High risk breast lesions identified on MRI-guided vacuum-assisted needle biopsy: outcome of surgical excision and imaging follow-up

Abstract

Objective:: To determine whether breast MRI-guided vacuum-assisted biopsy (MRI-VAB) high-risk lesion histology influences surgical or long-term imaging follow-up outcomes.

Methods:: Patients with imaging-concordant high-risk findings on 9-gauge breast MRI-VAB between January 2007 and July 2012 who had surgical histopathology or 2 year imaging follow-up were retrospectively reviewed.

Results:: 90 patients with 99 lesions were included. Lesions were atypical ductal hyperplasia (ADH) (n = 21), lobular neoplasia [n = 36; atypical lobular hyperplasia (ALH) (n = 22), lobular carcinoma in situ (LCIS) (n = 6), and ALH plus LCIS (n = 8)], and other high-risk lesion (n = 42; papillary lesions, radial scar, flat epithelial atypia, atypia unspecified). Of 53 excised lesions, 6 (11%) were upgraded to invasive cancer or ductal carcinoma in situ (DCIS). 4 of 21 (19%) ADH lesions were upgraded to DCIS. 2 of 36 (6%) lobular neoplasia lesions, both combined ALH and LCIS, were upgraded to DCIS, and invasive lobular carcinoma, respectively. The remaining 46 lesions were managed conservatively with imaging follow-up: 17 (37%) had mammography only, while 29 (63%) had mammography and MRI follow-up. There was no evidence of breast cancer development at the site of MRI-VAB in the cases with only imaging follow-up.

Conclusion:: We conclude that the upgrade rate for high-risk lesions at MRI-VAB at surgical excision is low. Surgical excision is warranted for ADH and combined ALH-LCIS lesions. For other lesions, a multidisciplinary approach to decide on personalized management may be appropriate.

Advances in knowledge:: Surgical excision is warranted for ADH lesions and combined ALH-LCIS lesions identified at breast MRI-VAB. A multidisciplinary approach to patient management of other high-risk lesions may be appropriate.

Figure 1.

Imaging follow-up and surgical management of 99 high-risk benign breast lesions detected on MRI-VAB. MRI = dynamic contrast-enhanced breast MRI. MRI-VAB, MRI-vacuum-assisted biopsy.

Figure 2.

A 69-year-old female presented with palpable area of thickening in left superior breast with no correlate seen on mammography or sonography. (2A) Sagittal T₁- post-contrast (subtraction) breast MRI image demonstrates clumped non-mass enhancement with segmental distribution at 12 o’clock position, corresponding to area of palpable finding (arrow). (2B) Axial T₁ weighted post-contrast image obtained during MRI-guided vacuum-assisted needle biopsy confirms obturator position within suspicious lesion targeted for MRI-guided biopsy (arrow). Histopathology from VAB revealed ADH. Surgical excision was recommended and upgrade to DCIS, intermediate grade involving an area of approximately 2.5 cm, was revealed at segmental mastectomy. ADH, atypical ductal hyperplasia; DCIS,ductal carcinomain situ; VAB, vacuum-assisted biopsy.

Figure 3.

A 57-year-old female with abnormal screening mammogram. (3A) Diagnostic mammogram spot compression LM view shows architectural distortion (arrow) at left breast 3 o’clock position. No correlate was identified on sonography. MRI was performed. (3B) Sagittal T₁ weighted post-contrast (subtraction) breast MRI image demonstrates 4.2 cm clumped non-mass regional enhancement (arrow) at 3 o’clock position, corresponding to area of concern on mammography. (3C) Axial T₁ weighted post-contrast image obtained during MRI-guided vacuum-assisted needle biopsy confirms obturator position within the suspicious lesion targeted for MRI-guided biopsy (arrow). Histopathology review revealed LCIS focally involving complex sclerosing lesion. Surgical excision was recommended at multidisciplinary conference. Surgical pathology revealed no upgrade to malignancy. LCIS, lobular carcinoma in situ.