Author: Rodrigo Arrangoiz MS, MD, FACS, FSSO

Choledochal Cysts – Types and Management

Choledochal cysts are congenital cystic dilatations of the biliary tree. They are associated with an abnormal pancreaticobiliary junction and carry a significant lifetime risk of malignancy (especially cholangiocarcinoma).

Classification (Todani Classification)

The most widely used system is the Todani classification, which divides choledochal cysts into five main types:

Type I – Extrahepatic bile duct dilatation (most common, 50–80%)
• Ia – Diffuse cystic dilatation of CBD
• Ib – Focal segmental dilatation
• Ic – Fusiform dilatation of CBD

Management:
→ Complete excision of extrahepatic bile duct + Roux-en-Y hepaticojejunostomy

Type II – True diverticulum of CBD
• Saccular outpouching from extrahepatic bile duct

Management:
→ Diverticulectomy ± primary closure of CBD

Type III – Choledochocele
• Intraduodenal dilatation of distal CBD (within ampulla)

Management:
→ Endoscopic sphincterotomy (often sufficient)
→ Surgical excision if large/symptomatic

Type IV – Multiple cysts
• IVa – Both intrahepatic and extrahepatic involvement
• IVb – Multiple extrahepatic cysts only

Management:
→ Excision of extrahepatic bile duct + Roux-en-Y hepaticojejunostomy
→ Liver resection if localized intrahepatic disease
→ Liver transplant if diffuse severe intrahepatic disease

Type V – Caroli Disease
• Multiple intrahepatic cystic dilatations only

Associated with congenital hepatic fibrosis.

Management:
→ Segmental liver resection (localized)
→ Liver transplantation (diffuse disease)

Clinical Presentation
• Children: classic triad (rarely complete)
• Abdominal pain
• Jaundice
• Palpable mass
• Adults:
• Recurrent cholangitis
• Pancreatitis
• Biliary colic
• Incidental finding

Investigations
• Ultrasound – initial test
• MRCP – investigation of choice
• CT if malignancy suspected
• LFTs

ERCP mainly therapeutic (type III).

Complications
• Cholangitis
• Pancreatitis
• Stones
• Strictures
• Rupture (rare)
• Cholangiocarcinoma (10–30% lifetime risk if untreated)

Principles of Management (Important for Practice)

1. Complete cyst excision whenever possible
2. Avoid drainage procedures (obsolete due to cancer risk)
3. Long-term follow-up due to residual malignancy risk
4. Early surgery in children once diagnosed

Surgical Standard Operation

Cyst excision + Roux-en-Y hepaticojejunostomy
→ Gold standard for Type I and IV

19th St. Gallen International Breast Cancer Conference (2025)

Consensus Recommendations – Early Breast Cancer

🧬 1️⃣ ER-Positive / HER2-Negative Disease

🔹 Genomic Testing

Strong support for multigene assays (Oncotype DX, MammaPrint, etc.) in: Node-negative disease 1–3 positive nodes (especially postmenopausal) In premenopausal patients with 1–3 nodes → chemotherapy often still favored even with low genomic risk.

🔹 Chemotherapy

Postmenopausal, N1 (1–3 nodes), low genomic risk → chemo can be omitted. Premenopausal, N1 disease → chemotherapy generally recommended (ovarian suppression contribution acknowledged but not universally accepted as replacement).

🔹 Ovarian Function Suppression (OFS)

Recommended in: High-risk premenopausal patients Node-positive disease AI + OFS preferred over tamoxifen alone in higher-risk settings.

🔹 CDK4/6 Inhibitors

Abemaciclib recommended in: High-risk node-positive (monarchE-like criteria) Ribociclib data discussed but not yet fully standard globally.

🟡 2️⃣ HER2-Positive Early Breast Cancer

🔹 Neoadjuvant Therapy

Standard for: Tumors ≥2 cm Node-positive disease Preferred regimen: Taxane + dual anti-HER2 (trastuzumab + pertuzumab)

🔹 Residual Disease After Neoadjuvant Therapy

T-DM1 (KATHERINE data) remains standard.

🔹 Duration of Trastuzumab

12 months remains consensus standard. 6 months acceptable only in select lower-risk or toxicity cases.

🔹 De-escalation

Small node-negative HER2+ (<2 cm): TH regimen acceptable (APT-like approach). Ongoing interest in response-adapted therapy.

🔵 3️⃣ Triple-Negative Breast Cancer (TNBC)

🔹 Neoadjuvant Therapy

Standard: Anthracycline + taxane backbone Addition of pembrolizumab supported in stage II–III

🔹 Residual Disease

Continue pembrolizumab (KEYNOTE-522 strategy) Capecitabine considered if no prior immunotherapy

🔹 BRCA-Mutated

Adjuvant olaparib recommended (OlympiA criteria)

🟢 4️⃣ Axillary Management

🔹 Clinically Node-Negative

Sentinel lymph node biopsy (SLNB) standard.

🔹 1–2 Positive Sentinel Nodes (Upfront Surgery)

Omission of ALND supported if: Undergoing breast-conserving therapy Whole-breast RT planned (Z0011 principles upheld)

🔹 After Neoadjuvant Therapy

If cN+ → ycN0: SLNB acceptable if ≥3 nodes retrieved + dual tracer. Residual nodal disease → ALND still recommended in most settings.

