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European Radiology
Published in: European Radiology 2/2021

01-02-2021 | Breast Cancer | Breast

Positive predictive value for malignancy of uncertain malignant potential (B3) breast lesions diagnosed on vacuum-assisted biopsy (VAB): is surgical excision still recommended?

Authors: Marco Lucioni, Chiara Rossi, Pascal Lomoro, Francesco Ballati, Marianna Fanizza, Alberta Ferrari, Carlos A. Garcia-Etienne, Emanuela Boveri, Giulia Meloni, Maria Grazia Sommaruga, Elisa Ferraris, Angioletta Lasagna, Elisabetta Bonzano, Marco Paulli, Adele Sgarella, Giuseppe Di Giulio

Published in: European Radiology | Issue 2/2021

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Abstract

Purpose

Breast lesions classified as of “uncertain malignant potential” represent a heterogeneous group of abnormalities with an increased risk of associated malignancy. Clinical management of B3 lesions diagnosed on vacuum-assisted breast biopsy (VABB) is still challenging: surgical excision is no longer the only available treatment and VABB may be sufficient for therapeutic excision. The aim of the present study is to evaluate the positive predictive value (PPV) for malignancy in B3 lesions that underwent surgical excision, identifying possible upgrading predictive factors and characterizing the malignant lesions eventually diagnosed. These results are compared with a subset of patients with B3 lesions who underwent follow-up.

Methods

A total of 1250 VABBs were performed between January 2006 and December 2017 at our center. In total, 150 B3 cases were diagnosed and 68 of them underwent surgical excision. VABB findings were correlated with excision histology. A PPV for malignancy for each B3 subtype was derived.

Results

The overall PPV rate was 28%, with the highest upgrade rate for atypical ductal hyperplasia (41%), followed by classical lobular neoplasia (29%) and flat epithelial atypia (11%). Only two cases of carcinoma were detected in the follow-up cohort, both associated with atypical ductal hyperplasia at VABB.

Conclusion

Open surgery is recommended in case of atypical ductal hyperplasia while, for other B3 lesions, excision with VABB only may be an acceptable alternative if radio-pathological correlation is assessed, if all microcalcifications have been removed by VABB, and if the lesion lacks high-risk cytological features.

