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Breast Premalignant lesions imaging

diagnosis & interventional Luc Rotenberg, Gregory Lenczner,

Jean Guigui, Catherine Beges, Mehdi CadiRPO – ISHH

Clinique Hartmann-CMC Ambroise Paré26-27 bd Victor Hugo

92200 Neuilly Sur Seine - Francedr.rotenberg@radiologieparisouest.com

Du 5 au 8 nov 2015 / from nov 5th to 8th 2015

14è Edition Hanoï - Vietnam

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Hard and spiculated = malignant ? Smooth and regular = benign ?

Conventional Wisdom in Breast imaging

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Benign : mastopathy Malignant : IDC grade 3

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Premalignant lesions imaging DCIS, ADH, ALH, LCIS…

S  Screening, detection or diagnosis : S  Mammography

S  Full Digital Mammography S  3D Digital Breast Tomosynthesis - DBT

S  Sonography S  High frequency probe S  Doppler S  elastography

S  MRI S  1,5 or 3T magnet S  Morphologic and dynamic study, perfusion S  Diffusion S  Spectroscopy-MRI

S  Goal = evaluation for a risk : BIRADS classification

S  No specifity for premalignant lesion

PML prevalence out of DCIS ADH 5 % ALH/LCIS 0,9 to 2 %

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Premalignant lesions imaging DCIS, ADH, ALH, LCIS…

S  Histological diagnosis by the pathologist always mandatory

S  No histological diagnosis on imaging !

S  However, diagnostic hypotheses and indications of

action to be taken are welcome

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Premalignant lesions imaging DCIS, ADH, ALH, LCIS…

S  All imaging pattern can be found associated with PML S  Mass

S  Mass with calcifications

S  µcalcifications

S  No mass lesion : S  focal density, desorganisation, ehancement

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Breast Cancer Risk Factors

Risk Factor Min Max x LCIS on biopsy 1.00 8.70 8.70 No. 1st degree relatives with breast cancer 1.00 6.80 6.80 Mammographic density 0.41 1.76 4.29 No. of biopsies 1.00 2.88 2.88 Tamoxifen 0.45 1.00 2.22 Biopsy with atypical hyperplasia 0.93 1.82 1.96 Oral contraceptives / Menop Horm Therapy 1.00 1.49 1.49 Alcohol use / Obesity 0.99 1.41 1.42 Early menarche / late menopause 1.00 1.21 1.21

From http://www.halls.md/breast/gailmods.htm

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Unusual breast lesion?

S  Patient S  High risk, young, anxious…

S  Imaging pattern

S  Location

S  Pathologic findings

Unusual, uncommon, bizarre, strange or exceptional is our daily work and practice

every patient is unique

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BI-RADS

Breast Imaging Reporting and Data System

2nd french edition 4th american edition

Indications

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Birads 1 screening

Birads 2 screening

Birads 3 Follow up except high risk

Birads 4 a Follow up except

progressive or high risk

Birads 4 b,c LCB or VABB

diagnosis

Birads 5/6 LCB or VABB

diagnosis ou stategical

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Probably benign malignancy 0,2 à 5%

§  Follow up §  No biopsy indication excepted for :

§  High risk patient §  BRCA mutation

§  synchronous cancer

§ Impossible follow up § Cancerophobia

Bi-Rads 3

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suspicious lesion malignancy 5 to 95%

Biopsy indication

4 a ?

Bi-Rads 4

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suspicious lesion malignancy 5 to 95%

Biopsy indication

4 a ?

Bi-Rads 4

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Very suspicious lesion for malignancy

§  fine needle aspiration : no more or sentinal lymph nodes

§  Core biopsy 16 or 14 G §  histology, HR, Her2...

§  Suspicious for recidive §  after surgery §  after radiotherapy

Bi-Rads 5 to 6

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Birads 5

Strategical indications 1.  Before surgery & sentinel

lymph node technique 2.  Before surgery for extended

DCIS (mastectomy) 3.  Multicentric and bilateral

lesion

Bi-Rads 5 to 6

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Digital Breast Tomosynthesis

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Breast US diagnostic & balistic

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US Biopsy & Wire Marking

Surgery : IDC grade 1, RH+, Her2 -

Large core 16g Biopsy Wire marker

LCB : DCIS High grade

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Birads 5 bilatéral

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50 y

Right consevative treatment1 998

BRAC1 Mutation - MRI screening Courtesy of Dr Corinnne Balleyguier, IGR

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DCIS excised in 2009, follow up

DCIS recurence in the scar

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Evolution 2010 2011

Cystosteatonecrosis or recurence ? Stereotactic VABB

Cytosteatonecrosis

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57 y, LCIS left UIQ 2005, progression µcal UQ left cluster birads 4 Deep preaxillary

