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Positive predictive value for malignancy of uncertain malignant potential (B3) breast lesions diagnosed on vacuum-assisted biopsy (VAB): is surgical excision still recommended?

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Abstract

Purpose

Breast lesions classified as of “uncertain malignant potential” represent a heterogeneous group of abnormalities with an increased risk of associated malignancy. Clinical management of B3 lesions diagnosed on vacuum-assisted breast biopsy (VABB) is still challenging: surgical excision is no longer the only available treatment and VABB may be sufficient for therapeutic excision. The aim of the present study is to evaluate the positive predictive value (PPV) for malignancy in B3 lesions that underwent surgical excision, identifying possible upgrading predictive factors and characterizing the malignant lesions eventually diagnosed. These results are compared with a subset of patients with B3 lesions who underwent follow-up.

Methods

A total of 1250 VABBs were performed between January 2006 and December 2017 at our center. In total, 150 B3 cases were diagnosed and 68 of them underwent surgical excision. VABB findings were correlated with excision histology. A PPV for malignancy for each B3 subtype was derived.

Results

The overall PPV rate was 28%, with the highest upgrade rate for atypical ductal hyperplasia (41%), followed by classical lobular neoplasia (29%) and flat epithelial atypia (11%). Only two cases of carcinoma were detected in the follow-up cohort, both associated with atypical ductal hyperplasia at VABB.

Conclusion

Open surgery is recommended in case of atypical ductal hyperplasia while, for other B3 lesions, excision with VABB only may be an acceptable alternative if radio-pathological correlation is assessed, if all microcalcifications have been removed by VABB, and if the lesion lacks high-risk cytological features.

Key Points

• Surgical treatment is strongly recommended in case of ADH, while the upgrade rate in case of pure FEA, especially following complete microcalcification removal by VABB, may be sufficiently low to advice surveillance as a management strategy.

• The use of 11-G- or 8-G-needle VABB, resulting in possible complete diagnostic excision of the lesion, can be an acceptable alternative in case of RS, considering open surgery only for selected high-risk patients.

• LN management is more controversial: surgical excision may be recommended following classical LN diagnosis on breast biopsy if an additional B3 lesion is concurrently detected while in the presence of isolated LN with adequate radiological-pathological correlation follow-up alone could be an acceptable option.

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Abbreviations

ADH:

Atypical ductal hyperplasia

CNB:

Core needle biopsy

FEA:

Flat epithelial atypia

LN:

Classical lobular neoplasia

PL:

Papillary lesions

PPV:

Positive predictive value

PT:

Benign phyllodes tumors

RS:

Radial scars

VABB:

Vacuum-assisted breast biopsy

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Funding

The authors state that this work has not received any funding.

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Authors and Affiliations

  1. Anatomic Pathology Section, Department of Human Pathology, University of Pavia, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy

    Marco Lucioni, Chiara Rossi, Emanuela Boveri & Marco Paulli

  2. Breast Imaging Department, Valduce Hospital, Via Dante Alighieri 11, 22100, Como, Italy

    Pascal Lomoro

  3. Breast Imaging Department, University of Pavia, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy

    Francesco Ballati, Marianna Fanizza, Giulia Meloni, Maria Grazia Sommaruga & Giuseppe Di Giulio

  4. Breast Surgery Department, Fondazione IRCCS Policlinico San Matteo, Università degli Studi di Pavia, Pavia, Italy

    Alberta Ferrari, Carlos A. Garcia-Etienne & Adele Sgarella

  5. Medical Oncology, Fondazione IRCCS Policlinico San Matteo and, Università degli Studi, Pavia, Italy

    Elisa Ferraris & Angioletta Lasagna

  6. University of Pavia and Department of Radiation Oncology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy

    Elisabetta Bonzano

Authors
  1. Marco Lucioni
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  2. Chiara Rossi
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  3. Pascal Lomoro
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  4. Francesco Ballati
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  16. Giuseppe Di Giulio
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Correspondence to Pascal Lomoro.

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The scientific guarantor of this publication is Di Giulio Giuseppe.

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The authors of this manuscript declare no relationships with any companies whose products or services may be related to the subject matter of the article.

Statistics and Biometry

No complex statistical methods were necessary for this paper

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Written informed consent was obtained from all subjects (patients) in this study.

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Institutional Review Board approval was not required because it is a retrospective study.

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Lucioni, M., Rossi, C., Lomoro, P. et al. Positive predictive value for malignancy of uncertain malignant potential (B3) breast lesions diagnosed on vacuum-assisted biopsy (VAB): is surgical excision still recommended?. Eur Radiol 31, 920–927 (2021). https://doi.org/10.1007/s00330-020-07161-5

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