Surgical excision of pure flat epithelial atypia identified on core needle breast biopsy

Prowler, Vanessa; Joh, Jennifer E.; Ács, Géza; Kiluk, John V.; Laronga, Christine; Khakpour, Nazanin; Lee, M. Catherine

doi:10.1016/j.breast.2014.01.013

Cited by 26 publications

(16 citation statements)

References 16 publications

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“…On literature review, approximately 8% of pure flat epithelial atypia diagnosed on core needle biopsy was upgraded to carcinoma, with a range of 0-21% (Table 7). 19,20,22,24,30,[85][86][87][88][89][90][91][92][93][94][95][96][97][98][99][100][101][102][103][104] In our study, no statistically significant radiologic differences were seen between upgraded and not upgraded flat epithelial atypia core needle biopsy groups; however, residual calcification after biopsy was associated with upgrade. For pure flat epithelial atypia, as stated in the World Health Organization Working Group, careful radiological-pathological correlation is necessary, and in the absence of residual calcifications or other indications for excision, surveillance may be acceptable.…”

Section: Discussioncontrasting

confidence: 66%

Upgrade rates of high-risk breast lesions diagnosed on core needle biopsy: a single-institution experience and literature review

2016

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Optimal management of high-risk breast lesions detected by mammogram yielding atypical ductal hyperplasia, flat epithelial atypia, atypical lobular hyperplasia, lobular carcinoma in situ, and radial scar without atypia on core needle biopsy is controversial. This is a single-institution retrospective review of 5750 core needle biopsy cases seen over 14.5 years, including 249 (4.3%), 72 (1.3%), 50 (0.9%), 37 (0.6%), and 54 (0.9%) cases of atypical ductal hyperplasia, flat epithelial atypia, atypical lobular hyperplasia, lobular carcinoma in situ, and radial scar without atypia, respectively. Patient age, radiologic characteristics, needle gauge, and excision diagnoses were recorded. Of 462 high-risk cases analyzed, 333 (72%) underwent excision. Upgrade rate to ductal carcinoma in situ, pleomorphic carcinoma in situ, or invasive mammary carcinoma was 18% for atypical ductal hyperplasia, 11% for flat epithelial atypia, 9% for atypical lobular hyperplasia, 28% for lobular carcinoma in situ, and 16% for radial scar. Carcinoma diagnosed on excision was more likely to be in situ than invasive, and if invasive, more likely to be low grade than high grade. Overall, cases that were benign (vs high risk or carcinoma) on excision were less likely to have residual calcifications after biopsy (17% vs 27%, P=0.013), and more likely to have a smaller mass size (<1 cm) (82% vs 50%, P=0.001). On subgroup analysis, atypical ductal hyperplasia cases that were benign (vs high risk or carcinoma) on excision were more likely to have smaller mass size (<1 cm) (P=0.025). Lobular neoplasia diagnosed incidentally (vs targeted) on core needle biopsy was less likely to upgrade on excision (5% vs 39%, P=0.002). A comprehensive literature review was performed, identifying 116 studies reporting high-risk lesion upgrade rates, and our upgrade rates were similar to those of more recent larger studies. Careful radiological-pathological correlation is needed to identify high-risk lesion subgroups that may not need excision.

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Section: Discussioncontrasting

confidence: 66%

Upgrade rates of high-risk breast lesions diagnosed on core needle biopsy: a single-institution experience and literature review

2016

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“…Previous research suggests that up to 10% of all core needle breast biopsies may have FEA noted by the interpreting pathologist. 2 Our study corroborates these observations. Although studies have evaluated the incidence of breast cancer in women with FEA, 39,40 their applicability relies on the reproducibility of FEA as a diagnostic entity.…”

Section: Discussionsupporting

confidence: 90%

“…2 Each year, 1.6 million breast biopsies are performed on women in the United States, 3,4 suggesting a large number of women will be diagnosed with FEA. The World Health Organization (WHO) established the defining features of FEA in 2003.…”

