Flat Epithelial Atypia on Core Needle Biopsy

Abstract

The clinical significance and management (surgical excision vs. follow-up) of the patients with the diagnosis of flat epithelial atypia (FEA) on core needle biopsy (CNB) are actually under discussion. Using standardized criteria and precise terminology, we analyzed retrospectively our CNB diagnosis of FEA, dividing patients with pure FEA as the most advanced pathologic lesion from patients with FEA associated to atypical ductal hyperplasia (FEA+ADH). Both the categories were correlated with radiologic data and findings on subsequent surgery. We evaluated 875 core needle biopsies (11-gauge stereotactic vacuum-assisted procedure), performed over a 5-year period. A CNB diagnosis of pure FEA was made in 33/875 (3.7%) cases; in other 11 (1.2%) cases we observed the coexistence of FEA and ADH. Subsequent surgical excisions were available in 20/33 pure FEA and in 10/11 FEA+ADH: of the 20 patients with pure FEA on CNB, none had either ductal carcinoma in situ or invasive carcinoma in their excisional biopsy, whereas 3/10 (30%) FEA+ADH on CNB showed, at subsequent surgery, more advanced lesions (2 ductal carcinoma in situ, 1 invasive carcinoma). Our results suggest that patients with an 11-gauge vacuum-assisted CNB diagnosis of pure FEA (especially if related to a small radiologic target, completely or almost completely removed by the needle biopsy procedure) could be spared surgical excision and managed with close radiologic follow-up.

Morphological parameters of flat epithelial atypia (FEA) in stereotactic vacuum-assisted needle core biopsies do not predict the presence of malignancy on subsequent surgical excision

“…The identification of FEA also poses a diagnostic challenge to the pathologist, particularly in CB, because FEA with mild cytological atypia may be subtle and care should be taken not to overlook the lesion or to over-diagnose it and reporting as atypical any columnar cell lesion 17,18 . Our results confirm previous reports 11,[25][26][27] that almost all patients (185/190, 97.4 %) with pure FEA are asymptomatic and that microcalcifications are the main determinant in 91 % (173/190) of cases. As earlier studies reported 11 , we found moderate to severe chronic inflammation in 12 % of pure FEA cases (23/190) and stromal changes, including myxoid change and fibrosis in 36.3 % (69/190), of which the significance remains to be clarified.…”

“…Although there is no definitive agreement at present on the clinical management of FEA (underestimation rates for CB diagnosis of pure FEA reported in the literature vary from 0 to 67 % 13 ), the currently prevailing recommendation is that it warrants follow-up surgical excision 1,27 . A few studies in the published literature support the follow-up observation for the management of pure FEA 26,28,29 .…”

“…It may contribute to the assessment of the clinical and biological significance of pure FEA and to the management of patients with VANCB diagnosis of pure FEA. All VANCB cases were histologically reviewed and diagnoses were agreed by the panel of 14 pathologists participating in the study using non-ambiguous terminology 25,26 .…”

Management of flat epithelial atypia on breast core biopsy may be individualized based on correlation with imaging studies

“…Another recent study of 24 cases showed an upgrade rate of 3.2%. 28 Piubello et al 29 and Noel et al 30 reported no cases with carcinoma on excision in two smaller series in which only the patients with residual suspicious calcifications underwent surgical biopsy for flat epithelial atypia. It must also be noted that all but one of the pre-core biopsy imaging studies in our series were BIRADS-4.…”

Clinicopathologic characteristics of carcinomas that develop after a biopsy containing columnar cell lesions

“…The first question, which pertains to the diagnostic and therapeutic relevance of columnar cell atypia, is still being debated in the literature [16][17][18][19] ; the second question addresses the long-term significance and possible precursor nature of this lesion. In this study, we have addressed the second question with an analysis of the follow-up data from the Nashville Breast Cohort.…”