Elsevier

The Breast

Volume 17, Issue 6, December 2008, Pages 623-630
The Breast

Original article
Lobular neoplasia: Core needle breast biopsy underestimation of malignancy in relation to radiologic and pathologic features

https://doi.org/10.1016/j.breast.2008.05.007Get rights and content

Abstract

The purpose of this study is to assess the positive predictive value (PPV) for malignancy of core needle biopsy (CNB) demonstrating lobular neoplasia (LN). From 3920 CNBs, 35 (0.89%) LNs (14 atypical lobular hyperplasia – ALH – and 21 lobular carcinoma in situ – LCIS) were identified. Twenty-eight patients underwent surgical excision and seven radiologic follow-up. We describe the imaging findings and excision histology outcomes. We report the PPV for malignancy based on excision histology (n = 28) and on excision or follow-up (n = 35), and according to the histologic type, biopsy probe and guidance, lesion diameter, and BI-RADS category. PPV for malignancy (based on excision histology) was 46.4% (13/28) and PPV (based on excision or follow-up) was 37.1% (13/35). The overall rate of malignancy for LN was 37.1% (13/35), with a PPV for malignancy of ALH and LCIS of 7.1% (1/14) and 57.1% (12/21), respectively (p = 0.003). Estimates of the PPV for malignancy were: stereotactic-guided vacuum-assisted biopsy (22.7%) versus ultrasound-guided automated CNB (61.5%), p = 0.053; lesions < 20 mm (31.2%) versus lesions > 20 mm (100%), p = 0.043; lesions classified as BI-RADS 3 (16.7%) versus BI-RADS 4 or 5 (41.4%), p = 0.377. Underestimation of malignancy was therefore more likely in cases of LCIS, US-guided CNB, and lesions that were large and suspicious on imaging. Nevertheless, the absence of these features does not spare the need for surgical excision in lobular neoplasia diagnosed on CNB.

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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