Excising High-Risk Breast Lesions Justified

Pam Harrison

April 08, 2013

VIENNA, Austria — The malignancy upgrade rate is high enough to justify excising high-risk breast lesions as standard practice in symptomatic patients, according to new research.

"There is controversy surrounding the optimal management of high-risk breast lesions detected on image-guided biopsy," said Jane Cunningham, MD, from Beaumont Hospital in Dublin, Ireland.

"Our current practice is to excise all these lesions," she explained. But she and her team wondered if that is necessary.

"Our analysis showed that there was an overall malignancy upgrade rate of 20%. Given this, we advocate surgical excision for symptomatic patients with a high-risk lesion," she explained.

Dr. Cunningham presented the findings here at the European Congress of Radiology 2013.

The researchers reviewed results from 3711 ultrasound-guided, stereotactic, and magnetic resonance imaging-guided biopsies performed in their hospital's symptomatic breast unit. High-risk lesions were identified using the hospital's pathology database.

Postoperative histopathology was determined for all lesions and the malignancy upgrade rate was calculated. For B4 lesions — a very high suspicion of malignancy — the malignancy upgrade rate was 70%, which is not surprising, Dr. Cunningham noted. Pathologists generally assume that when excised, B4 lesions will be malignant.

For B3 lesions — lacking definitive data to indicate excision — the malignancy upgrade rate was 16%, she reported.

The overall prevalence of high-risk lesions was actually very low, even in this symptomatic population; 4.4% were B3 lesions and 0.3% were B4 lesions.

"The distribution of high-risk lesions in a symptomatic breast unit is different from that in a screening population," Dr. Cunningham emphasized.

"However, all of our subtypes had a rate of subsequent malignancy higher than 2%. That's why we feel it's prudent to excise these lesions...rather than to follow them with imaging."

Table. Malignancy Upgrade Rate at Surgical Excision

Subtype Distribution of High-Risk Lesions, % Malignancy Upgrade Rate, %
Papillary lesions 45.6 11.0
Atypical ductal hyperplasia 21.4 50.0
Radial scars 16.5 18.0
Lobular neoplasias 13.6 36.0
Flat epithelial lesions 2.9 33.0


If the probability of malignancy does not exceed 2% on the Breast Imaging-Reporting and Data System (BI-RADS) grading, the lesion is generally considered benign and does not require excision.

These results are in line with those reported in the literature, supporting the groups' recommendation to excise high-risk lesions as the standard of care, said session cochair Luca Carbonaro, MD, from IRCCS Policlinico San Donato Hospital in Milan, Italy, who was asked by Medscape Medical News to comment on the findings.

However, "each lesion type showed a different risk of malignancy, so a single uniform approach may not be appropriate for the management of all high-risk breast lesions," Dr. Carbonaro added.

A recent study determined that patients with high-risk lesions associated with the lowest likelihood of malignancy (papilloma and radial scar) and without suspicious findings on MRI can safely undergo follow-up instead of surgery (AJR Am J Roentgenol. 2012;198:272-280).

Unfortunately, MRI is not helpful in cases of lobular neoplasia or atypical ductal hyperplasia because of its low negative predictive value. "All these lesions should be excised," Dr. Carbonaro said. However, he said he believes that "individualized treatment options should still be offered to patients and that collaboration between the radiologist and the pathologist is fundamental in the management of these high-risk lesions."

Dr. Cunningham and Dr. Carbonaro have disclosed no relevant financial relationships.

European Congress of Radiology (ECR) 2013: Abstract B564. Presented March 9, 2013.