Continued Disagreement on Whether Certain “High Risk” Breast Lesions on Core Biopsy Require Surgery

I recently posted a pdf version of our course on “Controversies on the Management of High Risk Breast Lesions on Core Biopsy” that my Radiology colleague and I gave in San Diego last year.  The diagnoses we are referring to as “high risk” on core biopsy include atypical lobular hyperplasia/lobular carcinoma in situ, papilloma, radial scar/complex sclerosing lesion, and flat epithelial atypia. This year we repeated that course in Chicago at the ARRS annual meeting (radiologists mostly).  While last year we had an audience response system to use to get “real time” answers to clinical scenarios, this year we used a pre-conference survey with the same questions but collected the data prior to the talk to provide the audience with a comparison.

Once again, we found marked disparities in how the participating physicians would recommend which patient goes to surgery following a core biopsy of one of these high risk lesions. Here is the pdf of the tables showing the differences in recommendations for the 2010 and 2011 participants:  ARRS-2011

The questions asked to the audience participants and the remainder of the discussion including literature review are available in my prior blog post or, if you are interested in reading more in depth, can be found in our book chapter on high risk lesions.

My Radiology colleague and I feel very strongly that women are being treated so differently depending on which doctor or hospital they go to.  For example, if you go to one doctor and get a diagnosis of ALH on core biopsy that is concordant with your imaging, he or she may recommend surgical excision whereas a doctor across the street would say there is no need for surgery.

Look at the numbers in the tables.  Unfortunately, it seems there is NO consensus in the breast care community about how to treat a patient with one of these diagnoses on core biopsy.  We need more research and more prospective studies to come to an agreement so patients are not facing surgery or possibly not getting the appropriate surgery based on conflicting evidence in the literature.

4 Responses

  1. After reading through your information about ALH, ADH, and Flat Epithelial Atypica – I noticed that your opinions are based on core biopsy. Is that a general term applying to all needle-based biopsies, including stereotactic vacuum-assisted biopsy? Or is the latter method considered different all together, and not considered in your research? I presently have all 3 findings in my stereotactic vacuum assisted biopsy pathology report, and have been referred to surgeon for excisional biopsy. Regardless of any findings, or the success rate of the biopsy procedure I had done, or error rate of the pathologists, I personally would opt for this additional procedure (better safe than sorry). Can you tell me if any of your research focused on vacuum assisted biopsies?

    *Mammo-recall showed mildly pleomorphic microcalcifications, BI RADS 4 (with 2nd area found close to 1st on closer examination of images) prior to stereotactic biopsies.

  2. Thank you for your comment. As you mentioned, there are many types of needle biopsy techniques, one of which is vacuum-assisted. Regardless of the needle biopsy technique, given that you have a diagnosis of ADH, the literature strongly supports surgical excision. Regarding ALH and FEA (flat epithelial atypia), the literature is a little more confusing regarding need for surgical excision.

  3. I have been reading research abstracts since my pathology findings for my core biopsy: adenosis and fibrocystic changes with microcalcifications in benign ducts and stroma, usual ductile hyperplasia, and FEA. I’m being urged to go ahead with excision biopsy. This seems extreme if (as I understand) the most likely finding, if there’s any associated cancer, it’s non-invasive/dcis. What is the probability of FEA being associated with invasive cancer at the time of biopsy? Is there any literature on this?

  4. Thank you for your comment. I wish I could give you a definitive answer as to whether surgery is necessary in your situation, but (as you have probably deduced from doing your research) there remains no consensus in the breast medical literature regarding how to treat FEA and other high risk lesions diagnosed on core needle biopsy. Since my Radiology colleague and I published our paper and book chapter on this topic several years ago the literature has unfortunately remained unchanged. Some studies still suggest surgery is recommended following a diagnosis of FEA on core biopsy while others suggest observation/clinical follow-up. In some of the studies the risk of finding a more significant lesion at surgery includes cases of invasive carcinoma as well as DCIS and these percentages are quite variable among the studies out there. You indicated that you have been reading research abstracts so you may have already researched the National Library of Medicine via If not, that might be something to look into to get some of the most recent research study abstracts on FEA (some abstracts will allow full access to the entire research article via a link on the site). Again, I’m sorry I cannot give you a definitive recommendation, but I’m glad you are doing research and getting as much information as you can in order to have a meaningful discussion with your doctor regarding what is the optimal treatment decision for your particular situation.

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