Upgrade Rate of Percutaneously Diagnosed Pure Atypical Ductal Hyperplasia: Systematic Review and Meta-Analysis of 6458 Lesions

Abstract

Background: Management of percutaneously diagnosed pure atypical ductal hyperplasia (ADH) is an unresolved clinical issue.Purpose: To calculate the pooled upgrade rate of percutaneously diagnosed pure ADH. Materials and Methods:A search of MEDLINE and EMBASE databases was performed in October 2018. Preferred Reporting Items for Systematic Reviews and Meta-Analyses, or PRISMA, guidelines were followed. A fixed-or random-effects model was used, along with subgroup and meta-regression analyses. The Newcastle-Ottawa scale was used for study quality, and the Egger test was used for publication bias.Results: Of 521 articles, 93 were analyzed, providing data for 6458 ADHs (5911 were managed with surgical excision and 547 with follow-up). Twenty-four studies used core-needle biopsy; 44, vacuum-assisted biopsy; 21, both core-needle and vacuum-assisted biopsy; and four, unspecified techniques. Biopsy was performed with stereotactic guidance in 29 studies; with US guidance in nine, with MRI guidance in nine, and with mixed guidance in eight. Overall heterogeneity was high (I 2 = 80%). Subgroup analysis according to management yielded a pooled upgrade rate of 29% (95% confidence interval [CI]: 26%, 32%) for surgically excised lesions and 5% (95% CI: 4%, 8%) for lesions managed with follow-up (P , .001). Heterogeneity was entirely associated with surgically excised lesions (I 2 = 78%) rather than those managed with follow-up (I 2 = 0%). Most variability was explained by guidance and needle caliper (P = .15). At subgroup analysis of surgically excised lesions, the pooled upgrade rate was 42% (95% CI: 31%, 53%) for US guidance, 23% (95% CI: 19%, 27%) for stereotactic biopsy, and 32% (95% CI: 22%, 43%) for MRI guidance, with heterogeneity (52%, 63%, and 56%, respectively) still showing the effect of needle caliper. When the authors considered patients with apparent complete lesion removal after biopsy (subgroups in 14 studies), the pooled upgrade rate was 14% (95% CI: 8%, 23%). Study quality was low to medium; the risk of publication bias was low (P = .10). Conclusion:Because of a pooled upgrade rate higher than 2% (independent of biopsy technique, needle size, imaging guidance, and apparent complete lesion removal), atypical ductal hyperplasia diagnosed with percutaneous needle biopsy should be managed with surgical excision.

B3 lesion upgrade rates in a tertiary Australian breast centre: a 8‐year experience (2012–2019)

“…The upgrade rates for ADH are very variable, ranging between 7% and 45%. 4,[21][22][23][24] Some studies suggest ADH may be overtreated by open surgical excisional biopsy, 4,[23][24][25] thus new approaches have been made based on surveillance, especially if all microcalcifications are removed using VAEB or if co-existing columnar cell lesion is present. 23,26,27 Management of ADH may have implications for DCIS, as ADH is regarded as a precursor lesion to DCIS.…”

“…4,[21][22][23][24] Some studies suggest ADH may be overtreated by open surgical excisional biopsy, 4,[23][24][25] thus new approaches have been made based on surveillance, especially if all microcalcifications are removed using VAEB or if co-existing columnar cell lesion is present. 23,26,27 Management of ADH may have implications for DCIS, as ADH is regarded as a precursor lesion to DCIS. 5,[21][22][23] To date, there are several large prospective randomized controlled trials investigating active surveillance for low-risk DCIS compared to conventional surgery with or without adjuvant radiotherapy or hormonal therapy: LOw Risk DCIS study (LORD, Europe), The LOw RISk DCIS trial (LORIS, UK) and Comparing an Operation to Monitoring, With or Without Endocrine Therapy (COMET, USA).…”

“…23,26,27 Management of ADH may have implications for DCIS, as ADH is regarded as a precursor lesion to DCIS. 5,[21][22][23] To date, there are several large prospective randomized controlled trials investigating active surveillance for low-risk DCIS compared to conventional surgery with or without adjuvant radiotherapy or hormonal therapy: LOw Risk DCIS study (LORD, Europe), The LOw RISk DCIS trial (LORIS, UK) and Comparing an Operation to Monitoring, With or Without Endocrine Therapy (COMET, USA). [28][29][30][31] All three trials are currently still recruiting.…”

Impact of Non-Calcified Specimen Pathology on the Underestimation of Malignancy for the Incomplete Retrieval of Suspicious Calcifications Diagnosed as Flat Epithelial Atypia or Atypical Ductal Hyperplasia by Stereotactic Vacuum-Assisted Breast Biopsy

“…Wagoner et al ( 25 ) observed an ADH upgrade rate of 5% (three of 57 cases) when percutaneous biopsy resulted in the complete retrieval of all suspicious calcifications followed by subsequent excision. Schiaffino et al ( 26 ) performed a meta-analysis study including 6458 lesions to estimate the upgrade rate of percutaneously diagnosed pure ADH and found that even if patients with apparent complete lesion removal after biopsy were considered, the pooled upgrade rate was 14%. Most studies emphasized the importance of pathological diagnosis of calcified lesions, but none of them mentioned the association between non-calcified lesions and disease ( 16 17 18 ).…”

Decoding and Systematization of Medical Imaging Features of Multiple Human Malignancies

“…All the retrieved full-text articles were downloaded and read by our investigators for information extraction. Then, the Newcastle-Ottawa scale (25), a critical appraisal tool for studies in systematic review, was used to assess the quality of all the articles we included in this review. See Appendix E1 (supplement) for details on article inclusion and exclusion criteria.…”