Can problematic fibroepithelial lesions be accurately classified on core needle biopsies?

Bandyopadhyay, Sudeshna; Barak, Stephanie; Hayek, Kinda; Thomas, Sumi; Saeed, Haleema; Beydoun, Rafic; Shi, Dan; Arabi, Haitham; Ruterbusch, Julie J.; Coté, Michele L.; Ali-Fehmi, Rouba

doi:10.1016/j.humpath.2015.09.001

Cited by 15 publications

(10 citation statements)

References 29 publications

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“…Fibroadenoma (FA) is a commonly diagnosed lesion in clinical pathology . In the presence of increased stromal cellularity, core needle biopsy may struggle to definitively distinguish FA from benign PT . In such cases, the term “fibroepithelial lesion” is used and excision is typically performed for definitive classification.…”

Section: Introductionmentioning

confidence: 99%

Is excision biopsy of fibroadenomas based solely on size criteria warranted?

et al. 2018

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Fibroadenomas (FA) are the most common benign tumor in the female breast. Most are managed conservatively provided there is clinical, radiologic, and pathologic concordance. However, surgical excision is typically recommended for cellular fibroepithelial lesions or those lesions with clinical, radiologic, or pathologic features concerning for phyllodes tumor (PT). Some studies have suggested surgical excision in all FA >30 mm to reduce core needle biopsy (CNB) sampling errors. The aim of our study was to evaluate, in the absence of any other concerning clinicopathologic features, whether surgical excision of FA was warranted based on size criteria alone. Cork University Hospital is a large academic center in Southern Ireland. Its breast cancer center provides both a screening and symptomatic service and diagnoses approximately 600 cancers per year. The breast histopathological data base was reviewed for all CNBs from January 1, 2010, to June 30, 2015, with a diagnosis of FA that went on to have excision at our institution. We excluded all cellular fibroepithelial lesions and those cases with co-existent lobular neoplasia, ductal carcinoma in situ, invasive carcinoma, atypical ductal hyperplasia, or lesions which would require excision in their own right. Cases in which the radiologic targeted mass was discordant with a diagnosis of FA were also excluded. Patient demographics and preoperative radiologic size and the radiologic target were recorded in each case. All radiology was reviewed by a breast radiologist prior to inclusion in the study, and there was histologic radiologic concordance with a diagnosis of FA in all cases. A total of 12,109 consecutive radiologically guided CNB were performed January 2010-June 2015; 3438 with a diagnosis of FA were identified of which 290 cases went on to have surgical excision. Of those 290 cases; 98.28% (n = 285) were confirmed as FA on excision. The remaining 1.72% (n = 5) had atypical features-FA with LCIS (n = 1), benign PT (n = 3), and invasive ductal carcinoma (n = 1). Our study suggests that, excision based solely on size is not warranted in clinical and radiologically concordant cases with a diagnosis of FA on CNB.

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Section: Introductionmentioning

confidence: 99%

Is excision biopsy of fibroadenomas based solely on size criteria warranted?

et al. 2018

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“…Poor interobserver agreement in FELs on CNB is demonstrated by only 8/69 (11%) cores where unanimous diagnoses from all pathologists occurred (all FAs), 15 (21%) cases where both FA and PT were simultaneously offered as diagnoses by different pathologists and ‘weak’ mean kappa statistics between diagnoses (0.36). Similarly, in their recent study, Bandyopadhyay et al 4 demonstrated only ‘fair’ (0.20) core biopsy diagnostic agreement of FELs between five pathologists within their institution, which showed minimal improvement to 0.27 with departmental education. The interobserver agreement on cores when assessed specifically by specialist breast pathologists was higher (mean kappa of 0.44 vs 0.35), yet in a study of surgical specimens by Lawton et al ,3 only a poor agreement between specialist breast pathologists was observed, with unanimous agreement in only 2/15 cases.…”

