Progression risk of columnar cell lesions of the breast diagnosed in core needle biopsies

Abstract

Columnar cell lesions (CCLs) of the breast are recognized as putative precursor lesions of invasive carcinoma, but their management remains controversial. We therefore conducted a retrospective study on 311 CCLs, diagnosed in 4,164 14‐gauge core needle biopsies (CNB): 221 CCLs without atypia (CCL), 69 with atypia (CCL‐A), and 21 atypical ductal hyperplasias originating in CCL (ADH‐CCL). Two groups were identified: “immediate treatment” group undergoing excision within four months after the CNB diagnosis of CCL (N = 52) and the “wait‐and‐see” group followed up to 8 years (median 3.5 years, N = 259). In 7 of 31 women (22.5%, 1 CCL, 4 CCL‐A, 2 ADH‐CCL) who underwent immediate surgical excision and were initially biopsied for microcalcifications, ductal carcinoma in situ (DCIS) was present and in 2/31 women (6.5%, 1 CCL, 1 CCL‐A) invasive carcinoma. In 2/21 excisions (9.5%, 1 CCL, 1 CCL‐A) initially biopsied for a density, DCIS was present and invasive carcinoma in 5/21 excisions (23.8%, 2 CCL, 3 CCL‐A). In the wait‐and‐see group, 9/259 women (3.5%) developed invasive carcinoma, 6 ipsi, and 3 contralaterally. Progression risks of CCL‐A and ADH‐CCL were 18% and 22%,versus 2% for CCL without atypia (p < 0.001). In conclusion, CCL‐A or ADH‐CCL in a CNB were associated with a high risk of DCIS/invasive carcinoma in immediate surgical excision biopsies. The 8‐years progression risks for CCL‐A and ADH‐CCL were around 20%. This illustrates that an atypical CCL in a CNB may signal the presence of concurrent lesions or development of advanced lesions in future and may justify (“mini”) surgical excision.

Do columnar cell lesions exist in the male breast?

“…In larger vacuum biopsies more material is investigated, often showing lower underestimation risks [sometimes with no ( in‐situ ) cancer] in subsequent excision biopsies . Longer follow‐up studies that have investigated the chance of developing DCIS or invasive carcinoma after the diagnosis of a CCL in a core needle biopsy not followed by excision biopsy are sparse, and report a range of increased risk from none to about 20% within 8 years if unexcised . With a CCL‐A diagnosis on a core needle biopsy, multidisciplinary discussion is advised, also taking into account the radiological features.…”

“…25 Longer follow-up studies that have investigated the chance of developing DCIS or invasive carcinoma after the diagnosis of a CCL in a core needle biopsy not followed by excision biopsy are sparse, and report a range of increased risk from none to about 20% within 8 years if unexcised. [26][27][28][29][30] With a CCL-A diagnosis on a core needle biopsy, multidisciplinary discussion is advised, also taking into account the radiological features. Surgical resection or removal of all microcalcifications by large vacuum biopsies or the Breast Lesion Excision System may be considered.…”

The low nuclear grade breast neoplasia family

“…The risk of subsequent malignancy (positive predictive value; PPV) following a diagnosis of CCL with atypia on NCB varies from 15% to 18% in FEA which increases upto 20%e37% in CCL with ADH. 21,23,28 The PPV for LN is 15e40% and this rate increases to 50% in pure ADH and upto 60% in ADH associated with LN. Although the proportion of BC following NCB diagnosis of pure atypia is low (w2% of all BC), diagnosis of these lesions, which comprises w5% of all NCB diagnoses, carries important management implications.…”

Flat epithelial atypia in directional vacuum-assisted biopsy of breast microcalcifications: surgical excision may not be necessary

“…However, the impact of other factors in these studies could not be determined due to their retrospective nature, and missing and heterogeneous data. Review of published reports that included 20 or more cases of flat epithelial atypia with subsequent excision (totaling 734 cases among 12 reports) [30][31][32][33][34][35][36][37][38][39][40][41] showed that a higher upgrade rate is encountered among cases that included calcifications associated with masses or other mammographic abnormalities, biopsy samples procured by cutting needles, and limited sampling of calcifications. For example, in a large retrospective multiinstitutional study by Bianchi et al [37], the authors noted a trend for higher upgrade rate in cases with incomplete removal of calcifications, associated mass or architectural distortion (9% of cases), and lesions with BI-RADS 4 and 5 combined (23% of cases).…”

“…Published studies have reported an upgrade rate to in situ or invasive carcinoma in the follow-up excision after a diagnosis of flat epithelial atypia on core needle biopsy in up to 20% of cases [36][37][38][39][40][41]43]. Although several authors have advocated for clinical follow-up, if flat epithelial atypia is the worst pathologic finding in the core needle biopsy and all the calcifications are removed by core biopsy [17][18][19][20][21][22][23][24][25][26][27][28][29], others recommend follow-up excision to rule out a higher risk lesion [30][31][32][33][34][35][36][37][38][39][40][41]43].…”