Significance of flat epithelial atypia on mammotome core needle biopsy: Should it be excised?

University of Michigan, Ann Arbor, Michigan, United States
Human Pathlogy (Impact Factor: 2.77). 02/2007; 38(1):35-41. DOI: 10.1016/j.humpath.2006.08.008
Source: PubMed


The aim of this study was to determine the morphologic types, associations, and significance of flat epithelial atypia (FEA) with or without atypical ductal hyperplasia (ADH) in mammotome core needle biopsies. We evaluated the correlation of FEA in core biopsies with follow-up excision biopsies to predict the likelihood of upgrade to carcinoma. We also investigated the utility of Ki-67 in predicting which lesions were associated with carcinoma in the excisional biopsies. Core biopsies with a diagnosis of atypia were categorized as pure FEA, pure ADH, or both. The following parameters were recorded: indication for core biopsies, presence of microcalcifications, inflammation, and stromal changes. A total of 60 core biopsies from 56 patients were studied. Pure ADH, pure FEA, and concomitant FEA and ADH were seen in 13%, 23%, and 64% of core biopsies, respectively. The most common architectural pattern of FEA resembled blunt duct adenosis (52%), followed by cystically dilated ducts with secretions (38%) and apocrine features (10%). Chronic inflammation and stromal changes were noted in 29% and 36% of FEA, respectively. Excisional biopsies in 48 of 56 patients demonstrated ductal carcinoma in situ and/or invasive carcinoma in 10 patients (21%), lobular carcinoma in situ or atypical lobular hyperplasia in 5 (11%), residual ADH in 11 (23%), and no atypia in 24 patients (50%). Three (21%) of 14 pure FEA upgraded to ductal carcinoma in situ and/or invasive carcinoma on excisional biopsy. The staining for Ki-67 in FEA/ADH was similar regardless of whether they were upgraded to carcinoma or not. In summary, we found a strong association between FEA and ADH, which may reflect a biologic progression. Most FEAs have a low-power appearance of a well-circumscribed group of ducts. Chronic inflammation and stromal changes are present in a subset of cases. Flat epithelial atypia shows a risk of upgrade to carcinoma similar to that of ADH and, hence, should be recognized and warrants a follow-up excision.

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    • "As discussed by Kunju et al. [8], the solution may lie in the discovery of biomarkers that are able to predict which sites of FEA are likely to be associated with a carcinoma, as this would guide the management of patients either towards further surgical excision or close monitoring. "
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    ABSTRACT: Purpose: To determine whether it is appropriate to routinely undertake surgery if flat epithelial atypia (FEA) or pure flat epithelial atypia (pFEA) is found on large-core biopsy. Patients and methods: Between 2005 and 2010, 1678 large-core biopsy procedures were carried out, which led to 136 FEA sites being identified, 63 of which across 59 patients were pFEA (four patients had two sites of pFEA each). Forty-eight patients underwent further surgical excision, equating to 52 excised sites of pFEA. Results: Of the 52 operated sites, there were 20 benign lesions (38%), 26 borderline lesions (56%), and three ductal carcinomas in situ (6%). The rate of histologic underestimation was put at 3.8%. Of the three cases that were underestimated, one was discarded because the definitive histology was not representative of the site from which microcalcifications had initially been taken. The other two cases that were underestimated were found in patients with an increased individual risk of breast cancer. Conclusion: In patients with no personal or first-degree family history of breast cancer, after complete or subtotal excision under radiology of the radiological lesion, and while excluding images fitting BI-RADS 5, annual monitoring may be offered as an alternative to surgical excision in view of the absence of underestimation found in our study.
    Diagnostic and interventional imaging 03/2013; 94(9). DOI:10.1016/j.diii.2013.01.011
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    • "ADH was the most common lesion for which women were referred for a surgical biopsy and previous studies which were not limited to screening populations, report comparable rates of malignant diagnosis (31-48% as compared with 47% in this study) after surgical excision of ADH with some smaller samples report rates ranging from 10-60%[3,4,11]. The concerns with ADH are that it not only coexists with malignancy, it is a non-obligate precursor to breast cancer[4,11-15]. Moreover, it is difficult to distinguish ADH from a low grade DCIS and in sampling a lesion using CNB, any ADH seen on histological assessment may represent only part of a lesion which also contains DCIS. "
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    ABSTRACT: The Australian Capital Territory and South East New South Wales branch of BreastScreen Australia (BreastScreen ACT&SENSW) performs over 20,000 screening mammograms annually. This study describes the outcome of surgical biopsies of the breast performed as a result of a borderline lesion being identified after screening mammography and subsequent workup.A secondary aim was to identify any parameters, such as a family history of breast cancer, or radiological findings that may indicate which borderline lesions are likely to be upgraded to malignancy after surgery. From a period of just over eight years, all patients of BreastScreen ACT&SENSW who were diagnosed with a borderline breast lesion were identified. These women had undergone needle biopsy in Breastscreen ACT&SENSW and either atypical ductal hyperplasia (ADH), flat epithelial atypia (FEA), atypical lobular hyperplasia (ALH), radial scar/complex sclerosing lesion, papillary lesion, mucocoele-like lesion (MLL) or lobular carcinoma in situ (LCIS) was found. Final outcomes for each type of borderline lesion after referral for surgical biopsy were recorded and analysed. Results of the surgical biopsy were compared to the type of needle biopsy and its result, radiological findings and family history status. Of the 94 surgical biopsies performed due to the presence of a borderline breast lesion, 20% showed benign pathology, 55% remained as borderline lesions, 17% showed non-invasive malignancy and 7% showed invasive malignancy. VALCS biopsy was the most common needle biopsy method used to identify the lesions in this study (76%). Malignant outcomes resulted from 24% of the surgical biopsies, with the most common malignant lesion being non-comedo ductal carcinoma in situ (DCIS). The most common borderline lesion for which women underwent surgical biopsy was ADH (38%). Of these women, 22% were confirmed as ADH on surgical biopsy and 47% with a malignancy. Further research is required to determine whether characteristics of the mammographic lesion (particularly calcification patterns), the area targeted for biopsy and number of core samples retrieved, can indicate a closer correlation with eventual pathology. This study identified no findings in the diagnostic assessment that could exclude women with borderline lesions from surgical biopsy.
    World Journal of Surgical Oncology 09/2010; 8(1):78. DOI:10.1186/1477-7819-8-78 · 1.41 Impact Factor
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    ABSTRACT: Columnar cell change in breast epithelium is frequently encountered in biopsies performed for evaluation of radiographically detected microcalcifications. While columnar cell change by itself is typically of no clinical consequence, on occasion cytologic atypia may be present, a finding now termed "flat epithelial atypia (FEA)". Morphologic, immunophenotypic, and genetic associations between FEA and low grade in situ and invasive breast carcinomas provide compelling evidence that FEA represents a precursor lesion in the spectrum of low grade breast neoplasia. Despite this information, the ultimate clinical impact of FEA and, thus, the best management strategy for it remains unknown. Herein, current concepts regarding FEA are reviewed, including pathologic definition, evidence supporting its role as a neoplastic precursor, and suggested management strategies.
    The Open Breast Cancer Journal 05/2014; 4(1). DOI:10.2174/1876817201002011090
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