🔴 5️⃣ Radiation Therapy

🔹 Hypofractionation

Standard for most patients. Ultra-hypofractionation (FAST-Forward-like) widely accepted.

🔹 Omission of RT

May be considered in: Age ≥70 Small ER+ tumors Planned endocrine therapy

🔹 Regional Nodal Irradiation

Recommended in: Node-positive disease High-risk biology

🟠 6️⃣ De-escalation Themes

Avoid overtreatment in: Low-risk luminal A disease Elderly/frail patients Tailor treatment based on: Biology > anatomy alone Genomic profiling Patient preference

🧪 7️⃣ Liquid Biopsy & MRD

ctDNA promising but: Not yet standard for treatment decision Still investigational for escalation/de-escalation

🧬 8️⃣ Germline Mutation Carriers

BRCA1/2: Consider bilateral mastectomy (case-dependent) Adjuvant olaparib in high-risk early disease PALB2 increasingly treated similarly to BRCA in high-risk scenarios.

🧠 9️⃣ Artificial Intelligence & Imaging

MRI not routine for all early-stage patients. PET-CT not recommended for stage I routine staging. AI emerging for: Risk stratification Imaging interpretation Treatment personalization

🎯 Key Global Themes of St. Gallen 2025

Precision > escalation Biology-driven treatment Safe de-escalation when supported by data Increased use of CDK4/6 inhibitors and immunotherapy in early disease Continued minimization of axillary surgery

• Conference Overview
  Held March 12–15, 2025 in Vienna with >3,100 global participants.
  Focused on early breast cancer (BC): evidence, controversies, consensus, and breakthroughs.
  Included lectures, debates, poster sessions, and the renowned St. Gallen Consensus Session.
  Hansjoerg Senn Memorial Lecture was introduced to honor a major contributor to BC care. 
  
  🔬 Systemic Therapy & Novel Agents
  Goal of early BC therapy is to improve overall survival (OS) through better systemic and local treatment.
  Surrogate endpoints (e.g., pathological complete response) are crucial for accelerating drug development.
  New endocrine therapies (SERDs) are being evaluated, with emphasis on QoL and resistance mechanisms.
  Anti-HER2 advances from metastatic setting are being translated to early BC, including adaptive trial designs.
  Antibody-drug conjugates (ADCs) hold potential in early BC; ongoing trials are evaluating various indications. 
  
  🧬 Liquid Biopsy & Biomarkers
  ctDNA and liquid biopsy show promise for minimal residual disease (MRD) detection and relapse risk stratification.
  Tumor-informed assays have higher sensitivity than tumor-agnostic panels.
  Circulating tumor cells (CTCs) are prognostic but less sensitive; CHIP mutations may confound results.
  Multiple trials are exploring ctDNA as a tool for guiding post-treatment strategies. 
  
  HER2+ Breast Cancer
  Trastuzumab remains a foundational therapy after 20 years.
  Duration of trastuzumab (6 vs. 12 months) continues to be debated; 12 months remains standard.
  Improved HER2 testing and classification helps tailor therapies, especially in HER2-low disease.
  De-escalation strategies (e.g., PET-adapted) are under study for selected patients.
  Residual disease post-neoadjuvant therapy moves toward T-DM1 or other combinations; new trials are ongoing. 
  
  Tailoring Treatment & De-Escalation
  Omitting radiotherapy (RT) or endocrine therapy (ET) in very low-risk patients is under investigation.
  Minimally invasive alternatives (e.g., cryoablation) are being evaluated to reduce surgical burden.
  Older patients need individualized decision making rather than age-based exclusion from therapy.
  Tools like ESMO Magnitude of Clinical Benefit Scale can help weigh benefits vs toxicity. 
  
  Surgery & Local Management
  Breast-conserving surgery (BCS) remains preferred when feasible; mastectomy does not guarantee survival benefit.
  Radiotherapy tailoring (partial, hypofractionation) reduces toxicity while maintaining control.
  Post-neoadjuvant surgery focuses on resection of residual disease; MRI radiomics and biopsies aid prediction.
  Reconstruction decisions must be individualized, involving patient preferences and RT considerations. 
  
  ER+ Disease Nuances
  Optimizing adjuvant therapy (ET, CDK4/6 inhibitors, genomic assays) depends on recurrence risk and biomarkers.
  Chemotherapy benefit varies by genomic risk scores and age—particularly in premenopausal women.
  Extended ET decisions benefit from clinical, genomic, and novel biomarkers like ctDNA.
  Invasive lobular carcinoma (ILC) and ER-low tumors need refined imaging and therapeutic stratification. 
  
  Artificial Intelligence (AI) Integration
  AI has potential to enhance:
  Biomarker discovery and response prediction
  Treatment planning and radiation delivery
  Target identification and clinical decision support
  Collaboration between AI developers and clinicians is essential for clinical implementation. 
  
  Imaging & Staging Updates
  PET-CT may be useful in higher-stage early BC; routine use in stage I remains limited.
  Breast MRI improves staging but increases interventions without clear outcome benefit; selective use recommended.
  Follow-up imaging remains guided by existing evidence; future strategies might integrate new technologies and ctDNA. 
  
  Hereditary BC & Prevention
  Germline mutations (BRCA1/2, PALB2, ATM, CHEK2) justify altered management and intensive screening.
  Risk-reducing surgeries lower incidence, though survival benefits require longer follow-up.
  Non-surgical options (e.g., intensified screening, risk-reducing medications) are important for many carriers. 
  
