atypical ductal hyperplasia, increased risk of malignancy papillary lesions… · 2014-10-13 ·...

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Atypical ductal hyperplasia,Atypical ductal hyperplasia,Papillary lesions,Papillary lesions,

And Lobular carcinoma in And Lobular carcinoma in situsitu

in Breast Core Biopsiesin Breast Core BiopsiesDr. Andrew RenshawDr. Andrew Renshaw

Baptist HospitalBaptist Hospital

Miami, FLMiami, FL

Management of lesions with Management of lesions with increased risk of malignancyincreased risk of malignancy

�� Risk comes from multiple sourcesRisk comes from multiple sources

�� Specimen identificationSpecimen identification

�� SAMPLINGSAMPLING

�� Patient characteristicsPatient characteristics

Approach to lesions with Approach to lesions with increased risk of malignancyincreased risk of malignancy

�� Goal is no longer to define the lesion but Goal is no longer to define the lesion but ratherrather

�� To define the risk associated with itTo define the risk associated with it

�� To allow the patient and the clinician to To allow the patient and the clinician to make informed decisionmake informed decision

Approach to lesions with Approach to lesions with increased risk of malignancyincreased risk of malignancy

�� Unfortuantely, while we can make the risk Unfortuantely, while we can make the risk very low, we can rarely make it go away very low, we can rarely make it go away entirelyentirely

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Breast core identificationBreast core identification

�� Prior to 2006 Prior to 2006 –– at least 5 specimen mix at least 5 specimen mix upsups

�� ? in radiology ? in radiology -- ? in pathology? in pathology

�� No system to verify identityNo system to verify identity

�� All the clinicians blamed pathologyAll the clinicians blamed pathology

Inking breast coresInking breast cores

�� 2006 2006

�� Specimens received in mesh bags directly Specimens received in mesh bags directly from radiologyfrom radiology

�� 5 color inking strategy5 color inking strategy

Breast cores since 2006Breast cores since 2006

�� 2 specimen mix ups 2 specimen mix ups �� One wrong block cutOne wrong block cut�� One incorrect labelling of slideOne incorrect labelling of slide

�� Five typographical error (wrong color typed)Five typographical error (wrong color typed)

�� ALL detected prior to sign outALL detected prior to sign out

�� Make sure your pathologist has a system to Make sure your pathologist has a system to ensure specimen identificationensure specimen identification

SAMPLINGSAMPLING

�� We excise benign lesions because of what We excise benign lesions because of what might be left behind after core biopsymight be left behind after core biopsy

�� What is the overall sampling error of core What is the overall sampling error of core needle biopsy (assuming radiologic needle biopsy (assuming radiologic correlation)?correlation)?

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Estimating Sampling errorEstimating Sampling error

�� Risk of malignancy with a benign Risk of malignancy with a benign diagnosis:diagnosis:

�� 11--2% (but up to 4%) in multiple studies2% (but up to 4%) in multiple studies

�� Similar to other organsSimilar to other organs

�� Implies risks >2% may need excision (unless Implies risks >2% may need excision (unless you are always going to excise)you are always going to excise)

Atypical ductal hyperplasiaAtypical ductal hyperplasia

Atypical ductal hyperplasiaAtypical ductal hyperplasia

�� Diagnosed in 4Diagnosed in 4--7% of biopsies7% of biopsies

�� Upgraded (DCIS or invasion) 18Upgraded (DCIS or invasion) 18--31% of 31% of patientspatients

�� Everyone recommends excision (much Everyone recommends excision (much higher than 2%higher than 2%

ADH ADH –– reasons for upgradereasons for upgrade

�� Partial sampling by radiologyPartial sampling by radiology

�� Partial sampling by pathologyPartial sampling by pathology

�� Under diagnosis by pathology Under diagnosis by pathology

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ADH undersampling by ADH undersampling by radiologyradiology

�� Jackman Radiology 1994Jackman Radiology 1994

�� More cores led to:More cores led to:�� More DCIS diagnosesMore DCIS diagnoses�� Less ADH diagnosesLess ADH diagnoses�� Less upgrading of ADH to DCISLess upgrading of ADH to DCIS

ADH undersampling by ADH undersampling by pathologypathology

�� ? How many levels?? How many levels?

