Department of Pathology and Laboratory Medicine, Emory University, 1364 Clifton Road, Atlanta, GA, 30322, USA.
Breast Disease Center, The Affiliated Hospital of Qingdao University, Qingdao, China.
Breast Cancer Res Treat. 2021 Feb;185(3):573-581. doi: 10.1007/s10549-020-05977-9. Epub 2020 Oct 17.
The management of high-risk breast lesions diagnosed on image-guided core biopsy remains controversial. We implemented a high-risk breast conference attended by breast pathologists, imagers, and surgeons to prospectively review all contemporary cases in order to provide a consensus recommendation to either surgically excise or follow on imaging at 6-month intervals for a minimum of 2 years.
Between May, 2015 and June, 2019, 127 high-risk lesions were discussed. Of these 127 cases, 116 had concordant radiology-pathology (rad-path) findings. The remaining 11 patients had discordant rad-path findings. Of the 116 concordant cases, 6 were excluded due to lack of the first imaging follow-up until analysis. Of the remaining 110 patients, 43 had atypical ductal hyperplasia (ADH), 12 had lobular carcinoma in situ (LCIS), 19 had atypical lobular hyperplasia (ALH), 33 had radial scar (RS), 2 had flat epithelial atypia (FEA), and 1 had mucocele-like lesion (ML). We recommended excision for ADH if there were > 2 ADH foci or < 90% of the associated calcifications were removed. For patients with LCIS or ALH, we recommended excision if the LCIS or ALH was associated with microcalcifications or the LCIS was extensive. We recommended excision of RS when < 1/2 of the lesion was biopsied. We recommended all patients with FEA and ML for 6-month follow-up.
Following conference-derived consensus for excision, of the 27 ADH excised, 9 were upgraded to invasive carcinoma or ductal carcinoma in situ. Of the six LCIS cases recommended for excision, none were upgraded. Nine excised radial scars revealed no upgrades. Additionally, 3 patients with ADH, 2 with ALH, 1 with LCIS, and 2 with RS underwent voluntary excision, and none were upgraded. All other patients (13 with ADH, 5 LCIS, 17 ALH, 22 RS, 2 FEA and 1 ML) were followed with imaging, and none revealed evidence of disease progression during follow-up (187-1389 days). All 11 rad-path discordant cases were excised with 2 upgraded to carcinoma.
The results of this prospective study indicate that high-risk breast lesions can be successfully triaged to surgery versus observation following establishment of predefined firm guidelines and performance of rigorous rad-path correlation.
在影像引导核心活检诊断出的高危乳腺病变的管理仍存在争议。我们实施了高危乳腺会议，邀请乳腺病理学家、成像专家和外科医生参加，前瞻性地审查所有当前病例，以便为手术切除或在 6 个月间隔内进行至少 2 年的影像学随访提供共识建议。
在 2015 年 5 月至 2019 年 6 月期间，共讨论了 127 例高危病变。其中 116 例有一致的影像学-病理学（rad-path）发现。其余 11 例患者的 rad-path 发现不一致。在 116 例一致的病例中，由于缺乏首次影像学随访，直到分析时，有 6 例被排除在外。在剩下的 110 例患者中，43 例有非典型导管增生（ADH），12 例有小叶原位癌（LCIS），19 例有非典型小叶增生（ALH），33 例有放射状瘢痕（RS），2 例有扁平上皮不典型性（FEA），1 例有粘蛋白样病变（ML）。如果 ADH 有＞2 个病灶或＜90%的相关钙化被切除，我们建议切除 ADH。对于 LCIS 或 ALH 患者，如果 LCIS 或 ALH 与微钙化有关，或 LCIS 广泛存在，我们建议切除。当＜1/2 的病变被活检时，我们建议切除 RS。我们建议所有 FEA 和 ML 患者进行 6 个月的随访。
根据会议得出的切除共识，在切除的 27 例 ADH 中，有 9 例升级为浸润性癌或导管原位癌。在建议切除的 6 例 LCIS 病例中，没有升级。9 例切除的放射状瘢痕未见升级。此外，3 例 ADH、2 例 ALH、1 例 LCIS 和 2 例 RS 患者自愿切除，均未升级。所有其他患者（13 例 ADH、5 例 LCIS、17 例 ALH、22 例 RS、2 例 FEA 和 1 例 ML）均进行了影像学随访，在随访期间均未发现疾病进展的证据（187-1389 天）。所有 11 例 rad-path 不一致的病例均被切除，其中 2 例升级为癌。
这项前瞻性研究的结果表明，在建立明确的既定准则并进行严格的 rad-path 相关性后，高危乳腺病变可以成功地通过手术与观察进行分类。