  Axillary Management
  Sentinel lymph node biopsy (SLNB) remains standard for clinically node-negative patients.
  Omission of upfront axillary surgery is considered in select scenarios with multidisciplinary input.
  Trials are evaluating safe approaches to avoid full axillary dissection post-neoadjuvant therapy. 
  
  Clinical Trials & Patient-Centered Design
  High-quality trials require real-world applicability, patient involvement, meaningful endpoints, and QoL measures.
  Trial design frameworks (e.g., SPIRIT, PRECIS-2) help balance explanatory vs pragmatic objectives. 
  
  Special Populations
  BC during pregnancy requires tailored imaging and therapy planning to optimize maternal and fetal safety.
  Young patients and those with reproductive concerns need individualized counseling and treatment adaptation. 

https://ecancer.org/en/journal/article/2075-the-19th-st-gallen-international-breast-cancer-conference-primary-therapy-of-patients-with-early-breast-cancer-evidence-controversies-consensus-key-moments-and-breakthroughs?utm_campaign=automated-emails&utm_source=siteupdates-en-html-20260213&utm_medium=email&utm_target=d8628274966ebe70f6f44ff9393f2797c2d952c553cc7fa3f43de5e1c17fd7171edb509c851169c954d77de3b71e4aa86c3e034376f2253f-f23386

Paper summary (Eur Arch Otorhinolaryngol, 2026) — “The impact of drains on surgical outcomes in thyroid surgery”

This is a meta-analysis of randomized controlled trials comparing drain vs no drain after adult thyroid surgery (search Jan 1995–Aug 2025). It included 10 RCTs (n=1,078) and assessed haematoma/seroma (primary) plus SSI, return-to-theatre, pain, and length of stay. 

Key findings

No significant difference with drains for: Haematoma (p=0.15) Seroma (p=0.64) Return-to-theatre (p=0.22)  Drains were associated with worse outcomes: Higher SSI (4.2% vs 0.5%, p=0.01) Longer LOS (≈ +1.2 days, p<0.0001) More pain (MD ≈ +2.2, p=0.001) 

Conclusion of the authors: routine drains don’t reduce clinically important collections/bleeding outcomes and should be selective/patient-specific. 

Additional high-yield evidence on the same question

Systematic reviews

2017 meta-analysis (14 studies, n=1,927): drains increased infection and length of stay, with no significant differences in haematoma/seroma or RLN palsy/hypoparathyroidism.  Cochrane review: highlights the key limitation of drains—they can block with clot and do not replace meticulous haemostasis / re-exploration when bleeding occurs; overall evidence did not support routine use. 

Randomized trials (examples)

2013 RCT (Uganda, n=68): no-drain group had shorter LOS and less pain, with no signal that drains prevented important complications.  2023 RCT (lobectomy + central neck dissection, n=104): no routine drain needed; no-drain group had shorter LOS and better comfort metrics. 

Evidence-based recommendation (practical)

1) Default position

For uncomplicated thyroidectomy/hemithyroidectomy, the best available RCT/meta-analysis evidence supports NO routine drain because it does not reduce haematoma/seroma and does increase SSI, pain, and LOS. 

2) When a drain may be reasonable (selective use)

Consider a drain selectively when you believe a drain will meaningfully manage expected ongoing output or permit monitoring in a high-risk scenario, e.g.:

Extensive dissection / large dead space (e.g., combined procedures, broad flap elevation) Significant intraoperative oozing despite optimization (coagulopathy, difficult hemostasis) Reoperative thyroid surgery Very large goiter/substernal component (case-dependent) Neck dissection / lateral compartment work (many surgeons drain these by default; note: classic drain trials often exclude lateral neck dissections) 

(Even in these settings, it’s worth emphasizing: drains don’t “prevent” a dangerous post-thyroidectomy hematoma—rapid recognition and evacuation remain key, and drains may clot off.) 

3) What to do instead of routine drains (high-impact steps)

Meticulous hemostasis + Valsalva before closure Layered closure / dead-space minimization Standardized post-op neck checks and early warning protocol (swelling, tightness, voice change, stridor) Clear hematoma pathway (immediate bedside opening vs OR depending on severity/resources)