Sampling breast coresSampling breast cores

�� Renshaw Am J Clin Pathol, 2001Renshaw Am J Clin Pathol, 2001

�� 1 level 1 level –– 32% of ADH32% of ADH

�� 2 levels 2 levels –– 55% of ADH55% of ADH




�� Similar results for DCIS and invasive Similar results for DCIS and invasive tumorstumors

Underdiagnosis by pathologyUnderdiagnosis by pathology

�� Pathology textbooks consistently Pathology textbooks consistently recommend NOT diagnosing low grade recommend NOT diagnosing low grade ductal carcinoma on core needle biopsy ductal carcinoma on core needle biopsy unless it is incontrovertible (large)unless it is incontrovertible (large)

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ADH ADH –– not controversialnot controversial

�� Excise because the risk of upgrading is Excise because the risk of upgrading is very highvery high

�� Unlikely to change any time soonUnlikely to change any time soon

PapillomaPapilloma

Papillary lesionsPapillary lesions

�� <4% of all core needle biopsies<4% of all core needle biopsies

�� At least 30% will be upgraded if coAt least 30% will be upgraded if co--exist exist with ADH with ADH –– no controversy about no controversy about managementmanagement

�� Overall “10%” will have coOverall “10%” will have co--existent DCIS existent DCIS or invasive carcinoma BUTor invasive carcinoma BUT


�� More likely to have DCIS or Inv CA if:More likely to have DCIS or Inv CA if:

�� Atypia presentAtypia present�� Age >45 yearsAge >45 years�� Larger lesions (>1.5cm)Larger lesions (>1.5cm)�� Sampled with 14 gauge or smaller needleSampled with 14 gauge or smaller needle

�� Excision usually recommendedExcision usually recommended

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Atypical papillary lesionAtypical papillary lesion Papillary lesions without atypiaPapillary lesions without atypia

�� Despite a “10%’” risk of upgrading:Despite a “10%’” risk of upgrading:

�� Series with 0Series with 0--2% upgrading exist and are 2% upgrading exist and are becoming more common becoming more common McGahn, Am Surg 2013McGahn, Am Surg 2013

�� Clinical followClinical follow--up for up to 5 years shows a up for up to 5 years shows a very low rate of upgrading (0very low rate of upgrading (0--2%) 2%) Wyss, Breast Wyss, Breast 20142014

“Benign” papillary lesions: what “Benign” papillary lesions: what changed?changed?

�� Larger guage needlesLarger guage needles

�� More cores takenMore cores taken

�� Better recognition of “atypia”Better recognition of “atypia”

�� Better exclusion criteria (age, size)Better exclusion criteria (age, size)

�� Recognition that the results in real life Recognition that the results in real life were no longer matching the published were no longer matching the published resultsresults

�� Recognition that these patients could be Recognition that these patients could be followed and excised laterfollowed and excised later


�� With ADH = 30% risk With ADH = 30% risk –– exciseexcise

�� With “atypia” = ?10% risk With “atypia” = ?10% risk –– exciseexcise

�� With older age, large size With older age, large size –– consider consider excisionexcision

�� Benign papilloma = ?0Benign papilloma = ?0--5% risk 5% risk –– discuss discuss with patient recognizing that this risk is in with patient recognizing that this risk is in fluxflux

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“Benign” papilloma: the future“Benign” papilloma: the future

�� Expect to see more and more studies Expect to see more and more studies showing a lower and lower rate of showing a lower and lower rate of upgrading and more and more upgrading and more and more recommendations for clinical followrecommendations for clinical follow--up up rather than excisionrather than excision

�� More pressure on clinicians to assess their More pressure on clinicians to assess their patient’s (and their own) risk tolerancepatient’s (and their own) risk tolerance

Lobular carcinoma in situLobular carcinoma in situ

Lobular carcinoma in situ (LCIS)Lobular carcinoma in situ (LCIS)

�� <2% of breast cores<2% of breast cores

�� Overall 20Overall 20--30% upgrade rate, BUT30% upgrade rate, BUT

LCISLCIS�� Even 10 years ago there was evidence Even 10 years ago there was evidence

that this figure was too highthat this figure was too high

�� Upgrade rates of 3% when radiographic Upgrade rates of 3% when radiographic discordance excluded (LCIS does not form discordance excluded (LCIS does not form a mass a mass –– upgrade rate 38%) upgrade rate 38%) Middleton Mod Middleton Mod Pathol, 2003Pathol, 2003

�� Upgrade rates of <3% when 5 levels Upgrade rates of <3% when 5 levels obtained obtained Renshaw Am J Clin Pathol, 2002Renshaw Am J Clin Pathol, 2002

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LCIS LCIS –– when should you when should you excise?excise?

