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Excision of High-Risk Breast Lesions on Needle Biopsy: Is There a Standard of Core?

¹ Seattle Breast Pathology Consultants Seattle, WA
² Harvard Medical School Boston, MA

 
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Over the past decade, core needle biopsy has emerged as the first-line procedure for the diagnosis of imaging-detected and palpable breast lesions. The literature has made it clear that some lesions must be surgically excised whereas others can be followed, but significant controversy remains over how to treat several so-called "high-risk" lesions [1, 2]. Included in this group are lobular neoplasia (atypical lobular hyperplasia [ALH] and lobular carcinoma in situ [LCIS]), papillary lesions, flat epithelial atypia, and radial scar.

We wanted to find out how varied the treatment options were for patients diagnosed with one of these high-risk lesions, so we performed an informal poll of our colleagues in breast pathology and breast imaging around the United States (Table 1). All are academic subspecialists who were chosen for their significant contributions to their fields. Our suspicions were confirmed—not only are patients with one of these high-risk lesions treated differently depending on geographic region, but also we found that within specific institutions and hospitals, patients were treated differently depending on their respective physicians.

Why is there still no consensus as to how to treat high-risk lesions on core needle biopsy? The main problem is that nearly all of the articles regarding these lesions are based on small, single-institution studies that are retrospective and have inherent built-in selection bias. Thus, recommendations for or against surgical excision are based on poorly controlled studies with few patients, resulting in little statistical significance [3]. The end result is that the decision to send a patient for surgery after a core biopsy diagnosis of a high-risk lesion is random. For instance, in our poll, 80% of physicians thought that LCIS should be excised, but recent data have cast doubt on whether this is a legitimate recommendation [4]. The same can be said for flat epithelial atypia: 90% of our colleagues recommend excision, but a recent study contradicts earlier studies [5].

These controversies are not trivial. Significant costs and risks are associated with performing an open surgical biopsy. Alternatively, those patients whose physicians do not recommend surgical excision may possibly be undertreated. The retrospective studies in the literature are not helping us answer these questions, and, as a result, patients are not being served well. Pathology and radiology need to come together and perform prospective controlled studies on these high-risk lesions so that there is a consensus regarding the pathologic definitions of the high-risk lesions and the need for open surgical biopsy.

References

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1. Jacobs TW, Connolly JL, Schnitt SJ. Nonmalignant lesions in breast core needle biopsies: to excise or not to excise? Am J Surg Pathol 2002; 26:1095 -1110[CrossRef][Medline]
2. Zuiani C, Londero V, Bestagno A, Puglisi F, Di Loreto C, Bazzocchi M. Proliferative high-risk lesions of the breast: contribution and limits of US-guided core biopsy. Radiol Med 2005;110 : 589-602[Medline]
3. Kopans DB. LCIS found at core needle biopsy may not need surgical excision. (letter and reply) AJR 2008;191 :[web]W152 -W153[Free Full Text]
4. Hwang H, Barke LD, Mendelson EB, Susnik B. Atypical lobular hyperplasia and classic lobular carcinoma in situ in core biopsy specimens: routine excision is not necessary. Mod Pathol2008; 21:1208 -1216[CrossRef][Medline]
5. Martel M, Barron-Rodriguez P, Tolgay Ocal I, Dotto J, Tavassoli FA. Flat DIN 1 (flat epithelial atypia) on core needle biopsy: 63 cases identified retrospectively among 1,751 core biopsies performed over an 8-year period (1992–1999). Virchows Arch 2007;451 : 883-891[CrossRef][Medline]

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				A. Linda, C. Zuiani, A. Furlan, V. Londero, R. Girometti, P. Machin, and M. Bazzocchi Radial Scars Without Atypia Diagnosed at Imaging-Guided Needle Biopsy: How Often Is Associated Malignancy Found at Subsequent Surgical Excision, and Do Mammography and Sonography Predict Which Lesions Are Malignant? Am. J. Roentgenol., April 1, 2010; 194(4): 1146 - 1151. [Abstract] [Full Text] [PDF]

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