• Atypical ductal hyperplasia (ADH):
  • Is a benign proliferative breast lesion:
    • Characterized by filling and distention of ducts by dysplastic monotonous epithelial cells:
      • Forming architecturally complex patterns, including:
        • Cribriform-like secondary lumens or micropapillary formations
  • It is found in approximately 10% of benign breast biopsies
  • It confers a four-fold increased risk of subsequent breast cancer:
    • With a cumulative incidence approaching 30% at 25 years
• Definition and Histopathology:
  • ADH is defined by cytologic and architectural features:
    • Established by Page and colleagues in 1985
  • The lesion shows:
    • Proliferation of dysplastic, monotonous epithelial cells:
      • With architectural complexity and nuclear hyperchromasia
  • The key distinction from ductal carcinoma in situ (DCIS) is quantitative rather than qualitative:
    • ADH shares histologic features with low-grade DCIS but is less extensive
    • If the lesion meets criteria for DCIS in terms of quality but involves fewer than two ducts or measures less than 2 mm:
      • It is classified as ADH
  • This places ADH in a transitional zone between benign and malignant disease:
    • Making it a premalignant lesion
• Epidemiology:
  • ADH:
    • Is found in approximately 10% of core needle biopsy specimens with benign findings
  • Both atypical ductal and atypical lobular hyperplasia:
    • Occur with equal frequency and confer similar breast cancer risks
  • The lesion is typically discovered incidentally on screening mammography:
    • In asymptomatic women
• Risk Factors and Modifiers:
  • Younger age at diagnosis:
    • Is associated with higher subsequent breast cancer risk
  • Family history of breast cancer:
    • May increase risk, though data are conflicting
  • Number of atypical foci significantly impacts risk:
    • Women with ≥ 3 foci have a standardized incidence ratio (SIR) of 5.29 compared to 3.11 for a single focus
  • Dense breasts:
    • Increase risk compared to fatty breasts
• Imaging Characteristics:
  • ADH:
    • Has no pathognomonic imaging appearance and typically mimics findings seen in small cancers
  • Mammographic Features:
    • Clustered microcalcifications:
      • Are the most common finding directly correlated with ADH:
        • Present in 64% to 82% of cases
      • Calcifications of intermediate concern or higher probability of malignancy:
        • Are more frequent when ADH is associated with malignancy
    • May also present as masses, asymmetric densities, or architectural distortion
    • Direct mammographic-histologic correlation:
      • Occurs in approximately 41% of cases
  • Ultrasound Features:
    • Most lesions appear as hypoechoic masses (64%)
    • Irregular shape (51%) and microlobulated margins (49%)
    • No specific posterior acoustic features (53%)
    • Parallel orientation (57%)
    • Presence of calcifications on ultrasound is significantly associated with upgrade to malignancy
  • ADH lesions are typically assigned BI-RADS category 4 (suspicious abnormality):
    • Warranting tissue sampling by core needle biopsy
• Management:
  • Surgical Excision:
    • Surgical excision remains the standard of care for ADH diagnosed on core needle biopsy:
      • Due to upgrade rates of 15% to 30% to DCIS or invasive cancer
    • A 2020 meta-analysis of 6,458 lesions:
      • Found a 29% upgrade rate for surgically excised ADH
    • The Society of Surgical Oncology recommends routine excision:
      • Noting an upgrade rate of at least 20%
  • Emerging Evidence for Selective Observation:
    • Recent literature suggests that select low-risk ADH lesions may be candidates for observation rather than routine excision:
      • Lesions that appear completely removed at biopsy
      • Limited foci:
        • Fewer than 2 to 3 foci
      • No necrosis or significant atypia on pathology
      • Small groups of mammographic calcifications
      • No enhancement on MRI
      • No underlying risk factors:
        • No history of breast cancer
        • No genetic mutation
        • No concurrent high-risk lesions
  • A 2022 study found that selected women with ADH who met predetermined low-risk criteria and were managed nonoperatively:
    • Had a 1.2% index site cancer rate at median 5.2-year follow-up:
      • Comparable to the 1.5% rate in those who underwent surgery
  • A 2025 study applying COMET trial criteria:
    • Found only a 3.43% upgrade to invasive disease in low-risk patients
• Post-Diagnosis Management:
  • For women with confirmed ADH on excisional biopsy:
    • Enhanced surveillance:
      • Annual mammography plus breast MRI screening
    • Risk-reducing medications:
      • Endocrine therapy (tamoxifen or aromatase inhibitors) is strongly recommended by NCCN guidelines:
      • With an 86% risk reduction for women with atypical hyperplasia
    • Lifestyle modifications:
      • Counseling on healthy lifestyle factors
  • Prognosis:
    • ADH confers a relative risk of approximately 4 for future breast cancer compared to women without the diagnosis
    • The absolute risk is substantial and sustained over time:
      • Cumulative Breast Cancer Incidence:
        • 5 years: 6.6% (95% CI 4.4-9.7%)
        • 10 years: 13.9% (95% CI 7.8-23.6%)
