Ductal Carcinoma In Situ and Atypical Ductal Hyperplasia of the Breast Diagnosed at Stereotactic Core Biopsy

Abstract

Stereotactic core needle biopsy (SCNB) allows specific histopathologic diagnoses to be made without surgery and has been demonstrated to be an accurate, cost-effective method of diagnosing breast disease, particularly nonpalpable lesions. However, recent studies have concluded that the diagnosis of atypical ductal hyperplasia (ADH) by means of SCNB has resulted in nearly equal odds that a coexisting malignant lesion will be missed. Furthermore, others have concluded that SCNB diagnosed as DCIS cannot reliably indicate the absence of tumor invasion in surgical excision. Between 1993 and 1998, 1,221 consecutive SCNB of mammographically identified lesions were performed using a 14-gauge automated device with an average of 5.3 cores obtained per lesion. ADH was identified in 19 (1.6%) lesions and DCIS in 89 (7.3%). Surgical biopsy was performed in 89 of these patients and histopathologic results from SCNB and surgical biopsies were reviewed and correlated. In 12 cases of ADH diagnosed by SCNB, surgical biopsy showed ADH in 8 (67%) cases and DCIS in the other 4 (33%) cases. In 77 cases of DCIS diagnosed by SCNB, a surgical biopsy showed DCIS in 55 (71%) cases, 6 more cases (8%) had DCIS with focal microinvasion, and 15 (19%) had invasive ductal carcinoma. In one case no residual tumor was found at surgery. In the author's patient population, the diagnosis of ADH at SCNB indicates high probability of DCIS or residual ADH in the surgical biopsy. The diagnosis of DCIS at SCNB is confirmed in the majority of surgical biopsies; however, a significant number of cases may show microinvasion or invasive carcinoma.

Predictors of invasive disease in breast cancer when core biopsy demonstrates DCIS only

“…These findings are similar to that of the Nottingham Group [1] with a 44% rate of invasion, though higher than most studies which quote rates between 15% and 30% [5,[7][8][9][10]. Variety in reported rates may be affected by the meticulousness of pathology sectioning and reporting, the increased awareness of microinvasion or the accuracy or type of core biopsy.…”

Predictors of invasion in needle core biopsies of the breast with ductal carcinoma in situ

“…Similar to this last problem is the diagnosis of atypical duct hyperplasia in a core biopsy with subsequent upgrade to DCIS. 11,[27][28][29] These are all problematic because the differentiation is based on either the size or extensiveness of the lesion; and in a core biopsy, sampling error and size estimation is a built-in limitation. These are significant as the treatment methods differ between the different differentials.…”

“…However, some cases of needle core biopsy-diagnosed DCISs turned out to be invasive in the final excisions. This was not an uncommon occurrence, being reported in 8-44% [7][8][9][10][11][12][13][14][15][16][17][18] of multiple series of needle core biopsy-diagnosed DCISs of the breast. It is interesting to note that the upstaging rates of several series spanning over a period of time were similar, indicating that there has not been substantial progress in the histological evaluation of predictive factors of invasion in needle core biopsy showing DCIS only.…”

“…Whether these factors are totally insignificant is still debatable, as all of these had been shown to be significant or insignificant in different series. For instance, some studies showed that age, 16 number of cores, 16,21 grade, [7][8][9]11,16,21 architecture, 7,16,21 necrosis, 9,11,16,21 periductal stromal fibrosis or desmoplasia [14][15][16]21 and calcification 16,18 were insignificant, whereas other studies showed the same factors, including number of cores, 13,18 grade, 10,14,15,20 comedo necrosis, 10,11,19 and periductal inflammatory cells infiltrate, 14 to be significant. It seems that prediction of eventual invasion in needle core biopsy showing only DCIS is still fraught with uncertainty.…”

What the clinician wants to know: radiation oncology perspective

“…SLNB performed following excisional biopsy demonstrates satisfactory results [29,80] . Patients with ductal carcinoma-in-situ (DCIS) have an excellent long term prognosis (98% survival) but 10%-29% of these patients will have invasive cancer at definitive surgery [81][82][83][84][85][86][87] . Analysis of resected nodes from patients who had negative axillary surgery previously, demonstrated micrometastases in 13% of nodes but none in patients who had disease recurrence [88] .…”