ACR4B VABB/ Stereotactic recurence ILC G2

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2005 DCIS - IDC low grade

Scar – fat cytosteatonecrosis

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Right breast mammogram

DCIS

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Mrs A. 40 y. Right IUQ cancer 1997 Breast cancer familiar history. No mutation

Follow up /6 month M+US/IRM

05/2011 SD

CNB 14g : ADH

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§  local anesthesia §  external procedure §  Explanation +++ §  Time 15 to 40 mn

Vacuum Aspiration Breast biopsy

14 G 11 G 10 G 8 G 17 mg 95 mg 160 mg 300 mg

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Specimens XRays

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Discussion

S  Underestimation rate

ADH, DCIS, LCIS

S  Not eliminated with VABB

S  >> PPV : malignant

S  >> NPV : benign

S  Surgical indication

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DCIS Roger J. Jackman & al, Radiology February 2001 218:497-502

Stereotactic Breast Biopsy of Nonpalpable Lesions: Determinants of

Ductal Carcinoma in Situ Underestimation Rates

S  DCIS underestimation rates by biopsy device were S  20.4% (76 of 373) at large-core biopsy

S  11.2% (107 of 953) at vacuum-assisted biopsy (P < .001)

S  24.3% (35 of 144) of masses

S  12.5% (148 of 1,182) of microcalcifications (P < .001)

S  and by number of specimens per lesion S  17.5% (88 of 502) with 10 or fewer specimens

S  11.5% (92 of 799) with greater than 10 (P < .02).

S  DCIS underestimations increased with lesion size

1.9 times more frequent with masses than with calcifications

1.8 times more frequent with LCB than with VAB

1.5 times more frequent <10 or fewer specimens per lesion than with ≥ 10 specimens per lesion.

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Frederick R. Margolin1 Jessica W. T. Leung1,2 Richard P. Jacobs1 Susan R. Denny1 Percutaneous Imaging-Guided Core Breast Biopsy: 5 Years’ Experience in a Community Hospital, AJR:177, September 2001

ADH

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Peter R. Eby, Jennifer E. Ochsner, Wendy B. DeMartini & al, Frequency and Upgrade Rates of Atypical Ductal Hyperplasia Diagnosed at Stereotactic Vacuum-Assisted Breast Biopsy: 9- Versus 11-Gauge. AJR 2009; 192:229–234

ADH

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ADH Prevalence

RJ Jackman, RL Birdwell, DM Ikeda, Atypical Ductal Hyperplasia: Can Some Lesions Be Defined as Probably Benign after Stereotactic 11-gauge Vacuum- assisted Biopsy, Eliminating the Recommendation for surgical exision ? Radiology 2002; 224:548–554

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Radial Scars R. James Brenner, Roger J. Jackman, Steve H. Parker & al, Percutaneous Core Needle Biopsy of Radial Scars of the Breast: When Is Excision Necessary? AJR:179, November 2002

S  Carcinoma was found at excision in

S  28% (8/29) of lesions with associated atypical hyperplasia

S  4% (5/128) of lesions without associated atypia

S  In the latter group, carcinoma was found at excision in

S  3% (2/60) of masse

S  8% (3/40) of architectural distortions

S  0% (0/28) of microcalcification lesions

S  Malignancy was missed in

S  9% (5/58) of lesions biopsied with a spring-loaded device LCB

S  0% (0/70) of lesions biopsied with a directional vacuum-assisted device VABB

S  8% (5/60) of lesions sampled with less than 12 specimens

S  0% (0/68) sampled with 12 or more specimens

S  Lesion type, maximal lesion diameter, and type of imaging guidance (stereotactic or sonographic) were not significant factors in determining the presence of malignancy

S  CONCLUSION: Diagnosis of radial scar based on core needle biopsy is likely to be reliable when

S  no associated atypical hyperplasia

S  biopsy includes at least 12 specimens (VABB)

S  mammographic findings are reconciled with histologic findings.

S  If miss a criteria, excisional biopsy is indicated

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Lobular Neoplasia : ALH & LCIS at Percutaneous Breast Biopsy: Variables Associated with Carcinoma at Surgical Excision

Rachel F. Brem, Mary C. Lechner, Roger J. Jackman AJR 2008; 190:637–641

S  OBJECTIVE. better define the rate and variables associated with cancer underestimation when lobular neoplasia is found at breast biopsy. ALH or LCIS

S  MATERIALS AND METHODS. S  The records of 32,420 patients who underwent imaging- guided needle biopsy from 1988 to 2000

retrospectively reviewed. S  278 cases in which lobular neoplasia was the highest-risk lesion at biopsy were included. S  164 proceeded to surgical excision, allowing calculation of rates of underestimation from minimally

invasive biopsy.

