Should Incidental Microscopic Radiologically Occult Atypical Duct Hyperplasia of the Breast Be Excised?
Shabnam Jaffer, Irin Scordi-Bello, Chandandeep Nagi, Ira J Bleiweiss. The Mount SInai Medical Center, New York
Background: With improved radiologic studies and greater sampling of the breast, the incidence of incipient and incidental lesions has increased. For example, we have occasionally noticed incidental, radiologically occult, microscopic foci of atypical duct hyperplasia (ADH) seen in isolation, unrelated and away from the targeted area of calcifications or the mass being investigated. Given the standard of recommending excision of ADH diagnosed on core needle biopsy of the breast due to upstaging to ductal carcinoma in situ (DCIS) and associated sampling error, we currently also extend this practice for incidental microscopic foci of ADH, but question its necessity.
Design: To answer this question, we retrospectively identified 65 cases of incidental ADH from 1/1/2000 to 12/31/2008 using the pathology computerized data base. We defined incidental ADH as being microscopic (<0.2cm) and not associated with the targeted radiologic lesion, be it calcifications or a mass. We reviewed all core biopsies to confirm the diagnosis of incidental ADH and follow up excision specimens when available. Clinical, radiologic and pathologic information was gathered and correlated.
Results: Of the 65 patients, follow up information was available in 45. Forty three patients underwent excision whereas 2 patients refused surgery and have had >2 years stable radiologic follow up. The age of the patients ranged from 37 to 85 years (mean=57). The cases were detected mostly by stereotactic core biopsy (38) done for calcifications or ultrasound guided biopsies done for a mass (5), specifically a fibroadenoma (FA). The character of the calcifications in the sterotactic cases were as follows: clustered=20, new=4, faint=3, pleomorphic=4, indeterminant=5 nodular=2. The calcifications were identified in fibrocystic changes in 33 cases and in FA in 5. By pattern, the ADH were subdivided as follows: cribriform = 27, flat=9, micropapillary = 5. In 2 cases the ADH presented as focal pagetoid spread. The findings on the excision specimens were as follows: no residual atypia = 24, residual ADH = 15 and DCIS= 4. All the DCIS cases were continuous with ADH and low grade with the exception of 1 case which was high grade. The cases with residual ADH and DCIS remained unassociated with calcifications.
Conclusions: The pattern of ADH was not predictive of residual ADH or DCIS. ADH persisted on excision specimens in about 35% of cases or was upstaged to DCIS in 9.3% of cases. Based on our data, we would recommend excision of incidental radiologic occult ADH.
Monday, February 28, 2011 8:00 AM
Platform Session: Section C, Monday Morning