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Annals of Surgical Oncology
Published in: Annals of Surgical Oncology 10/2017

01-10-2017 | Breast Oncology

Challenging Atypical Breast Lesions Including Flat Epithelial Atypia, Radial Scar, and Intraductal Papilloma

Authors: Jennifer M. Racz, MD, MBA, Jodi M. Carter, MD, PhD, Amy C. Degnim, MD

Published in: Annals of Surgical Oncology | Issue 10/2017

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Excerpt

High-risk breast lesions are characterized by histologic epithelial abnormalities that are associated with an increased risk of breast cancer, either due to an underestimation by core needle biopsy (CNB) or an increased risk over the long-term. With the increased use of screening mammography, there has been an increase in the pathologic diagnosis of high-risk lesions on percutaneous image-guided CNB. It is thus essential that surgeons understand which lesions may require surgical excision to rule out the possibility of an associated malignancy. In the absence of a concurrent malignancy, a high-risk lesion is simply a histologic finding in breast tissue that is associated with an increased risk of breast cancer. The best-known high-risk lesions are atypical ductal hyperplasia (ADH), atypical lobular hyperplasia (ALH), and lobular carcinoma in situ (LCIS), which will be reviewed separately due to the extent of literature focusing just on these lesions. In addition to these, several other lesions are included in the challenging high-risk lesion category, including flat epithelial atypia (FEA), radial scar, and papillary lesions. In this article, we review the literature on these latter high-risk lesions and provide recommendations for clinical management (summarized in Table 1).
Table 1
Summary of management recommendations for flat epithelial atypia, radial scar, and papillary lesions
Core needle biopsy pathology
Risk association
Surgical excision
Observation
Prevention
Flat epithelial atypia (FEA)
Risk of upgrade to invasive carcinoma <10%, probably <3% for focal FEA
Risk of an associated high-risk lesion ~25–30%
Yes
May be appropriate if:
Focal FEA with no associated high-risk lesion
Radiologic-pathologic concordance
Removal of all microcalcifications at biopsy
Absence of an associated mass
Not recommended unless the patient also has AH or LCIS
Radial scar (RS)
Risk of upgrade for RS with no associated HRL ~1–3%
Risk of upgrade for RS with associated HRL ~1–14%
Yes, if high-risk lesion (i.e., ADH, ALH and/or LCIS), size >1 cm or discordant histologic and mammographic findings
May be appropriate if:
No associated high-risk lesion
Size <1 cm
Concordant histologic and mammographic findings
Biopsy with ≥14-gauge needle
Core biopsy with >12 samples
Not recommended unless the patient also has AH or LCIS
Papillary lesions
Risk of upgrade for benign papilloma ~2–7%
Risk of upgrade for papilloma with atypia 21–37%
Yes, for IDPs with atypia.
Consider selective surgical excision for benign papillomas:
Age >55 years
Size >1 cm
Associated ipsilateral breast cancer
If presence of an associated HRL will alter management
May be appropriate if:
Absence of atypia
Concordant histologic and mammographic findings
Complete removal of lesion on imaging
Not recommended unless the patient also has AH or LCIS
…
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Metadata
Title
Challenging Atypical Breast Lesions Including Flat Epithelial Atypia, Radial Scar, and Intraductal Papilloma
Authors
Jennifer M. Racz, MD, MBA
Jodi M. Carter, MD, PhD
Amy C. Degnim, MD
Publication date
01-10-2017
Publisher
Springer International Publishing
Published in
Annals of Surgical Oncology / Issue 10/2017
Print ISSN: 1068-9265
Electronic ISSN: 1534-4681
DOI
https://doi.org/10.1245/s10434-017-5980-6

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