Is the outcome at surgery different when flat epithelial atypia and lobular neoplasia are found in association at biopsy?

Abstract

Objective: To assess the impact on the final outcome at surgery of flat epithelial atypia (FEA) when found concomitantly with lobular neoplasia (LN) in biopsy specimens compared with pure biopsy-proven FEA.

Methods: The approval from the institutional review board of the CHUM (Centre Hospitalier Universitaire de Montréal) was obtained. A retrospective review of our database between 2009 and 2013 identified 81 females (mean age 54 years, range 38-90 years) with 81 FEA biopsy-proven lesions. These were pure or associated with LN only in 59/81 (73%) and 22/81 (27%) cases, respectively. Overall, 57/81 (70%) patients underwent surgery and 24/81 (30%) patients underwent mammographic surveillance with a mean follow-up of 36 months.

Results: FEA presented more often as microcalcifications in 68/81 (84%) patients and were mostly amorphous in 49/68 (72%). After excluding radio pathologically discordant cases, pure FEA proved to be malignant at surgery in 1/41 (2%; 95% confidence interval 0.06-12.9). There was no statistically significant difference in the upgrade to malignancy whether FEA lesions were pure or associated to LN at biopsy (p = 0.4245); however, when paired in biopsy specimens, these lesions were more frequently associated with atypical ductal hyperplasia (ADH) at surgery than with pure FEA (p = 0.012).

Conclusion: Our results show a 2% upgrade rate to malignancy of pure FEA lesions. When FEA is found in association with LN at biopsy, surgical excision yields more frequently ADH than pure FEA thus warranting close surveillance or even surgical excision. Advances in knowledge: The association of LN with FEA at biopsy was more frequently associated with ADH at surgery than with pure FEA. If a biopsy-proven FEA lesion is deemed concordant with the imaging finding, when paired with LN at biopsy, careful surveillance or even surgical excision is suggested.

Figure 1.

(a–d) 47-year-old female; first screening mammogram. (a) Magnified lateral view demonstrating a cluster of suspicious pleomorphic microcalcifications (arrow) for which stereotactic vacuum-assisted 11-gauge core needle biopsy was recommended and performed. (b) Radiograph of core specimen obtained reveals numerous microcalcifications (arrows). (c) Photomicrograph of core biopsy specimen [haematoxylin phloxine saffron (HPS) stain, magnification ×10] reveals dilated acini lined by stratified columnar cells with low-grade atypia diagnostic of FEA (arrows). Please note the normal-size acini in this terminal ductal lobular unit (arrowheads) contrasting with FEA. (d) Photomicrograph of surgical specimen (HPS stain; magnification ×10) shows atypical tubules invading the fat (arrows) and fibrous stroma (arrowheads) consisting with low-grade tubular invasive carcinoma.