Evaluation of Precancerous Breast Lesion Upgrade Rate

Background: Breast imaging guided core-needle biopsy enable the assessment of suspected precancerous lesions. In some precancerous lesion there is a risk of upgrading to cancer after surgical removal. This study was conducted to determine the upgrading rate of CNB-diagnosed precancerous breast lesions. Methods: A retrospective study was conducted to examine the data of patients who had undergone core needle biopsy from April 2016 to March 2019 at the Radiology Department of the Breast Clinic of Motamed Cancer Institute and whose pathological reports were indicative of a precancerous lesion such as atypical ductal hyperplasia, sclerosing adenosis, flat epithelial atypia or papillary lesion and had undergone surgery for this lesion. The upgrading rate and its related factors such as the size of the lesion, patient’s age, family history of breast cancer and method of core-needle biopsy were analyzed in SPSS software. Results: A total of 241 patients were recruited with a pathological report of pre-cancerous predisposing lesions. The mean age of the patients was 42.14 years and the highest upgrading rates in the analysis were observed for papillary lesion (19.3%) and atypical ductal hyperplasia, (21.4%), while the upgrading rates were (1.2% ) for sclerosing adenosis and (0%) for flat epithelial atypia. Data analysis showed that the lesions’ upgrading rate correlated with the lesion’s size (P=0.005).Conclusion: The findings of this study showed that size of the lesions increase the risk of upgrading to cancer, which is much higher in papillary lesion and atypical ductal hyperplasia compared to sclerosing adenosis and flat epithelial atypia. It seems that surgical excision of the entire lesion in patients with larger mass size may decrease the upgrading rate of cancer. Conducting specific studies on each distinct lesion can help yield more conclusive results.

Screening detects a myriad of breast disease – refining practice will increase effectiveness and reduce harm

For many individuals, the term ‘cancer’ equates to a disease that if untreated will progress, spread from the area initially affected and ultimately cause death. ‘Breast cancer’, however, is a diverse of range of pathological entities, incorporating indolent to fast-growing and aggressive lesions, with varying histological patterns, clinical presentations, treatment responses and outcomes. Screening for malignancy is based on the assumption that cancer has a gradual, orderly progression and that detecting lesions earlier in their natural history, and intervening, will reduce mortality. The natural history of epithelial atypia, ductal carcinoma in situ and even invasive breast cancer is poorly understood, but widely variable. We believe that population breast screening methodology needs to change to focus on diagnosis of lesions of greatest clinical relevance.

Histologic Findings of Uterine Niches

Objectives The disruption or defect of the myometrium in the uterine scar of a cesarean section (CS) has been known by various names, such as uterine niche, isthmocele, deficient uterine scar, scar pouch, or diverticulum. Symptomatology, risk factors for niche development, and available treatment modalities have been recently studied. However, the histologic features of this disease remain unknown. Methods The histologic features of eight uterine niches are thoroughly described and a summary of the most important aspects of the uterine niche literature is provided. Five cases of CS scars without niche formation are comparatively examined. Results Most uterine niches harbor endocervical mucosa, often cystically dilated and/or an atrophic or disorganized endometrial mucosa of lower uterine segment origin. Regenerative epithelial atypia and fibroblastic stromal reaction are frequent features. No granulomatous reaction, important inflammation, or hemorrhage is seen. CS scars without niche formation do not harbor endocervical mucosa or inclusion cysts, fibroblastic stroma, or regenerative atypia. Conclusions As more prospective studies of uterine niche development and treatment will be conducted, a detailed pathologic report with the criteria proposed herein can be designed.

Upgrade Rate of Flat Epithelial Atypia Diagnosed at Stereotactic Core Needle Biopsy of Microcalcifications: Is Excisional Biopsy Indicated?

Objective Whether the optimal management of pure flat epithelial atypia (FEA) found on core needle biopsy (CNB) specimens is surgical excision or imaging follow-up remains controversial. This study aimed to determine the upgrade rate to ductal carcinoma in situ (DCIS), invasive carcinoma or a high-risk lesion (atypical ductal hyperplasia, atypical lobular hyperplasia, or lobular carcinoma in situ), and it explored the relationship between a family history of breast cancer and the risk of upgrade. Methods Cases with pure FEA found on stereotactic CNB of microcalcifications between March 2011 to December 2017 were followed by excisional biopsy or periodic imaging. The proportion of cases upgraded to a high-risk lesion and the odds of upgrade as related to a family history of breast cancer were determined with 95% confidence intervals (CIs). Results We identified 622 cases of pure FEA; 101 (16.2%) underwent surgical excision and 269 (43.2%) had imaging follow-up of ≥ 24 months. There were no upgrades to DCIS or invasive cancer in any of these 370 individuals (0%), and 4.6% (17/370; 95% CI: 2.9%–7.2%) were upgraded to a high-risk lesion. There was a nonstatistically significant trend between family history and upgrade to high-risk lesion (odds ratio 1.72 [95% CI: 0.65%–4.57%]). Conclusion In our study, the upgrade rate of pure FEA to malignancy was 0%. We suggest that regular imaging follow-up is an appropriate alternative to surgery. Because of potential differences in biopsy techniques and pathologist interpretation of the primary biopsy, individual institutions should audit their own results prior to altering their management of FEA.