S  RESULTS S  lobular neoplasia was found in 278 = 0.9% S  164/278 (59%) continued to surgical excision S  cancer confirmed in 38 = 23% S  No difference underestimation rates LCIS = 25%, 17 of 67 / ALH = 22%, 21 of 97 lesions S  Statistically significant underestimation

S  masses (with or without associated µcalcifications) > µcalcifications only S  higher BI-RADS category S  core biopsy device rather than a vacuum device S  obtaining fewer specimens

S  CONCLUSION

S  all patients with lobular neoplasia at core or vacuum-assisted biopsy should undergo surgical excision until further differentiating criteria can be determined.

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Lobular carcinoma in situ/atypical lobular hyperplasia on breast needle biopsies: does it warrant surgical excisional biopsy? A study of 27 cases

O’Neil M, Madan R, Tawfik OW, Thomas PA, Fan F. Ann Diagn Pathol 2010;14(4):251–255

S  3163 breast core needle biopsies were retrieved from the surgical pathology files between 2003 and 2009

S  among them, 56 (1.8%) cases were identified with a diagnosis of ALH or LCIS

S  Eleven cases were excluded because of the presence of a concurrent more severe lesion in the biopsies that mandated excision

S  The remaining 45 cases contained only ALH or LCIS

S  27 had surgical excision follow-up

S  In the surgical excision specimens, 5 (19%) of 27 (11% of 45) cases showed more severe lesions or were "upgraded »

S  3 invasive ductal carcinomas

S  1 invasive lobular carcinoma

S  1 ductal carcinoma in situ

S  Histologic features of the lobular neoplasia on the core were found to have no predictive value for a more severe lesion in the subsequent excision

S  We suggest that patients with LCIS/ALH on core needle biopsy should be considered for surgical excision to rule out a more significant lesion regardless of the histologic features.

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Atypical Lobular Hyperplasia and Lobular Carcinoma in Situ at Core Breast Biopsy: Use of Careful Radiologic-Pathologic Correlation to Recommend Excision or

Observation

Kristen A. Atkins, Michael A. Cohen, Brandi Nicholson, Sandra Rao. Northwestern Memorial Hospital, Prentice Women’s Hospital, Chicago.

Radiology, 2013, Vol.269: 340-347, 10.1148/radiol.13121730

Flow diagram of total number of cases partitioned into radiologic and histologic concordance or discordance. IC = invasive carcinoma.

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Atypical Lobular Hyperplasia and Lobular Carcinoma in Situ at Core Breast Biopsy: Use of Careful Radiologic-Pathologic Correlation to Recommend Excision or

Observation

Kristen A. Atkins, Michael A. Cohen, Brandi Nicholson, Sandra Rao. Northwestern Memorial Hospital, Prentice Women’s Hospital, Chicago.

Radiology, 2013, Vol.269: 340-347, 10.1148/radiol.13121730

S  Advance in Knowledge S  When careful radiologic-pathologic correlation is conducted in the setting of a

breast core biopsy with atypical lobular hyperplasia or lobular carcinoma in situ some women can be safely triaged to observation

S  of the 43 benign concordant cases, none were upgraded at surgery or extended follow-up

S  Implication for Patient Care S  Focused and complete radiologic-pathologic correlation may

obviate excisional biopsy in patients with benign concordant biopsy findings

S  Additional validation of this is required before this approach can be universally applied

• None of the 43 (95% CI: 0%, 8%) benign concordant cases were upgraded at subsequent surgical excision or extended imaging follow-up

• which suggests that arbitrary excision in all cases of ALH or LCIS may not be necessary.

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Discussion

to excise or to sample ?

�  Excision for probably benign lesion + clip

S  Birads 3 S  Birads 4a

�  Sample for suspicious or malignant lesion

S  Birads 4 b & c S  Birads 5 & 6

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Minimal invasive diagnosis Minimal invasive treatment ?

•  Benign lesion • Malignant lesion ?

•  Premalignant lesions ???

•  New paradigme

•  New guideline

•  Most studies •  Overdiagnosis •  Overtreatment

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Local Treatment Surgery / Minimaly treatment US procedures

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Intact system

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Intact system

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S  No imaging specificity for PML

S  Histology correlation for all Birads 4 and 5 lesions

S  PML prevalence out of DCIS S  ADH 5 %

S  ALH/LCIS 0,9 to 2 %

S  Under-estimation rate S  ≈ 10 % VABB

S  ≈ 20 % LCNB

S  PML refered for surgical excision S  ALH ?...

S  Present & Next Futur : S  Minimal invasive therapy/ patient selection

S  Benign

S  Premalignant and Malignant ?

Take home message