        • 25 years: 30% (either DCIS or invasive cancer)
      • The 10-year cumulative incidence is approximately 14.6%:
        • Representing about 1% per year
      • Risk increases with the number of atypical foci present:
        • Women with ≥ 3 foci have nearly double the risk of those with a single focus
    • Important Prognostic Considerations:
      • Risk affects both the ipsilateral and contralateral breast:
        • Though ipsilateral risk may be slightly higher
      • The risk does not plateau but continues to increase linearly over decades
      • Approximately half of subsequent breast cancers:
        • Occur within the first 5 years after ADH diagnosis
      • Both DCIS and invasive cancer contribute to subsequent events
      • The NCCN Breast Cancer Risk Reduction guidelines:
        • Classify women with atypical hyperplasia as high-risk and recommend risk-reducing endocrine therapy for those with life expectancy ≥ 10 years, given the substantial and sustained elevation in breast cancer risk
• References:
  • Atypical Hyperplasia of the Breast — Risk Assessment and Management Options. Hartmann LC, Degnim AC, Santen RJ, Dupont WD, Ghosh K. The New England Journal of Medicine. 2015;372(1):78-89. doi:10.1056/NEJMsr1407164.
  • Updates on Management of Atypical Hyperplasia of the Breast. Klassen CL, Fraker JL, Pruthi S. Mayo Clinic Proceedings. 2025;100(6):1051-1057. doi:10.1016/j.mayocp.2025.01.029.
  • Subsequent Breast Cancer Risk Following Diagnosis of Atypical Ductal Hyperplasia on Needle Biopsy. Menes TS, Kerlikowske K, Lange J, et al. JAMA Oncology. 2017;3(1):36-41. doi:10.1001/jamaoncol.2016.3022.
  • Benign Breast Disease and Breast Cancer Risk in the Percutaneous Biopsy Era. Sherman ME, Vierkant RA, Winham SJ, et al. JAMA Surgery. 2024;159(2):193-201. doi:10.1001/jamasurg.2023.6382.
  • Atypical Hyperplasia of the Breast: Mammographic Appearance and Histologic Correlation. Helvie MA, Hessler C, Frank TS, Ikeda DM. Radiology. 1991;179(3):759-64. doi:10.1148/radiology.179.3.2027988.
  • Imaging Characteristics of and Multidisciplinary Management Considerations for Atypical Ductal Hyperplasia and Flat Epithelial Atypia: Review of Current Literature. Harper LK, Carnahan MB, Bhatt AA, et al. Radiographics : A Review Publication of the Radiological Society of North America, Inc. 2023;43(10):e230016. doi:10.1148/rg.230016.
  • Atypical Ductal Hyperplasia Diagnosed at Sonographically Guided Core Needle Biopsy: Frequency, Final Surgical Outcome, and Factors Associated With Underestimation. Mesurolle B, Perez JC, Azzumea F, et al. AJR. American Journal of Roentgenology. 2014;202(6):1389-94. doi:10.2214/AJR.13.10864.
  • Mucocele-Like Tumors of the Breast as Cystic Lesions: Sonographic-Pathologic Correlation. Kim SM, Kim HH, Kang DK, et al. AJR. American Journal of Roentgenology. 2011;196(6):1424-30. doi:10.2214/AJR.10.5028.
  • Diagnosis of Columnar Cell Lesions and Atypical Ductal Hyperplasia by Ultrasound-Guided Core Biopsy: Findings Associated With Underestimation of Breast Carcinoma. Ahn HS, Jang M, Kim SM, et al. Ultrasound in Medicine & Biology. 2016;42(7):1457-63. doi:10.1016/j.ultrasmedbio.2016.02.009.
  • Society of surgical oncology medical student & trainee primer for breast surgical oncology. Marissa K. Boyle, Julia M. Selfridge, Rachel E. Sargent, et al.
    Upgrade Rate of Percutaneously Diagnosed Pure Atypical Ductal Hyperplasia: Systematic Review and Meta-Analysis of 6458 Lesions. Schiaffino S, Calabrese M, Melani EF, et al. Radiology. 2020;294(1):76-86. doi:10.1148/radiol.2019190748.
  • Risk of Breast Cancer in Selected Women With Atypical Ductal Hyperplasia Who Do Not Undergo Surgical Excision. Kilgore LJ, Yi M, Bevers T, et al. Annals of Surgery. 2022;276(6):e932-e936. doi:10.1097/SLA.0000000000004849.
  • Implications of the COMET Trial for the Management of Atypical Ductal Hyperplasia. Zaveri S, Sun SX, Bevers TB, Albarracin CT, Bedrosian I. Annals of Surgical Oncology. 2025;:10.1245/s10434-025-18236-2. doi:10.1245/s10434-025-18236-2.
  • Atypical Hyperplasia of the Breast: Clinical Cases and Management Strategies. Vegunta S, Mussallem DM, Kaur AS, Pruthi S, Klassen CL. Cleveland Clinic Journal of Medicine. 2023;90(7):423-431. doi:10.3949/ccjm.90a.22098.
    Breast Cancer Risk Reduction. National Comprehensive Cancer Network. Updated 2025-08-29.
  • Use of Endocrine Therapy for Breast Cancer Risk Reduction: ASCO Clinical Practice Guideline Update. Visvanathan K, Fabian CJ, Bantug E, et al. Journal of Clinical Oncology : Official Journal of the American Society of Clinical Oncology. 2019;37(33):3152-3165. doi:10.1200/JCO.19.01472.
    Practice Bulletin Number 179: Breast Cancer Risk Assessment and Screening in Average-Risk Women. Obstetrics and Gynecology. 2017;130(1):e1-e16. doi:10.1097/AOG.0000000000002158.
  • Atypical Ductal or Lobular Hyperplasia, Lobular Carcinoma in-Situ, Flat Epithelial Atypia, and Future Risk of Developing Breast Cancer: Systematic Review and Meta-Analysis. Baker J, Noguchi N, Marinovich ML, et al. Breast (Edinburgh, Scotland). 2024;78:103807. doi:10.1016/j.breast.2024.103807.
  • Trajectory of Subsequent Breast Cancer Diagnoses in a Diverse Patient Cohort With Breast Atypia. Limberg JN, Thomas SM, Dalton JC, et al. Annals of Surgical Oncology. 2024;31(11):7550-7558. doi:10.1245/s10434-024-15788-7.