Key Points

• Surgical treatment is strongly recommended in case of ADH, while the upgrade rate in case of pure FEA, especially following complete microcalcification removal by VABB, may be sufficiently low to advice surveillance as a management strategy.
• The use of 11-G- or 8-G-needle VABB, resulting in possible complete diagnostic excision of the lesion, can be an acceptable alternative in case of RS, considering open surgery only for selected high-risk patients.
• LN management is more controversial: surgical excision may be recommended following classical LN diagnosis on breast biopsy if an additional B3 lesion is concurrently detected while in the presence of isolated LN with adequate radiological-pathological correlation follow-up alone could be an acceptable option.
Literature
1.
Perry N, Broeders M, de Wolf C, Törnberg S, Holland R, von Karsa L (2008) European guidelines for quality assurance in breast cancer screening and diagnosis. Fourth edition--summary document. Ann Oncol 19(4):614–622PubMed
2.
Lakhani SR, Ellis IO, Schnitt SJ, Tan PH, van de Vijver MJ (2012) WHO classification of tumours of the breast, 4th edn. International Agency for Research on Cancer, Lyon
3.
Rakha EA, Shaaban AM, Haider SA et al (2013) Outcome of pure mucocele-like lesions diagnosed on breast core biopsy. Histopathology 62(6):894–898PubMed
4.
Latronico A, Nicosia L, Faggian A et al (2018) Atypical ductal hyperplasia: our experience in the management and long term clinical follow-up in 71 patients. Breast 37:1–5PubMed
5.
AGO (2016) Guidelines of the AGO breast committee: lesions of uncertain malignant potential (B3) (ADH, LIN, FEA, Papilloma, Radial Scar)
6.
Alonso-Bartolomé P, Vega-Bolívar A, Torres-Tabanera M et al (2004) Sonographically guided 11-G directional vacuum-assisted breast biopsy as an alternative to surgical excision: utility and cost study in probably benign lesions. Acta Radiol 45(4):390–396PubMed
7.
8.
Wolff AC, Hammond ME, Hicks DG et al (2013) Recommendations for human epidermal growth factor receptor 2 testing in breast cancer: American Society of Clinical Oncology/College of American Pathologists clinical practice guideline update. J Clin Oncol 31(31):3997–4013PubMed
9.
Hahn M, Okamgba S, Scheler P et al (2008) Vacuum-assisted breast biopsy: a comparison of 11-gauge and 8-gauge needles in benign breast disease. World J Surg Oncol 6:51PubMedPubMedCentral
10.
Ruggirello I, Nori J, Desideri I et al (2017) Stereotactic vacuum-assisted breast biopsy: comparison between 11- and 8-gauge needles. Eur J Surg Oncol 43(12):2257–2260PubMed
11.
Piubello Q, Parisi A, Eccher A, Barbazeni G, Franchini Z, Iannucci A (2009) Flat epithelial atypia on core needle biopsy: which is the right management? Am J Surg Pathol 33(7):1078–1084PubMed
12.
Rakha EA, Ho BC, Naik V et al (2011) Outcome of breast lesions diagnosed as lesion of uncertain malignant potential (B3) or suspicious of malignancy (B4) on needle core biopsy, including detailed review of epithelial atypia. Histopathology 58(4):626–632PubMed
13.
Rageth CJ, O'Flynn EA, Comstock C et al (2016) First International Consensus Conference on lesions of uncertain malignant potential in the breast (B3 lesions). Breast Cancer Res Treat 159(2):203–213PubMedPubMedCentral
14.
Rageth CJ, O'Flynn EAM, Pinker K et al (2019) Second International Consensus Conference on lesions of uncertain malignant potential in the breast (B3 lesions). Breast Cancer Res Treat 174(2):279–296PubMed
15.
Calhoun BC, Sobel A, White RL et al (2015) Management of flat epithelial atypia on breast core biopsy may be individualized based on correlation with imaging studies. Mod Pathol 28(5):670–676PubMed
16.
Hayes BD, O’Doherty A, Quinn CM (2009) Correlation of needle core biopsy with excision histology in screen-detected B3 lesions: the Merrion Breast Screening Unit experience. J Clin Pathol 62(12):1136–1140PubMed
17.
