Original articleLobular neoplasia: Core needle breast biopsy underestimation of malignancy in relation to radiologic and pathologic features
Introduction
Core needle biopsy (CNB) under stereotactic and sonographic guidance is now widely used, as an alternative to surgical excision, for the diagnosis of clinically occult breast lesions.1, 2, 3, 4, 5, 6, 7, 8, 9
CNB accuracy in the diagnosis of invasive carcinomas and most of the benign lesions is well established, with reported sensitivity rates ranging from 92% to 100% for ultrasound (US)-guided CNB10 and from 90% to 97% for stereotactically-guided vacuum-assisted biopsy (VAB). The sensitivity of stereotactic biopsy is a function of lesion type and of the number of sample cores, with the reported rates ranging from 95% to 99% for masses and from 83% to 87% for microcalcifications.3, 7, 10
With the wide diffusion of screening programs and of imaging tools able to detect very subtle findings, the incidence of benign proliferative high risk lesions is increasing in the setting of CNB histologic results. These lesions include atypical ductal hyperplasia (ADH), lobular neoplasia (atypical lobular hyperplasia [ALH] and lobular carcinoma in situ [LCIS], LN), papillary lesions (PL), radial sclerosing lesions (RSL), fibroepithelial lesions, mucocele-like lesions and columnar cell lesions.
Although the subsequent management (surgical excision versus follow-up) is well standardized in case of CNB diagnosis of invasive cancer, ductal carcinoma in situ (DCIS) and most benign lesions, the treatment strategy for borderline lesions (B3 lesions with uncertain malignant potential) is still a debated issue.8, 10, 11, 12, 13, 14
This issue is particularly substantial in the case of percutaneous diagnosis of LN, as its biologic behaviour is still uncertain. For many years, LN has been considered a marker for bilateral increased risk (10–20 times) for invasive breast carcinoma; however, recently, the hypothesis that it might be a precursor of invasive carcinoma has been raised.
The difficulties in LN management are also due to its significant association with malignancy underestimation rates when diagnosed on CNB (reported rates ranging from 0% to 58.3%).10, 13, 14, 15, 16
Thus, at the present time, there are no clear guidelines as regards the appropriate management of patients who received a diagnosis of LN at CNB.
Some authors have advocated surgical excision after percutaneous diagnosis of LN,17, 18, 19, 20, 21, 22, 23, 24, 25, 26 while others27, 28, 29 suggest a conservative management, like mammographic follow-up, possibly associated with chemoprophylaxis with tamoxifen.
Liberman et al.28 recommended surgical excision only in case of previous or present history of breast neoplasm, LN associated with another “high risk lesion” (like ADH, RSL, PL, …), histologic features of DCIS (difficulties in distinguishing LCIS with intraductal diffusion and DCIS with cancerization of the lobules), or radiologic–pathologic discordance.
The aim of our study was to retrospectively evaluate the frequency of malignancy after a percutaneous diagnosis of lobular neoplasia (ALH and LCIS), reporting on excision histology outcomes. The radiologic findings most frequently associated with the final diagnosis of malignancy were evaluated, in order to identify features that are able to predict definitive histologic results (malignancy versus benignity) and to select women who can be spared surgical excision.
Section snippets
Materials and methods
We retrospectively evaluated histologic results of all breast CNBs performed in our Department of Radiology between January 2000 and May 2007 and selected patients with diagnosis of pure ALH and pure LCIS. All patients with pathologic findings of other “high risk” lesions (ADH, RSL, PL) were excluded.
From a series of 3920 consecutives breast CNBs (3434 CNBS performed under sonographic guidance with 14-gauge probes and 486 VAB performed under stereotactic guidance with 11-gauge probes), 35
Results
In our series of 3920 consecutive breast CNBs, we identify 35 LNs (0.89%), corresponding to 14 ALH (40%) and 21 LCIS (60%) (Table 1).
The incidence of LN proved to be higher among lesions biopsied under stereotactic guidance (22/486, 4.5%) than among lesions biopsied under US-guidance (13/3434, 0.38%).
Discussion
The term lobular neoplasia encompasses a wide spectrum of pathologic entities originating from the terminal ductulo-lobular unit (TDLU) and characterized by solid proliferation of epithelial cells that fill and distend the acini. The distinction between ALH and LCIS is based on the degree of involvement of acinar units by the proliferating lobular cells. Recent studies have demonstrated that LCIS and ALH are not different biologic entities, but are part of a continuum of architectural,
Conclusions
In conclusion, LNs encompass a heterogeneous group of lesions, that may present as mammographic findings (calcifications, mass, mass with calcifications) or seldom as sonographic nodules, whose management should proceed from an accurate evaluation and multidisciplinary discussion of clinical, radiologic and pathologic features of each case. In case of percutaneous diagnosis of LN, surgical excision is warranted both because of its role as a precursor of breast cancer and because of the known
Conflict of Interest Statement
None declared.
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Risk for Upgrade to Malignancy After Breast Core Needle Biopsy Diagnosis of Lobular Neoplasia: A Systematic Review and Meta-Analysis
2020, Journal of the American College of RadiologyCitation Excerpt :Similar to other high-risk lesions, such as atypical ductal hyperplasia, radial scars, and complex sclerosing lesions, LN detected on core needle breast biopsy is frequently managed with surgical excision because of concern for possible undersampled malignancy, resulting in many surgical procedures for benign lesions [8]. The upgrade rates of LN to malignancy in the literature are highly variable, ranging from 0% to 67% for ALH and from 0% to 60% for LCIS [9-13], which contributes to the confusion over the appropriate approach to management. According to the National Comprehensive Cancer Network guidelines, either surgical excision or imaging follow-up for 1 year can be offered for management of imaging-concordant ALH and classic LCIS [14].
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2018, Seminars in RoentgenologyLesion stiffness measured by shear-wave elastography: Preoperative predictor of the histologic underestimation of US-guided core needle breast biopsy
2015, European Journal of RadiologyCitation Excerpt :Furthermore, the final assessment category on US was not an independent predictor for histologic underestimation. This result is not unexpected considering previous results that sonographic BI-RADS findings and final assessment category were not significantly associated with the underestimation of percutaneous biopsy-proven DCIS, ADH, lobular neoplasia, and phyllodes tumors [6–8,12,27,31]. For mammography and MRI, there is also little consensus regarding imaging features that are suggestive of histologic upgrade in biopsy-proven DCIS or high-risk lesions [6–9].