Second Look Alters 20% of Breast Biopsy Conclusions

Fran Lowry

May 07, 2015

The oft-repeated counsel to patients to get a second opinion applies to breast pathology too, a new study suggests.

The second opinion about a suspected breast cancer should be in the form of an "interinstitutional pathology consultation" (IPC) that includes a review by a specialized breast pathologist, the authors say.

"Specialized pathology is very important these days because there are so many advances in the field of pathology, and if you are not specialized, you will miss many of the new technologies and morphologies, new entities, etc, etc," author Thaer Khoury, MD, from Roswell Park Cancer Institute, Buffalo, New York, told Medscape Medical News.

The review of pathology reports for breast cancer can have a significant impact on patient care, Dr Khoury said.

In his study, a second look at the pathologic samples from needle biopsies that were sent to Roswell Park by outside institutions resulted in a change in 20% of the cases that were examined.

"These results underscore the need for a second review of the original pathologic material by a pathologist who specializes in breast cancer prior to the implementation of breast cancer therapy," he said.

The study was published online April 15 in the Breast Journal.

Interpreting Biomarkers Is a Key

"At Roswell Park Cancer Institute, it is a routine practice to review the outside pathology slides and reports of all patients referred from different health institutions for further treatment," Dr Khoury said.

"This type of review is a required part of our quality assurance policy, but it has never been formally evaluated in terms of the discordance rate and the subsequent clinical impact on patient care."

Consequently, Dr Khoury and colleague Yousef Soofi, MD, sought to evaluate the impact of IPC for breast core needle biopsies received at their institution.

They retrospectively reviewed 502 breast core biopsy cases provided by referring institutions during a 1-year period (2012).

The cases in the study were defined as reflecting a minor discordance when the change in diagnosis did not affect the patient; they were considered to reflect a major discordance when patient care was affected through a change in therapy modality.

Discordance was seen in 104 cases (20.7%). Of these, 40 (8%) had a major discordance, and 64 (13%) had a minor discordance.

Surgical pathology follow-up was available for 25 (62.5%) cases with major discordance and for 13 (20.3%) cases with minor discordance.

The resulting interpretation changed management in 15 patients (3%); 25 patients (5%) had a potential of management change.

The most common reason for major discordance was in interpreting biomarkers, such as the estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor type 2 (HER- 2).

"If a patient has a breast core biopsy that is ER positive, HER-2 negative, sometimes it can actually be ER negative, HER-2 positive, and this has important implications for therapy because if it is ER-positive, the patient gets hormonal therapy, and if she does not have an ER-positive cancer, she does not get hormonal therapy. And the same is true for HER-2. If it is HER-2 negative, you do not get hormonal therapy; if HER-2 positive, you do. So getting those markers interpreted correctly is very important for patient care," Dr. Khoury said.

Be Up to Date With NCCN Guidelines

It is essential for pathologists to know current National Comprehensive Cancer Network guidelines to correctly diagnose breast biopsy specimens. Unfortunately, this can be difficult, because the guidelines change frequently, Dr Khoury said.

"Every 3 or 4 years, we get new guidelines telling us what is positive, what is negative, based upon research. The numbers keep changing, and if you are not in touch with them, you just report whatever you knew 6 or 7 years ago," he said.

For example, the current cutoff values for ER and PR are 1%, explained Dr Khoury. But Roswell Park's major referring institution for core needle biopsies uses 5% as a cutoff. Discordance can be expected in such a situation, he suggested.

"We found 19 patients with discordant ER/PR results. Seven of these were major, and 12 were minor. Five patients who had positive ER and/or PR by our interpretation would have been denied an effective and potentially curable antihormonal therapy," Dr Khoury commented, referring to the study results.

"I definitely think that it is important to make sure that, as an institution, our surgeons are operating for the right reasons, and the confirmation of the diagnosis is the crux of this paper," said Sandra Shin, MD, from the New York Presbyterian Hospital – Weill Cornell Medical College, New York City, who was asked by Medscape Medical News to comment on this study.

"What they are doing at Roswell Park is definitely something all institutions do to varying extents, but in this instance, they are looking at their personal experience and showing that this interinstitutional review works well, because they caught a number of discordant cases," Dr Shin said.

Every institution could do a similar study and would probably catch a few discordant cases, "which is the whole purpose of doing this study. It's also a way to protect our own surgeons, so that they are not taking out tumors that are benign or doing other inappropriate procedures," she said.

Getting a second review by expert pathologists is a service that can benefit everyone, Dr Shin added.

"Sometimes we have clinicians at other institutions sending us their patient slides to confirm their diagnosis before they administer chemotherapy. So it's a service for everybody ― the patient, treating physicians who want to make sure everything is what it should be before they go ahead and treat with radiation or chemo or both," she said.

"This paper is important because it reminds everyone of the importance of this practice. Even though everyone has this policy, there is not 100% follow through with all of the treating physicians out there, in the sense of having these slides reviewed. The value of this paper is that it brings the issue to the fore to remind us to exercise this practice more than we probably are doing now."

Dr Khoury, Dr Soofi, and Dr Shin report no relevant financial relationships.

Breast J. Published online April 15, 2015. Abstract

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