Noske A, Pahl S, Fallenberg E et al (2010) Flat epithelial atypia is a common subtype of B3 breast lesions and is associated with noninvasive cancer but not with invasive cancer in final excision histology. Hum Pathol 41(4):522–527PubMed
18.
Mayer S, Kayser G, Rücker G et al (2017) Absence of epithelial atypia in B3-lesions of the breast is associated with decreased risk for malignancy. Breast 31:144–149PubMed
19.
Linda A, Zuiani C, Bazzocchi M, Furlan A, Londero V (2008) Borderline breast lesions diagnosed at core needle biopsy: can magnetic resonance mammography rule out associated malignancy? Preliminary results based on 79 surgically excised lesions. Breast 17(2):125–131PubMed
20.
Londero V, Zuiani C, Linda A, Girometti R, Bazzocchi M, Sardanelli F (2012) High-risk breast lesions at imaging-guided needle biopsy: usefulness of MRI for treatment decision. AJR Am J Roentgenol 199(2):W240–W250PubMed
21.
22.
Ancona A, Capodieci M, Galiano A, Mangieri F, Lorusso V, Gatta G (2011) Vacuum-assisted biopsy diagnosis of atypical ductal hyperplasia and patient management. Radiol Med 116(2):276–291PubMed
23.
Rageth CJ, Rubenov R, Bronz C et al (2019) Atypical ductal hyperplasia and the risk of underestimation: tissue sampling method, multifocality, and associated calcification significantly influence the diagnostic upgrade rate based on subsequent surgical specimens. Breast Cancer 26(4):452–458PubMed
24.
Nguyen CV, Albarracin CT, Whitman GJ, Lopez A, Sneige N (2011) Atypical ductal hyperplasia in directional vacuum-assisted biopsy of breast microcalcifications: considerations for surgical excision. Ann Surg Oncol 18(3):752–761PubMed
25.
McGhan LJ, Pockaj BA, Wasif N, Giurescu ME, McCullough AE, Gray RJ (2012) Atypical ductal hyperplasia on core biopsy: an automatic trigger for excisional biopsy? Ann Surg Oncol 19(10):3264–3269PubMed
26.
Menes TS, Rosenberg R, Balch S, Jaffer S, Kerlikowske K, Miglioretti DL (2014) Upgrade of high-risk breast lesions detected on mammography in the Breast Cancer Surveillance Consortium. Am J Surg 207(1):24–31PubMed
27.
Kohr JR, Eby PR, Allison KH et al (2010) Risk of upgrade of atypical ductal hyperplasia after stereotactic breast biopsy: effects of number of foci and complete removal of calcifications. Radiology 255(3):723–730PubMed
28.
Khoury T, Chen X, Wang D et al (2015) Nomogram to predict the likelihood of upgrade of atypical ductal hyperplasia diagnosed on a core needle biopsy in mammographically detected lesions. Histopathology 67(1):106–120PubMed
29.
Deshaies I, Provencher L, Jacob S et al (2011) Factors associated with upgrading to malignancy at surgery of atypical ductal hyperplasia diagnosed on core biopsy. Breast 20(1):50–55PubMed
30.
Rakha EA, Lee AH, Jenkins JA, Murphy AE, Hamilton LJ, Ellis IO (2011) Characterization and outcome of breast needle core biopsy diagnoses of lesions of uncertain malignant potential (B3) in abnormalities detected by mammographic screening. Int J Cancer 129(6):1417–1424PubMed
31.
Mesurolle B, Perez JC, Azzumea F et al (2014) Atypical ductal hyperplasia diagnosed at sonographically guided core needle biopsy: frequency, final surgical outcome, and factors associated with underestimation. AJR Am J Roentgenol 202(6):1389–1394PubMed
32.
Tsuchiya K, Mori N, Schacht DV et al (2017) Value of breast MRI for patients with a biopsy showing atypical ductal hyperplasia (ADH). J Magn Reson Imaging 46(6):1738–1747PubMedPubMedCentral
33.
Forgeard C, Benchaib M, Guerin N et al (2008) Is surgical biopsy mandatory in case of atypical ductal hyperplasia on 11-gauge core needle biopsy? A retrospective study of 300 patients. Am J Surg 196(3):339–345PubMed
34.
Prowler VL, Joh JE, Acs G et al (2014) Surgical excision of pure flat epithelial atypia identified on core needle breast biopsy. Breast 23(4):352–356PubMed
35.
Villa A, Chiesa F, Massa T et al (2013) Flat epithelial atypia: comparison between 9-gauge and 11-gauge devices. Clin Breast Cancer 13(6):450–454PubMed
36.
Dialani V, Venkataraman S, Frieling G, Schnitt SJ, Mehta TS (2014) Does isolated flat epithelial atypia on vacuum-assisted breast core biopsy require surgical excision? Breast J 20(6):606–614PubMed
