Marked Atypical Duct Hyperplasia Which Borders Low Grade Ductal Carcinoma In Situ on Core Biopsy Should Be Managed Conservatively
Christopher J VandenBussche, Eman Sbaity, Theodore N Tsangaris, Nagi Khouri, Russell Vang, Armanda Tatsas, Ashley Cimino-Mathews, Pedram Argani. The Johns Hopkins Medical Institutions, Baltimore, MD
Background: On breast needle core biopsy (NCB), the diagnosis of markedly atypical intraductal proliferations for which the differential diagnosis is the high end of atypical duct hyperplasia (ADH) and the low end of ductal carcinoma in situ (DCIS) can be especially difficult, due in part to lesional fragmentation and inter-observer variability. However, this distinction has significant clinical consequences. While the diagnosis of ADH usually results in no more than an excisional biopsy (EB), the diagnosis of DCIS on NCB can commit the patient to adjuvant radiation therapy (XRT) even if the resulting EB is negative, or it can even prompt an anxious patient to opt for bilateral mastectomy. We have favored a conservative approach to such cases (i.e. diagnose as marked ADH (MADH) and treat by EB); however, we know of no formal outcome studies to support this approach.
Design: We searched our computerized hospital database from the period of January 1, 1998 to January 1, 2009 for all breast NCB with the diagnosis of MADH. Patients who had a subsequent NCB showing DCIS or invasive ductal carcinoma (IDC) before EB were excluded. The resulting EB specimens were reviewed, and clinical follow up data were obtained.
Results: We diagnosed 164 patients with MADH on NCB. Among consultation cases in this group, 79% patients had been diagnosed with DCIS at the submitting institution. 82 patients underwent EB at our institution, and slightly over half (n=46, 56%) proved to have DCIS or IDC in their EB. Of these cases, 70% were managed by breast conserving therapy (BCT). However, almost half of the 82 cases (n=36, 44%) did not have DCIS or IDC on EB; of these, 15 EBs were benign, 18 showed atypical hyperplasia, 2 showed further MADH, and 1 showed lobular carcinoma in situ. Of these 36 patients, none received XRT and 23 had follow-up for at least 3 years. Only one of these patients had a “recurrence” of DCIS in the same breast, though on review this likely represented residual incompletely excised MADH.
Conclusions: Almost half the patients with MADH on NCB do not have DCIS or IDC on EB. These patients have a favorable outcome on limited follow-up without receiving XRT. Patients with MADH on NCB who prove to have DCIS or IDC on EB usually have localized disease which can be managed by BCT. While these results favor conservative approach to NCB with MADH to avoid over treatment, longer follow up is needed to determine if simple EB without XRT is adequate when no cancer is found in the EB.
Monday, March 19, 2012 9:30 AM
Poster Session I Stowell-Orbison/Surgical Pathology/Autopsy Awards Poster Session # 21, Monday Morning