A cutting-edge study published in npj Breast Cancer today reports validation of the HER2DX genomic test as a robust prognostic tool in first-line advanced HER2-positive breast cancer treated with trastuzumab, pertuzumab, and a taxane (THP). 

🔬 What was done: Researchers combined real-world data from 215 patients across Spanish and Polish cohorts. They assessed baseline tumor tissue using the HER2DX assay to derive genomic scores linked to outcomes in patients receiving standard first-line HER2-targeted therapy (THP). 

📊 Key findings:

• A high ERBB2 mRNA score was associated with significantly longer progression-free and overall survival, as well as higher objective response rates — independent of traditional clinical variables. 

• The team developed a HER2DX metastatic prognostic score that outperformed ERBB2 mRNA levels alone in predicting outcomes, suggesting genomic profiling can further refine risk stratification in advanced disease. 

📈 Implications: This study supports the clinical utility of HER2DX in identifying patients with HER2-positive advanced breast cancer who might derive the greatest benefit from existing first-line therapies — and highlights the growing role of genomic tools in precision oncology. 

Rodrigo Arrangoiz, MD

Surgical Oncologist, Mount Sinai Medical Center (MSMC)

Head & Neck and Breast Cancer Specialist

https://www.nature.com/articles/s41523-026-00909-0

Primary thyroid lymphoma is rare (<2% of thyroid malignancies), but it is crucial to recognize because management is very different from other thyroid cancers.

🧠 Key features

Arises from lymphoid tissue within the thyroid Strongly associated with Hashimoto’s thyroiditis Often presents with rapid thyroid enlargement over weeks Symptoms may include neck pressure, difficulty swallowing, or breathing changes

🔍 How is thyroid lymphoma diagnosed?

Ultrasound may show a diffusely enlarged, hypoechoic thyroid CT/MRI helps assess airway compression and extent Core needle biopsy (or surgical biopsy) is usually required FNA alone may be insufficient for definitive diagnosis

⚖️ How is it treated?

Unlike most thyroid cancers, surgery is NOT the main treatment.

Management typically includes:

Chemotherapy Radiation therapy Multidisciplinary care with medical oncology and radiation oncology

➡️ Surgery is reserved for airway compromise or diagnostic uncertainty.

📈 Prognosis

Depends on histologic subtype (e.g., MALT vs diffuse large B-cell) Many patients, especially with indolent subtypes, have excellent outcomes with appropriate therapy

🦋 Early recognition prevents unnecessary thyroid surgery and enables prompt, effective treatment.

👨‍⚕️ Dr. Rodrigo Arrangoiz, MD

Surgical Oncologist – Thyroid, Head & Neck, Breast

Mount Sinai Medical Center

📌 Take-home message:

A rapidly enlarging thyroid—especially in patients with Hashimoto’s—should raise suspicion for thyroid lymphoma and prompt specialist evaluation.

📚 References

Derringer GA et al. Primary thyroid lymphoma. Am J Surg Pathol Stein SA et al. Thyroid lymphoma. Endocrinol Metab Clin North Am NCCN Guidelines: B-Cell Lymphomas

• Invasive lobular carcinoma (ILC):
  • Is the second most common histologic form of breast cancer:
    • Comprising 10% to 15% of invasive tumors
• ILC is pathologically distinct from the much more common invasive ductal carcinoma (IDC):
  • With a unique clinical biology and pathogenesis and resultant implications for diagnosis and treatment
• The mean age at diagnosis of ILC:
  • Is 57 years
• Demonstrated risk factors include:
  • Age at menarche (early)
  • Age at first birth (late)
  • Hormone therapy:
    • Emphasizing the role of estrogen exposure in disease pathogenesis:
      • Which is also observed in most IDCs:
        • But shows a more pronounced association in ILC
• ILC also displays an increased propensity for:
  • Multifocal / multicentric presentation
• The incidence of ILC in the Western world over the past decades has corresponded to trends in the use of hormone replacement therapies:
  • With a sharp increase between 1975 and
    2000 and a decline between 2000 and 2004:
    • But now with an increasing incidence since 2005 with an unclear etiology
• Hereditary ILC:
  • Is rare:
    • But may be seen as a secondary tumor in families with hereditary diffuse gastric cancer syndrome:
      • Caused by a germline mutation in the tumor suppressor:
        • CDH1 gene
  • ILC otherwise accounts for a small minority of the breast cancers associated with known breast cancer susceptibility genes:
    • Comprising less than 5% of breast cancers in patients with BRCA1 or TP53 mutations and less than 10% of breast cancers in those with BRCA2 mutations
• Molecular characteristics of invasive lobular carcinoma (ILC):
  • Classic ILC is characterized by discohesive cells that infiltrate the breast stroma in a distinctive
    single-file pattern:
    • With a limited host inflammatory response [Figure 1 a and b]
  • Several variant (nonclassic) forms of ILC have also been described:
    • Distinguished by morphology:
      • Dispersed, alveolar, solid, trabecular, and mixed
    • Distinguished by cytology:
      • Pleomorphic, apocrine, histiocytoid, signet ring, and tubulolobular
    • They have inactivation of CDH1
    • Frequent mutations in the PIK3CA pathways
    • Gain in chromosome 1q and loss of 16q
    • Majority are luminal A intrinsic subtype

