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Letters |
The George Washington University Washington, DC
Stanford University Palo Alto, CA
Park Nicollet Clinic–St. Louis Park St. Louis Park,
MN
WEB—This is a Web exclusive article.
We agree with Dr. Kopans [1] that it would be optimal to study the cancer underestimation rate of lobular neoplasia and, indeed, of all high-risk lesions found at percutaneous breast biopsy using "...prospective data in which all women in this category go on to excisional biopsy...." Histologic lesions that underestimate the associated presence of cancer are initially retrospectively found after biopsy when lesions diagnosed as benign progress during imaging follow-up, leading to rebiopsy that reveals cancer. To our knowledge, no large prospective studies have been done on any of the high-risk lesions found at percutaneous breast biopsy.
The number of lesions that must be biopsied to provide valid answers about the cancer underestimation rate of high-risk lesions is so large that prospective studies may never be done. In the meantime, the data from retrospective studies are still valuable. In the largest retrospective review of atypical ductal hyperplasia (ADH), which is the most common high-risk lesion, 18,601 lesions were biopsied to find the 894 ADH study lesions [3]. With a cancer underestimation rate of 29% in that review, it is now the standard of practice to surgically excise lesions diagnosed as ADH at percutaneous biopsy.
In our retrospective study, 32,420 lesions were biopsied to find the 278 lobular neoplasia lesions [2]. Of the lobular neoplasia lesions that underwent surgical excision, cancer was confirmed in 23% (38 of 164). Because biopsy is recommended if a mammographic lesion is thought to have more than a 2% chance of cancer, one might logically apply that same criterion to the need for surgical excision of specific histologic lesions diagnosed at core needle biopsy [3]. If our 114 lobular neoplasia lesions that had imaging follow-up alone had instead undergone surgical excision, and if no cancers were found at excision (which we deem to be unlikely), underestimation would still have occurred in 14% (38 of 278) of our study lesions [2], substantially more than 2%.
We are aware of one article that prospectively studied some lobular neoplasia lesions [4]. In that study, all the lesions studied both retrospectively and prospectively had subsequent surgical excision. The cancer underestimation rate was 27% (four of 15) for lesions studied retrospectively and 28% (five of 18) for lesions studied prospectively. That study supports our suggestion that lesions diagnosed as lobular neoplasia at percutaneous biopsy need surgical excision. It also suggests there may not be a significant difference in the underestimation rate between prospective and retrospective studies.
Our study parallels multiple prior retrospective studies evaluating the rate of underestimation at minimally invasive biopsy, and therefore we think that our published study is not only valid but a critical addition to the literature regarding lobular neoplasia found at minimally invasive biopsy.
Not obtaining the data in a prospective manner and not further stratifying the lobular neoplasia does not diminish the importance of our findings. Our study, like all studies, has limitations. We directly addressed these limitations in the discussion in the article. Nevertheless, even with the limitations pointed out by Dr. Kopans [1] and addressed in the article, this study is the largest and only multiinstitutional study to date to define the rate of underestimation of cancer in lesions found to be lobular neoplasia at minimally invasive breast biopsy, and we believe our conclusions are correct.
We await future studies that will further stratify lobular neoplasia to better define which of these lesions require surgical excision. Until that time, we remain con vinced that surgical excision is not only reasonable but necessary in patients with lobular neoplasia identified at minimally invasive biopsy.
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