Section: Introductionmentioning

confidence: 99%

Surgical implications and variability in the use of the flat epithelial atypia diagnosis on breast biopsy specimens

et al. 2017

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Objectives Flat epithelial atypia (FEA) is a relatively new diagnostic term with uncertain clinical significance for surgical management. Any implied risk of invasive breast cancer associated with FEA is contingent upon diagnostic reproducibility, yet little is known regarding its use. Materials and Methods Pathologists in the Breast Pathology Study interpreted one of four 60-case test sets, one slide per case, constructed from 240 breast biopsy specimens. An electronic data form with standardized diagnostic categories was used; participants were instructed to indicate all diagnoses present. We assessed participants’ use of FEA as a diagnostic term within: 1) each test set; 2) 72 cases classified by reference as benign without FEA; and 3) six cases classified by reference as FEA. 115 pathologists participated, providing 6,900 total independent assessments. Results Notation of FEA ranged from 0% to 35% of the cases interpreted, with most pathologists noting FEA on 4 or more test cases. At least one participant noted FEA in 34 of the 72 benign non-FEA cases. For the 6 reference FEA cases, participant agreement with the case reference FEA diagnosis ranged from 17% to 52%; diagnoses noted by participating pathologists for these FEA cases included columnar cell hyperplasia, usual ductal hyperplasia, atypical lobular hyperplasia, and atypical ductal hyperplasia. Conclusions We observed wide variation in the diagnosis of FEA among U.S. pathologists. This suggests that perceptions of diagnostic criteria and any implied risk associated with FEA may also vary. Surgical excision following a core biopsy diagnosis of FEA should be reconsidered and studied further.

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“…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.…”

Section: Discussionmentioning

confidence: 96%

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

et al. 2015

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Flat epithelial atypia of the breast commonly co-exists with atypical ductal hyperplasia, lobular neoplasia, and indolent forms of invasive carcinomas such as tubular carcinoma. Most patients with pure flat epithelial atypia on core biopsy undergo surgical excision to evaluate for carcinoma in the adjacent breast tissue. Studies to date have reported varying upgrade rates with most recommending follow-up excision. These studies have often lacked detailed radiographic correlation, central review by breast pathologists and information regarding the biology of the carcinomas identified upon excision. In this study, we report the frequency of upgrade to invasive carcinoma or ductal carcinoma in situ in excision specimens following a diagnosis of pure flat epithelial atypia on core biopsy. Radiographic correlation is performed for each case and grade/receptor status of detected carcinomas is reported. Seventy-three (73) core biopsies containing pure flat epithelial atypia were identified from our files, meeting inclusion criteria for the study. In the subsequent excision biopsies, five (7%) cases contained invasive carcinoma or ductal carcinoma in situ and seventeen (23%) contained atypical ductal hyperplasia or lobular neoplasia. All of the ductal carcinoma in situ cases with estrogen receptor results were estrogen receptor positive and intermediate grade. The invasive tumors were small (pT1a) hormone receptorpositive, HER2-negative, low-grade invasive ductal or tubular carcinomas with negative sentinel lymph-node biopsies. No upgrades were identified in the 14 patients who had all of their calcifications removed by the stereotactic core biopsy. Our rate of upgrade to carcinoma, once cases with discordant imaging are excluded, is at the lower end of the range reported in the literature. Given the low upgrade rate and indolent nature of the carcinomas associated with flat epithelial atypia, case management may be individualized based on clinical and radiographic findings. Excision may not be necessary for patients without remaining calcifications following core biopsy.

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Surgical excision of pure flat epithelial atypia identified on core needle breast biopsy

Cited by 26 publications

References 16 publications

Upgrade rates of high-risk breast lesions diagnosed on core needle biopsy: a single-institution experience and literature review

Upgrade rates of high-risk breast lesions diagnosed on core needle biopsy: a single-institution experience and literature review

Surgical implications and variability in the use of the flat epithelial atypia diagnosis on breast biopsy specimens

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

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