• Over 90% of ILCs are:
  • Estrogen receptor (ER) positive
• At the level of the transcriptome:
  • The majority of ILCs are classified as luminal A
    • This proportion is observed to be slightly lower in more aggressive ILC variants
• HER-2 overexpression is rare:
  • Seen in 3% to 5% of classic ILCs:
    • Although it is more frequent in up to 10% of ILC variants:
      • Particularly the pleomorphic subgroup, and recurrent ILCs
• The more aggressive biology of the pleomorphic subgroup renders it a unique clinical entity:
  • Shown to present at a more advanced stage and more frequently metastasize
• The tumor biology of ILCs, as with all breast cancers:
  • Is of focal importance in both surgical and systemic treatment, as well as long-term outcomes
• Loss of E-cadherin expression:
  • Is the most consistently reported hallmark feature of ILC:
    • Seen in 80% to 90% of cases
    • It is believed to play an early and important role:
      • In disease pathogenesis
  • E-cadherin dysregulation originates from:
    • Mutations in the CDH1 gene located on chromosome 16q22.1:
      • Reported to occur at a frequency ranging from 30% to 80% in ILC
  • E-cadherin is a calcium-dependent transmembrane protein:
    • That forms a crucial component of adherens-type junctions between epithelial cells:
      • The loss of which predisposes to neoplastic proliferation
  • However, E-cadherin positivity does not, by itself, exclude a lobular neoplasm, and not all ILCs harbor CDH1 gene mutations
  • Several other novel mutations have recently been identified as more frequent in ILC compared with IDC:
    • By comprehensive molecular profiling of 817 breast tumors in The Cancer Genome Analysis (TCGA) study:
      • Seen both when comparing all ILCs with IDCs and when limiting comparison with luminal A samples
  • When comparing all cancers, alterations more frequently seen in ILC included:
    • CDH1 (63% in ILC versus 2% in IDC)
    • P1K3CA (48% versus 33%)
    • FOXA1 (7% versus 2%)
    • RUNX1 (10% versus 3%)
    • TBX3 (9% versus 2%)
  • Conversely, GATA3 mutations were enriched in:
    • IDC (5% in ILC versus 13% in IDC)
  • Importantly, when the analysis was limited to luminal A samples only, several alterations remained significantly more common among luminal A ILCs versus luminal A IDCs, as summarized here (Table)

• Staging:
  • All breast cancers are staged using the TNM staging system:
    • As defined by the American Joint
      Committee on Cancer (AJCC)
• Patients are initially staged clinically based on physical examination and imaging findings:
  • They are later staged pathologically based on pathologic data obtained from the surgical specimens
• Tumor size (T):
  • Comprises the first component of the TNM stage
  • Particularly relevant to ILCs:
    • Which more often present as multifocal / multicentric tumors:
      • Final T stage is based on the size of
        the largest mass on surgical pathology:
        • Not an additive sum of multiple tumors if present
  • If bilateral cancers are present, each cancer is staged separately
  • Most studies, including a large Surveillance, Epidemiology, and End Results (SEER) registry analysis of 263,408 women with either IDC or ILC:
    • Have observed a significantly higher likelihood for ILCs to be sized over 2 cm (T2 or higher) at diagnosis compared with IDC
  • Nodal status (N):
    • Known to be an important predictor of prognosis in breast cancer:
      • Is similarly staged both clinically and pathologically
      • The quantification of the size of nodal metastases as either isolated tumor cells (ITCs), micrometastases (sized 0.2 mm to 2 mm), or macrometastases (sized greater than 2 mm):
        • Is relevant in ILC, which has been shown in recent series to independently predict for the presence of micrometastatic disease, another proposed consequence of its discohesive biology
• The M stage:
  • Is determined by the presence of distant metastases:
    • With bone being the most common site of spread for all breast cancer types
    • Other frequent sites of metastasis, common to both IDC and ILC, include:
      • The lungs and central nervous system
    • Interestingly, ILCs display a unique predilection for:
      • Gastrointestinal, peritoneal, and ovarian metastases
  • The commonly ER-positive nature of ILCs also results in:
    • More frequent presentation of late metastases
  • The diagnosis of yet subclinical metastatic cancer in patients with locally advanced disease may be made by:
    • CT, bone scanning, or PET

