- Excisional biopsy:
- Is recommended for most ADH lesions diagnosed on core needle breast biopsy (CNB):
- The chance of upgrade at excision to ductal carcinoma in situ (DCIS) or invasive carcinoma:
- Is generally in the 12% to 22% range in the literature
- The chance of upgrade at excision to ductal carcinoma in situ (DCIS) or invasive carcinoma:
- The need for routine excision of pure flat epithelial atypia (FEA) has been less clear:
- Some authors have reported an upgrade rate of 9.6% following excision of lesions that show pure FEA without ADH:
- When the vast majority of biopsies were done with a 14-gauge spring-loaded core biopsy device
- Some authors have reported an upgrade rate of 9.6% following excision of lesions that show pure FEA without ADH:
- It is not clear that biopsy with a vacuum-assisted device would yield the same results:
- In fact, in one study reporting biopsy of low-risk calcifications with a vacuum-assisted device:
- Pure FEA never resulted in an upgrade to malignancy
- An article from the Mayo Clinic:
- Showed that FEA does not seem to convey an independent risk of breast cancer beyond that of associated proliferative disease without atypia or associated ADH
- In fact, in one study reporting biopsy of low-risk calcifications with a vacuum-assisted device:
- Is recommended for most ADH lesions diagnosed on core needle breast biopsy (CNB):
- The risk of upgrade at surgical excision for ADH:
- Has been reported to correlate with the number of ducts or terminal duct lobular units involved on vacuum-assisted core biopsy:
- With 2 or fewer foci of involvement:
- There was no upgrade on excision
- With 4 or more foci of involvement:
- There was a strong probability of upgrade to ductal carcinoma in situ or invasive carcinoma at excision
- With 2 or fewer foci of involvement:
- Has been reported to correlate with the number of ducts or terminal duct lobular units involved on vacuum-assisted core biopsy:
- Work continues to try to define a low-risk group who could potentially avoid excisional biopsy:
- Particularly those with small areas of calcifications completely removed with core needle biopsy and only focal ADH on pathology
- Apocrine metaplasia, florid epithelial hyperplasia of the usual variety, and columnar cell change without atypia:
- Do not confer a significant risk of upgrade and do not require excision
- References
- Eby PR, Ochsner JE, DeMartini WB, Allison KH, Peacock S, Lehman CD. Is surgical excision necessary for focal atypical ductal hyperplasia found at stereotactic vacuum-assisted breast biopsy? Ann Surg Oncol. 2008;15(11):3232-3238.
- Ely KA, Carter BA, Jensen RA, Simpson JF, Page DL. Core biopsy of the breast with atypical ductal hyperplasia: a probabilistic approach to reporting. Am J Surg Pathol. 2001;25(8):1017-1021.
- Khoumais NA, Scaranelo AM, Moshonov H, Kulkarni SR, Miller N, McCready DR, et al. Incidence of breast cancer in patients with pure flat epithelial atypia diagnosed at core-needle biopsy of the breast. Ann Surg Oncol. 2013;20(1):133-138.
- Said SM, Visscher DW, Nassar A, Frank RD, Vierkant RA, Frost MH, et al. Flat epithelial atypia and risk of breast cancer: a Mayo cohort study. Cancer. 2015;121(10):1548-1555.
- McGhan LJ, Pockaj BA, Wasif N, Giurescu ME, McCullough AE, Gray RJ. Atypical ductal hyperplasia on core biopsy: an automatic trigger for excisional biopsy? Ann Surg Oncol. 2012;19(10):3264-3269.
Rodrigo Arrangoiz MS, MD, FACS, FSSO 