Histopathologic Analysis of Atypical Lesions in Image-Guided Core Breast Biopsies

Abstract

Stereotactic or ultrasound-guided needle core breast biopsies (NCBB) are now routinely performed to assess suspicious microcalcifications or non-palpable masses detected by screening mammography. This approach has been shown to have high sensitivity and specificity in establishing the diagnosis of fibrocystic lesions, ductal carcinoma in situ (DCIS), and invasive carcinoma (1). As more NCBB are being performed, pathologists are encountering lesions with features of atypical ductal hyperplasia (ADH) or atypical lobular hyperplasia (ALH). There are two issues that impact the clinical evaluation of patients with atypical lesions in NCBB samples. First, malignant lesions are known to frequently coexist with ADH/ALH, either within the same segment of breast tissue or in different quadrants (the latter as a manifestation of so-called field effect alteration). Because of partial/limited sampling, it is thus theoretically possible that at least some patients with atypia on NCBB may harbor occult DCIS. This problem is highlighted by the consideration that histologic distinction between ADH and DCIS is partially quantitative in nature (2, 3). Second, microfocal lesions may be missed during the process of trimming the block (so-called sectioning artifact). This problem is exacerbated if cores are fragmented or associated with crushing,

Are columnar cell lesions the earliest histologically detectable non-obligate precursor of breast cancer?

“…Little is known about the underlying biology of microcalcifications in pre-neoplastic and pre-invasive lesions. However, since the microcalcifications that occur in CCLs are indistinguishable radiologically from those seen in atypical ductal hyperplasia (ADH; DIN1b) and ductal carcinoma in situ (DCIS), needle biopsy or excision is required for diagnosis [3,4,7,37]. The increased incidence of CCLs may reflect improved recognition by pathologists or reflect the increasing representation of biopsies generated by mammographic screening.…”

Pure flat epithelial atypia (DIN 1a) on core needle biopsy: study of 60 biopsies with follow-up surgical excision

“…A few small studies (less than 40 cases) (almost all published in abstract form) were confused and showed a more advanced lesion, either DCIS or IC, in between 0 and 30% of cases of subsequent surgical excision after FEA diagnosed with CNB [4,[15][16][17][18][19][20][21]. Thus, published studies are rare, lack standardized terminology and sometimes confuse FEA and ADH on pathology [4,16].…”

Needle Biopsy Diagnosis of Breast Cancer

“…80 In another review, several subsets of patients with a diagnosis of ADH on CNB with a high likelihood of DCIS in subsequent surgical excisions were identified. 81 These included patients in whom the CNB was diagnosed as ADH bordering on DCIS and patients with a diagnosis of ADH with papillary features, with a 63% and 36% likelihood of DCIS in subsequent surgical biopsies, respectively. The number of atypical foci in CNB and the mammographic span of the microcalcifications, greater than four foci and greater than 2 cm, also correlated with an increased likelihood of DCIS on excision.…”

“…The number of atypical foci in CNB and the mammographic span of the microcalcifications, greater than four foci and greater than 2 cm, also correlated with an increased likelihood of DCIS on excision. 81 What is the accuracy of predicting invasion by stereotactic core biopsy?…”