrade in 5/17 cases (29%). For patients with ADH, 51% (56/110) had surgical resection with an upgrade rate of 20% (11/56). 9/54 patients (17%) who did not undergo surgical resection subsequently developed a cancer at the biopsy site. Regarding RS, in 58% (35/60) of cases surgical resection was undertaken with a pathologic upgrade rate of 8% (3/35). In all three cases with an upgrade the biopsy had been performed on a hypoechogenic lesion. Conclusion: We conclude that the significant rate of pathologic upgrade in LCIS and ADH mandates a surgical excision when these lesions are found at CNB. The low rate of pathologic upgrade in RS in the absence of a hypoechogenic lesion and ALH may allow these cases to be observed.

Lobular neoplasia on core biopsy: Is excision always indicated?

75 Background: Lobular neoplasia (LN) is a continuum of rare, noninvasive lesions of the breast including lobular carcinoma in situ and atypical lobular hyperplasia. Current management is controversial and often includes excisional biopsy in women diagnosed with LN on percutaneous core biopsy (PCB) to exclude an occult malignancy. This strategy is based on retrospective data in women undergoing selective excisions. We performed routine excision of all lesions diagnosed as LN in our institution in order to ascertain a more accurate assessment of pathologic upgrade. Methods: Retrospective review of all prospectively collected cases of LN treated in a single institution from 2007-2010. Excisional biopsies were performed in all cases of LN excepting one (patient declined). Histologic findings of excisional biopsies were reviewed to assess the rate of pathologic upgrade. Results: Of the 2,289 PCBs performed during the study period, LN was found in 23 cases (1.0%). Twenty two (0.96%) cases proceeded to excisional biopsy. On final pathology, malignancy was found in 4 patients (18%). Two of 22 (9%) women were upgraded to ductal carcinoma in situ (DCIS) (both intermediate grade with foci of <1mm and 4mm) and 2/22 (9%) women were diagnosed with invasive lobular carcinoma. Conclusions: While 18% of women in our series had upgraded pathology at the time of excisional biopsy, we support selective rather than routine excisional biopsy. One of the invasive diagnoses was an incidental finding unrelated to the microcalcifications for which biopsy was initially performed. In the second case of invasive disease, the upgraded lesion was a mass identified on MRI performed for surgical planning in a woman already diagnosed with breast cancer. In both cases of DCIS, the area of malignancy was small (<1mm and 4mm) and of uncertain clinical significance. Based on these findings, we do not recommend routine excision of all LN identified on PCB. Cases in which the lesion is associated with a radiographic mass and/or is identified in a breast with a synchronous malignancy do warrant excisional biopsy. Patients without these high risk features can be counseled on the risks of malignancy and given the option of observation with close follow up.