37.
Bianchi S, Bendinelli B, Castellano I et al (2012) Morphological parameters of flat epithelial atypia (FEA) in stereotactic vacuum-assisted needle core biopsies do not predict the presence of malignancy on subsequent surgical excision. Virchows Arch 461(4):405–417PubMed
38.
Peres A, Barranger E, Becette V, Boudinet A, Guinebretiere JM, Cherel P (2012) Rates of upgrade to malignancy for 271 cases of flat epithelial atypia (FEA) diagnosed by breast core biopsy. Breast Cancer Res Treat 133(2):659–666PubMed
39.
Lavoué V, Roger CM, Poilblanc M et al (2011) Pure flat epithelial atypia (DIN 1a) on core needle biopsy: study of 60 biopsies with follow-up surgical excision. Breast Cancer Res Treat 125(1):121–126PubMed
40.
Chivukula M, Bhargava R, Tseng G, Dabbs DJ (2009) Clinicopathologic implications of “flat epithelial atypia” in core needle biopsy specimens of the breast. Am J Clin Pathol 131(6):802–808PubMed
41.
Darvishian F, Singh B, Simsir A, Ye W, Cangiarella JF (2009) Atypia on breast core needle biopsies: reproducibility and significance. Ann Clin Lab Sci 39(3):270–276PubMed
42.
Ingegnoli A, d'Aloia C, Frattaruolo A et al (2010) Flat epithelial atypia and atypical ductal hyperplasia: carcinoma underestimation rate. Breast J 16(1):55–59PubMed
43.
Verschuur-Maes AH, van Deurzen CH, Monninkhof EM, van Diest PJ (2012) Columnar cell lesions on breast needle biopsies: is surgical excision necessary? A systematic review. Ann Surg 255(2):259–265PubMed
44.
Morrow M, Schnitt SJ, Norton L (2015) Current management of lesions associated with an increased risk of breast cancer. Nat Rev Clin Oncol 12(4):227–238PubMed
45.
Meroni S, Bozzini AC, Pruneri G et al (2014) Underestimation rate of lobular intraepithelial neoplasia in vacuum-assisted breast biopsy. Eur Radiol 24(7):1651–1658PubMed
46.
Dabbs DJ (2012) Breast pathology, 1st edn. Elsevier
47.
D’Alfonso TM, Wang K, Chiu YL, Shin SJ (2013) 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. Arch Pathol Lab Med 137(7):927–935PubMed
48.
Wen X, Cheng W (2013) Nonmalignant breast papillary lesions at core-needle biopsy: a meta-analysis of underestimation and influencing factors. Ann Surg Oncol 20(1):94–101PubMed
49.
Kim MJ, Kim SI, Youk JH et al (2011) The diagnosis of non-malignant papillary lesions of the breast: comparison of ultrasound-guided automated gun biopsy and vacuum-assisted removal. Clin Radiol 66(6):530–535PubMed
50.
Mosier AD, Keylock J, Smith DV (2013) Benign papillomas diagnosed on large-gauge vacuum-assisted core needle biopsy which span <1.5 cm do not need surgical excision. Breast J 19(6):611–617PubMed
51.
Youk JH, Kim MJ, Son EJ, Kwak JY, Kim EK (2012) US-guided vacuum-assisted percutaneous excision for management of benign papilloma without atypia diagnosed at US-guided 14-gauge core needle biopsy. Ann Surg Oncol 19(3):922–928PubMed
52.
Calhoun BC, Collins LC (2016) Recommendations for excision following core needle biopsy of the breast: a contemporary evaluation of the literature. Histopathology. 68(1):138–151PubMed
53.
Ditsch N, Untch M, Thill M et al (2019) AGO recommendations for the diagnosis and treatment of patients with early breast cancer: update 2019. Breast Care (Basel) 14(4):224–245
Metadata
Title
Positive predictive value for malignancy of uncertain malignant potential (B3) breast lesions diagnosed on vacuum-assisted biopsy (VAB): is surgical excision still recommended?
Authors
Marco Lucioni
Chiara Rossi
Pascal Lomoro
Francesco Ballati
Marianna Fanizza
Alberta Ferrari
Carlos A. Garcia-Etienne
Emanuela Boveri
Giulia Meloni
Maria Grazia Sommaruga
Elisa Ferraris
Angioletta Lasagna
Elisabetta Bonzano
Marco Paulli
Adele Sgarella
Giuseppe Di Giulio
Publication date
01-02-2021
Publisher
Springer Berlin Heidelberg
Published in
European Radiology / Issue 2/2021
Print ISSN: 0938-7994
Electronic ISSN: 1432-1084
DOI
https://doi.org/10.1007/s00330-020-07161-5

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