• Lobular neoplasia:
  • Is an atypical proliferation of small, dyscohesive epithelial cell:
    • Within the terminal duct lobular unit (TDLU):
      • That encompasses both:
        • Atypical lobular hyperplasia (ALH) and lobular carcinoma in situ (LCIS)
• The hallmark feature is:
  • Loss of E-cadherin expression:
    • Resulting in cellular discohesion
• Lobular neoplasia:
  • Functions as both a:
    • Risk factor and non-obligate precursor to invasive breast carcinoma:
      • With LCIS conferring a 7-to-10-fold increased risk of breast cancer compared to the general population
• Definition and Classification:
  • The distinction between ALH and LCIS:
    • Is based on the extent of involvement:
      • ALH shows < 50% of acini in the affected TDLU distended by lobular proliferation
      • LCIS shows > 50% of acini in the affected TDLU distended by lobular proliferation with complete filling of at least one lobular unit
    • LCIS is further subdivided into three subtypes:
      • Classic LCIS:
        • Small, monomorphic, non-cohesive cells
        • Typically hormone receptor-positive and HER2-negative
      • Pleomorphic LCIS (PLCIS):
        • Greater nuclear pleomorphism, abundant cytoplasm
        • May be HER2-positive
      • Florid LCIS (FLCIS):
        • LCIS with necrosis and calcifications
• Imaging Diagnosis:
  • Classic lobular neoplasia (ALH and classic LCIS):
    • Is usually not visible on imaging and is typically diagnosed incidentally
    • When imaging abnormalities are present, the most common findings include:
      • Mammography:
        • Grouped amorphous calcifications (most common – 80% of cases)
      • Ultrasound:
        • Irregular, hypoechoic, avascular masses with posterior shadowing (uncommon)
      • MRI:
        • Heterogeneous non-mass-like enhancement with persistent kinetics
  • In contrast, FLCIS and PLCIS are typically imaging targets:
    • Most often manifesting as calcifications
  • Scrupulous radiologic-pathologic correlation is essential for appropriate management decisions
• Evidence-Based Management:
  • Management depends on the subtype and radiologic-pathologic concordance:
    • Classic LN (ALH and Classic LCIS) on concordant core biopsy:
      • Surveillance with imaging is now considered safe and appropriate
      • Surgical excision is not routinely required when radiologic-pathologic correlation is concordant
      • Studies show upgrade rates of only 0% to 5% for pure classic LN with concordant imaging
      • One large series showed 3-year conservative management failure rate of only 6.2%, with no same-quadrant cancers developing
      • Indications for surgical excision:
        • Radiologic-pathologic discordance
        • Concurrent high-risk lesions
    • Pleomorphic LCIS:
      • Requires excision:
        • With consideration for negative margins due to high upgrade rates
    • Florid LCIS:
      • Requires complete surgical excision due to high upgrade rates to invasive carcinoma
• Long-term risk management:
  • Annual breast cancer risk of 1% to 2% with LCIS diagnosis
  • Chemoprevention should be recommended to reduce risk
  • Enhanced surveillance:
    • High-risk imaging screening:
      • Annual mammography plus MRI for appropriate candidates
  • Bilateral prophylactic mastectomy is an option for select high-risk patients
  • Upgrade rates vary by study but range from 0% to 13% for classic LN when radiologic-pathologic correlation is performed
  • Most upgrades occur when discordance exists or when other high-risk lesions are present:
    • The decision between surveillance and excision should involve shared decision-making with consideration of personal and family history, patient preferences, and institutional protocols
• References:
  • Lobular Carcinoma in Situ: Diagnostic Criteria and Molecular Correlates. Sokolova A, Lakhani SR. Modern Pathology : An Official Journal of the United States and Canadian Academy of Pathology, Inc. 2021;34(Suppl 1):8-14. doi:10.1038/s41379-020-00689-3.
  • Non-Invasive Lobular Neoplasia: Review and Updates. Tjendra Y, Susnik B. Seminars in Diagnostic Pathology. 2025;42(4):150883. doi:10.1016/j.semdp.2025.150883.
  • Lobular Neoplasia of the Breast Revisited With Emphasis on the Role of E-Cadherin Immunohistochemistry. Dabbs DJ, Schnitt SJ, Geyer FC, et al. The American Journal of Surgical Pathology. 2013;37(7):e1-11. doi:10.1097/PAS.0b013e3182918a2b.
  • Lobular Neoplasia. Lunt L, Coogan A, Perez CB. The Surgical Clinics of North America. 2022;102(6):947-963. doi:10.1016/j.suc.2022.07.001.
  • Recommendations for Women With Lobular Carcinoma in Situ (LCIS). Oppong BA, King TA. Oncology (Williston Park, N.Y.). 2011;25(11):1051-6, 1058.
  • Atypical Hyperplasia of the Breast — Risk Assessment and Management Options. Hartmann LC, Degnim AC, Santen RJ, Dupont WD, Ghosh K. The New England Journal of Medicine. 2015;372(1):78-89. doi:10.1056/NEJMsr1407164.
  • Management of Lobular Neoplasia Diagnosed by Core Biopsy. Jani C, Lotz M, Keates S, et al. The Breast Journal. 2023;2023:8185446. doi:10.1155/2023/8185446.
  • Update on Lobular Neoplasia. Heller SL, Gao Y. Radiographics : A Review Publication of the Radiological Society of North America, Inc. 2023;43(10):e220188. doi:10.1148/rg.220188.
  • Lobular Carcinoma in Situ of the Breast: Clinical, Radiological, and Pathological Correlation. Scoggins M, Krishnamurthy S, Santiago L, Yang W. Academic Radiology. 2013;20(4):463-70. doi:10.1016/j.acra.2012.08.020.
    Atypical Ductal Hyperplasia and Lobular Neoplasia: Update and Easing of Guidelines. Lewin AA, Mercado CL. AJR. American Journal of Roentgenology. 2020;214(2):265-275. doi:10.2214/AJR.19.21991.
  • Society of surgical oncology medical student & trainee primer for breast surgical oncology. Marissa K. Boyle, Julia M. Selfridge, Rachel E. Sargent, et al.
  • Atypical Lobular Hyperplasia and Classic Lobular Carcinoma in Situ Can Be Safely Managed Without Surgical Excision. Laws A, Katlin F, Nakhlis F, et al. Annals of Surgical Oncology. 2022;29(3):1660-1667. doi:10.1245/s10434-021-10827-z.
  • Observation Versus Excision of Lobular Neoplasia on Core Needle Biopsy of the Breast. Schmidt H, Arditi B, Wooster M, et al. Breast Cancer Research and Treatment. 2018;168(3):649-654. doi:10.1007/s10549-017-4629-2.
  • Lobular Intraepithelial Neoplasia: Outcomes and Optimal Management. Boland PA, Dunne EC, Kovanaite A, et al. The Breast Journal. 2020;26(12):2383-2390. doi:10.1111/tbj.14117.