Flat epithelial atypia with and without atypical ductal hyperplasia: to re-excise or not. Results of a 5-year prospective study

Abstract

Flat epithelial atypia (FEA) of the breast have a tendency to calcify and, as such, are becoming increasingly detected by mammography. There is no consensus yet on whether to excise these lesions or not after diagnosis on core needle biopsies (CNB). We reviewed 3,948 cases of breast CNB between June 2004 and June 2009 correlating histomorphologic, radiological, and clinical features. There were 3.7 % (145/3,948) pure FEA and 1.5 % (58/3,948) concomitant FEA and atypical ductal hyperplasia (ADH). In the pure FEA population, 46.2 % (67/145) had microcalcifications on mammography with 65.5 % (95/145) of patients undergoing subsequent excisional biopsies with the following findings: benign 20 % (19/95), ADH 37.9 % (36/95), ductal carcinoma in situ (DCIS) 1.1 % (1/95), and DCIS and invasive ductal carcinoma (IDC) 2.1 % (2/95). In the concomitant FEA and ADH group, 86.2 % (50/58) patients had microcalcifications on radiograph with 74.1 % (43/58) of patients undergoing subsequent excisions with: benign 23.3 % (10/43), DCIS 9.3 % (4/43), DCIS and IDC 4.7 % (2/43), DCIS + lobular carcinoma in situ + invasive lobular carcinoma 2.3 % (1/43), and tubular carcinoma 2.3 % (1/43). The incidence of carcinoma in the FEA + ADH group is 18.6 % (8/43) and 3.2 % (3/95) for the pure FEA group. This difference is statistically significant (p = 0.0016). The relative risk of carcinoma in the ADH + FEA group versus the pure FEA group is 6.4773, with 95 % CI of 1.8432 and 22.76 24. Five-year mean follow-up in the unexcised pure FEA did not show any malignancies. These findings suggest that pure FEA has a very low association with carcinoma, and these patients may benefit from close clinical and mammographic follow-up while the combined pure FEA and ADH cases may be re-excised.

Flat epithelial atypia and risk of breast cancer: A Mayo cohort study

“…Although outside the scope of the current investigation, other retrospective studies have reported that cancer is found in approximately 3% to 13% of women with FEA on core needle biopsy who subsequently undergo surgical excision. 13,[30][31][32][33][34][35][36] This finding is not surprising, given the association between FEA and AH that we observed, and the known risk of an upgrade to cancer with surgical excision of AH. In addition to a small risk of detecting cancer at the time of surgical excision, multiple studies have reported finding other high-risk lesions (AH or lobular carcinoma in situ) in 20% to 52% of women undergoing excision of FEA found at core needle biopsy.…”

“…An issue in the current clinical management of FEA is the question of surgical excision when FEA is diagnosed with core needle biopsy. Although outside the scope of the current investigation, other retrospective studies have reported that cancer is found in approximately 3% to 13% of women with FEA on core needle biopsy who subsequently undergo surgical excision . This finding is not surprising, given the association between FEA and AH that we observed, and the known risk of an upgrade to cancer with surgical excision of AH.…”

“…This finding is not surprising, given the association between FEA and AH that we observed, and the known risk of an upgrade to cancer with surgical excision of AH. In addition to a small risk of detecting cancer at the time of surgical excision, multiple studies have reported finding other high‐risk lesions (AH or lobular carcinoma in situ) in 20% to 52% of women undergoing excision of FEA found at core needle biopsy . Although the majority of studies recommend surgical excision for FEA detected on core needle biopsy, others have suggested that this might not be warranted.…”

Do columnar cell lesions exist in the male breast?

“…As reported in our systematic review, CCL-A diagnosed in core needle biopsies showed the presence of cancer in 9.4% of the subsequent excisions. 14 In more recent publications the underestimation risks ranged between 3.2% and 19%, [15][16][17][18][19][20][21][22][23][24] dependent upon study method differences, as some of the studies did not take into account radiological findings and radiological-pathological discordances. In larger vacuum biopsies more material is investigated, often showing lower underestimation risks [sometimes with no (in-situ) cancer] in subsequent excision biopsies.…”

Paradigm Shifts in Breast Care Delivery: Impact of Imaging in a Multidisciplinary Environment

“…Flat epithelial atypia (FEA), a commonly encountered lesion in stereotactic biopsies performed for grouped calcifications, has an uncertain risk level and is another histopathologic lesion where the management is variable in different practices (31). …”