Atypical ductal hyperplasia on percutaneous breast biopsy: Scoring system to identify the lowest risk for upgrade

Abstract

Purpose NCCN guidelines recommend surgical excision for all patients with atypical ductal hyperplasia (ADH) on percutaneous biopsy. Improved imaging and biopsy techniques have lower contemporary upgrade rates, challenging standard practice. Methods A retrospective analysis identified 87 percutaneous biopsies diagnosing ADH who underwent surgical excision at a single institution from 01/2008 to 10/2015. Imaging was reviewed for lesion size and residual calcifications. Biopsy slides were reviewed for ADH features. Categorical variables were analyzed using Chi-square and Fisher’s exact tests; continuous variables with T- and Wilcoxon tests. Logistic regression model was used to determine association between odds of upgrade and number of low-risk features. Results Upgrade was identified in 13 cases (14.9%; 11 ductal carcinoma in situ and 2 invasive breast cancer). Imaging features associated with lowest risk of upgrade included imaging size < 1cm (p = 0.004) and > 50% removed by biopsy (p = 0.03). The only pathologic feature significantly associated with upgrade was the presence of micropapillary features (p = 0.10), with lower extent of ADH (1–2 foci, p = 0.12) trending toward significance. Those with the lowest risk of upgrade (0%) had all 4 low risk features (n = 17, 20%). The loss of a low-risk feature increased the odds of upgrade by 189% (OR = 1.89, 95% CI 0.241,0.742, p = 0.001). Conclusion Contemporary imaging and biopsy techniques have resulted in lower upgrade rates for ADH. Patients at lowest risk for upgrade can be identified using a scoring system and may be safely offered active surveillance over surgical excision.

Preneoplastic Low-Risk Mammary Ductal Lesions (Atypical Ductal Hyperplasia and Ductal Carcinoma In Situ Spectrum): Current Status and Future Directions

“…Amin et al followed up 71 patients who had ADH detected in screening mammography, treated with wide local excision, and had no upgrading (to DCIS or iBC) for a median time of 71.3 months. Nine (12%) patients developed subsequent cancer (four DCIS and five iBC), seven ipsilateral and two contralateral [33].…”