It looks like,
there is a consensus in the literature regarding the management of some high-risk lesions (e.g.
ADH) diagnosed at CNB as to surgically excise,
based on the risk of underestimation of malignancy,
while for others (e.g.
CCL,LN) definitive decisions are not yet defined as to excise or to follow-up radiologically (2,3,4,5,6,7).
ADH has been assigned as a moderately increased risk for development of both ipsilateral and contralateral breast cancer.
Besides,
it may coexist with DCIS and/or invasive carcinoma.
The rate of underestimation of carcinoma,
on core-needle biopsy,
is reported as high as 87 in the literature (2,3).
This was 31.3 % in a large study conducted on ADH by Deshaias et al.
as comparable to our rate of 28.5 %.
These facts warrant a follow-up excision.
Though we recommended excision for all of our ADH patients,
only 2 out of 16 patients preferred long-term follow-up instead and remained stable.
CCL term includes a wide variety of intraductal alterations of epithelial cells.
Lately,
it's believed to be an early precursor of malignancy due its strong association with ADH.
We had one patient with CCL,turned out to be DCIS on subsequent excision with an up-grade rate of 4.7 %.
This rate was identifed as 1.4-2 % in other studies (2,4).
We think that our rate seems higher probably because we had only 4 CCL patients.
And the other CCL patient in our study who was lost to follow-up,
returned with a diagnosis of IDC three years after.
This,we think,is a good example of the high-risk of upgrading to carcinoma of CCL.
The term lobular neoplasia (LN) includes lobular carcinoma in situ (LCIS) and atypical lobular hyperplasia (ALH).
There are not yet clear guidelines in the management of isolated LCIS or ALH on a CNB.
Up-grading rate changes from 1% to 46 % in different studies (1).
Our rate was similar (4.7 %) with the rate we obtained for CCL,
as we only had 1 patient with LN.
The recommendations in the literature in regard to follow-up or excise these lesions are quite variable as are for CCL.
Liberman et al.
conducted a large study with benign papillomas with a malignancy upgrade rate,
reported as 0 % for asymptomatic patients.
A similar result was reported by Bennett et al.
with no upgrade to malignancy.
We had 2 patients out of 12 who were underestimated before excisional biopsy.
We believe that close imaging follow-up is reasonable for CCL and papilloma without atypia and LN,
if radiology-pathology concordance is obtained.
Our 7 patients out of 8 were stable after an average of 26 months' imaging follow-up.
4 of them were papilloma,
2 were CCL and 2 were ADH as mentioned.
Another important point is that the patients scheduled for follow-up should be easy to keep in touch.
In the literature,
some factors are accepted to be associated with upgrading rate to carcinoma such as size of biopsy needle,
sampling method,number of samples and coexistence with other high-risk lesions.
We did not analyse these in our study due to small sample size.
There aren't still universally recognized criteria to identify patients for safe clinical-only follow-up without surgical excision of the lesions.The significance of imaging-pathologic correlation should also be kept in mind (5,6,7,8).
More prospective trials conducted on the spesific and predictive features of high-risk breast lesions with larger series of patients are needed,
to be able to guide the patients in the appropriate way.Individualized treatment options should also be offered for this population.