�� Pleomorphic LCIS Pleomorphic LCIS –– behaves like DCISbehaves like DCIS

�� Extensive LCIS Extensive LCIS –– ALH, LCIS, and ALH, LCIS, and extensive LCIS form a continuum of riskextensive LCIS form a continuum of risk

�� What about LCIS, NOS?What about LCIS, NOS?

LCIS LCIS –– the new datathe new data�� Although there are still recent studies Although there are still recent studies

showing high (>10%) upgrade rates for showing high (>10%) upgrade rates for LCIS, LCIS,

�� more and more studies are showing more and more studies are showing

�� Upgrade rates of 3% on excisionUpgrade rates of 3% on excision�� 33--5 year clinical follow5 year clinical follow--up rates of 3%up rates of 3%Middleton Cancer Med 2014Middleton Cancer Med 2014

LCIS: what changed?LCIS: what changed?

�� Larger guage needlesLarger guage needles

�� More cores taken, better correlationMore cores taken, better correlation

�� Better pathologic samplingBetter pathologic sampling

�� Better recognition of LCIS by pathologistsBetter recognition of LCIS by pathologists

�� Recognition that the recommendations for Recognition that the recommendations for LCIS on cores and excision were LCIS on cores and excision were discordantdiscordant

�� Recognition that these patients could be Recognition that these patients could be followed and excised laterfollowed and excised later

LCIS LCIS --riskrisk

�� If radiologicaly discordant (mass lesion), or If radiologicaly discordant (mass lesion), or pleomorphic or “extensive” pleomorphic or “extensive” –– excise excise (upgrade risk 10%)(upgrade risk 10%)

�� Otherwise Otherwise –– upgrade risk 3% upgrade risk 3% -- discuss discuss with patient to determine their and your with patient to determine their and your risk tolerance (3% is not 2% but it is close)risk tolerance (3% is not 2% but it is close)

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What about labs with high rates What about labs with high rates of upgrade for LCIS?of upgrade for LCIS?

�� My opinion My opinion --Evidence of poor performanceEvidence of poor performance

�� Radiology not taking enough tissueRadiology not taking enough tissue

�� Radiology not hitting the lesionRadiology not hitting the lesion

�� Radiology not correlating wellRadiology not correlating well

�� Pathology not sampling their cores Pathology not sampling their cores adequatelyadequately

�� Pathology not recognizing small foci of Pathology not recognizing small foci of LCISLCIS

Conclusions 1 of 4Conclusions 1 of 4

�� Make sure your pathologists have a Make sure your pathologists have a system for specimen identification in their system for specimen identification in their laboratorylaboratory


�� ADH on core is a high risk lesion (30% ADH on core is a high risk lesion (30% upgrade rate vs 1upgrade rate vs 1--2% for benign cases)2% for benign cases)

�� This is not changing any time soonThis is not changing any time soon

Conclusions 3 of 4 Conclusions 3 of 4 �� Atypical papilloma is a high risk lesion Atypical papilloma is a high risk lesion

(10% upgrade rate) excise(10% upgrade rate) excise

�� Benign papilloma without adverse Benign papilloma without adverse clinical/radiologic features (size, age) is a clinical/radiologic features (size, age) is a low risk lesion (0low risk lesion (0--5% upgrade rate) but this 5% upgrade rate) but this rate is still being defined and may changerate is still being defined and may change

�� Patients response to a 5% risk versus 1Patients response to a 5% risk versus 1--2% likely vary2% likely vary

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�� LCIS without a mass lesion or pleomorphic LCIS without a mass lesion or pleomorphic or extensive features is a very low risk or extensive features is a very low risk lesion (3% upgrade rate)lesion (3% upgrade rate)

�� This upgrade rate is unlikely to change in This upgrade rate is unlikely to change in the futurethe future

�� Patients response to a risk of 3% versus Patients response to a risk of 3% versus 11--2% likely vary2% likely vary

atypical ductal hyperplasia, increased risk of malignancy papillary lesions… · 2014-10-13 ·...

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