Section: Discussionmentioning

confidence: 87%

Interobserver variation in the diagnosis of fibroepithelial lesions of the breast: a multicentre audit by digital pathology

et al. 2018

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AimFibroepithelial lesions (FELs) of the breast span a morphological continuum including lesions where distinction between cellular fibroadenoma (FA) and benign phyllodes tumour (PT) is difficult. The distinction is clinically important with FAs managed conservatively while equivocal lesions and PTs are managed with surgery. We sought to audit core biopsy diagnoses of equivocal FELs by digital pathology and to investigate whether digital point counting is useful in clarifying FEL diagnoses.MethodScanned slide images from cores and subsequent excisions of 69 equivocal FELs were examined in a multicentre audit by eight pathologists to determine the agreement and accuracy of core needle biopsy (CNB) diagnoses and by digital point counting of stromal cellularity and expansion to determine if classification could be improved.ResultsInterobserver variation was high on CNB with a unanimous diagnosis from all pathologists in only eight cases of FA, diagnoses of both FA and PT on the same CNB in 15 and a ‘weak’ mean kappa agreement between pathologists (k=0.36). ‘Moderate’ agreement was observed on CNBs among breast specialists (k=0.44) and on excision samples (k=0.49). Up to 23% of lesions confidently diagnosed as FA on CNB were PT on excision and up to 30% of lesions confidently diagnosed as PT on CNB were FA on excision. Digital point counting did not aid in the classification of FELs.ConclusionAccurate and reproducible diagnosis of equivocal FELs is difficult, particularly on CNB, resulting in poor interobserver agreement and suboptimal accuracy. Given the diagnostic difficulty, and surgical implications, equivocal FELs should be reported in consultation with experienced breast pathologists as a small number of benign FAs can be selected out from equivocal lesions.

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“…Additional areas of diagnostic challenge include in situ lesions, fibroepithelial lesions, low-grade cancers, and papillary lesions. [5][6][7][8][9][10][11] In many situations diagnostic accuracy for challenging breast pathology diagnoses can be improved by the use of ancillary studies. For example, deeper levels aid in establishing margin status, and myoepithelial IHC markers may be helpful in establishing microinvasion or in the subclassification of papillary lesions.…”

Section: Discussionmentioning

confidence: 99%

“…Currently there is a lack of helpful IHC to aid in the differential diagnosis of fibroadenoma and phyllodes tumor, and pathologist interobserver agreement has been described as only fair with limited core biopsy sampling. 9 Additionally, currently available IHC may be, but is not always, helpful in the differential diagnoses for the remaining above-listed reasons for review. The higher proportion of these diagnostic questions further highlights pathologist knowledge of their challenging nature and higher likelihood of seeking expert consultation, despite flexible published guidelines for consultation.…”

Section: Discussionmentioning

confidence: 99%

“…3,4 Recent reports have suggested poor concordance among pathologists for certain breast pathology diagnoses, including atypias, in situ carcinomas, fibroepithelial lesions, lowgrade cancers, and papillary lesions. [5][6][7][8][9][10][11] In atypical and in situ lesions, the use of ancillary studies such as additional levels improved diagnostic accuracy when compared with a reference panel of expert pathologists. 12 Immunohistochemical (IHC) stains, second review, and changes in processing can be useful, especially in preventing overdiagnosis of atypias, such as atypical ductal hyperplasia (ADH) (ie, false positives).…”

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confidence: 99%

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Characteristics of a Breast Pathology Consultation Practice

East¹,

Zhao²,

Pang³

et al. 2017

Archives of Pathology &Amp; Laboratory Medicine

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Context.-Intradepartmental consultation is a routine practice commonly used for new diagnoses. Expert interinstitutional case review provides insight into particularly challenging cases.Objective.-To investigate the practice of breast pathology consultation at a large tertiary care center.Design.-We reviewed breast pathology cases sent for private consultation and internal cases reviewed by multiple pathologists at a tertiary center. Requisitions and reports were evaluated for diagnostic reason for consultation, rate of multiple pathologist review at the tertiary center, use of immunohistochemistry, and, for private consultation cases, type of sender and concordance with the outside diagnosis.Results.-In the 985 private consultation cases, the most frequent reasons for review were borderline atypia (292 of 878; 33.3%), papillary lesion classification (151 of Conclusions.-This study confirms areas of breast pathology that represent diagnostic challenge and supports that pathologists are appropriately using expert consultation.

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Can problematic fibroepithelial lesions be accurately classified on core needle biopsies?

Cited by 15 publications

References 29 publications

Is excision biopsy of fibroadenomas based solely on size criteria warranted?

Is excision biopsy of fibroadenomas based solely on size criteria warranted?

Interobserver variation in the diagnosis of fibroepithelial lesions of the breast: a multicentre audit by digital pathology

Characteristics of a Breast Pathology Consultation Practice

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