Borderline Atypical Ductal Hyperplasia/Low-grade Ductal Carcinoma In Situ on Breast Needle Core Biopsy Should Be Managed Conservatively

Abstract

The differential diagnosis of low–nuclear grade intraductal epithelial proliferations of the breast includes atypical ductal hyperplasia (ADH) and ductal carcinoma in situ (DCIS). This distinction can be difficult on core needle biopsy (CNB) but can have significant clinical ramifications. We examined the clinical course of patients diagnosed on CNB with borderline ADH/DCIS lesions [marked ADH (MADH)] at our institution. A total of 74 patients were diagnosed with MADH on CNB and underwent an excisional biopsy (EB). The majority of these CNBs reviewed at outside hospitals had been classified as DCIS. Twenty patients (27%) had benign findings or lobular neoplasia in their EB, 18 (24%) had ADH, 33 (45%) had DCIS, and 3 (4%) had DCIS and invasive ductal carcinoma (IDC). Among the 38 patients who were not diagnosed with DCIS or IDC on EB, no patient underwent further surgery or radiation post-operatively. Thirty-seven of these 38 patients had no recurrences, whereas 1 patient developed a “recurrence” that on our review was likely residual localized MADH. The mean follow-up for these patients was 54 months. Of the 36 patients diagnosed with DCIS or IDC on EB, < 20% required mastectomy. On review, MADH involving an intermediate-sized duct on CNB and the amount of residual lesion on imaging was significantly associated with DCIS or IDC on EB. Conversely, MADH involving columnar cell lesions and the presence of calcification on CNB were significantly associated with benign pathology on EB. In conclusion, our study provides preliminary data that justify a conservative approach to borderline ADH/DCIS lesions on CNB: that is, diagnose as MADH and treat by conservative excision.

Survival Benefit of Breast Surgery for Low-Grade Ductal Carcinoma In Situ

“…22,25 In addition, by integrating both conventional pathologic and molecular factors, such as human epidermal growth factor receptor 2, prostaglandinendoperoxide synthase 2, and Ki67, it may be possible to identify subpopulations of low-grade DCIS with more favorable prognoses. [26][27][28][29] The results from ongoing clinical trials (NCT00290745 and NCT01439711) looking at the role of neoadjuvant therapy for DCIS may provide more information that could help identify optimal biology-based DCIS treatment strategies. 30 We used multiple imputation to infer missing data pertaining to tumor size and ER status in the multivariable analysis because it characteristically yields less biased results than other methods.…”

Atypical Ductal Hyperplasia Bordering on Ductal Carcinoma In Situ

“…Vandenbussche et al 16 studied 74 cases with borderline ADH/DCIS diagnosis at core biopsy. Upgrade rate at excision was 49% (44% with DCIS, 4% with DCIS and invasive ductal carcinoma).…”

Current concepts in the diagnosis and pathobiology of intraepithelial neoplasia: A review by organ system

“…The distinction between ADH and LG DCIS is made on the basis of size and extent of ductal involvement, which at times can be difficult to assess on CNB because of tissue fragmentation. A conservative approach is recommended on CNB to avoid overdiagnosis of small, limited lesions as DCIS . Although concern for interobserver variability and reproducibility in the classification of intraductal and intralobular proliferations of the breast has received recent press, interobserver concordance can be readily reached with the application of standardized criteria in most cases on excision …”