brogi uscap isbp management of papillary lesions … · 3/27/2017 2 • type and size of the...

3/27/2017

1

Management of Papillary Lesions Diagnosed at Rad‐Path Concordant Core Biopsy (CNB)

Edi Brogi MD PhDAttending PathologistDirector of Breast PathologyISBP symposium @USCAP meeting ‐March 5, 2017

Disclosure of Relevant Financial Relationships

USCAP requires that all planners (Education Committee) in a position to

influence or control the content of CME disclose any relevant financial

relationship WITH COMMERCIAL INTERESTS which they or their

spouse/partner have, or have had, within the past 12 months, which relates to

the content of this educational activity and creates a conflict of interest.

Papilloma ???

Atypical papilloma EXCISIONPapillary DCIS EXCISION Papillary Carcinoma EXCISION

Management of Papillary Lesions Diagnosed at Rad‐Path Concordant CNB

Evaluation of a papillary lesionRULE OUT EPITHELIAL ATYPIA

Evaluate epithelial proliferation between two adjacent fibrovascular cores as if within a duct space

No atypia Atypia

Evaluation of papillary proliferations

• Pathologist’s expertiseupgrade rate to atypia/ carcinoma at EXC of benign papilloma at CNB

breast pathologists – 16.3% upgrade

non‐breast pathologists ‐ 26.3% upgrade

Jakate et al. Am J Surg Pathol 2012

• Use of IHC to rule out ADH or DCIS– ER

– CK5/6

– ADH5 cocktail

In an analysis of 204 benign papillary proliferations, IHC increased the identification of atypia/ carcinoma in CNB material, and reduced the rate of upgrade to carcinoma at EXC (7.4% vs 4.7%)

Koo JS et al. Breast Cancer Res Treat 2013

Strong and diffuse ER(+) and CK5/6(‐) support the diagnosis of ADH/ DCIS

3/27/2017

2

• Type and size of the imaging target– mass lesion– Ca2+– MRI mass or non‐mass enhancement

• Fragmented vs non‐fragmented cores– Fragmentation more common for

larger and more complex lesions– The nature of the epithelium may be

more difficult to evaluate in a fragmented specimen

• Complete removal by CNB– Small papillomas and/or vacuum

assisted CNB

Factors affecting upgrade at EXC of papilloma w/o atypia at CNB

Upgrade at EXC of papilloma w/o atypiaVacuum Assisted Biopsy (VAB) vs 14G CNB

Seely J The Breast Journal 2015

Papilloma @CNB: Upgrade rates to carcinoma or atypia in F/U EXC

author year ## carcinoma at EXC

atypia predictors recommendtotal invasive DCIS

Mercado 2006 36 2 (6%) 0 2 (5%) 8 (22%) none EXC

Bernik 2009 47 4 (9%) NS NS 13 (28%) none EXC

Lu 2012 66 4 (6%) 0 4 (6%) 8 (12%) none EXC

Fu 2012 203 34 (6%) 0 12 (5.9%) 41 (20%) none EXC

Tseng 2012 24 7 (29%) 2 (8%) 6 (25%) 0 none EXC

Rizzo 2012 234 21 (9%) 2 (0.9%) 19 (8.1%) 42 (17.9%) none EXC

Foley 2015 18827

(14.3%)7 (3.7%) 20 (10.6%) 21 (11%) older age EXC

Glenn 2015 146 7 (4.7%) NS NS 25 (17%) none EXC

Ahmadiyeh 2009 29 1 (3%) 0 1 (3%) NS none No EXC

Li 2012 370 7 (2%) 1 (0.3%)5 (1.3%)

1 P‐LCIS (0.3%)48 (13%) calcifications*

No EXC (except*)

Swapp 2013 77 0 0 0 0 none No EXC

Hong 2016 234 14 (6%) 5 (2%) 9 (4%) NS age >54 y; size >1 cm No EXC

Kim 2016 141 6 (2.6%) 2 (0.8%) 4(1.8%) 8 (5.6%) none No EXC

Nakhlis 2015 45 3 (6.6%) 1 (2.2%) 2 (4.4%) NS palpable mass No EXC

Pareja 2016 171 4 (2.3%) 2 (1.1%) 2 (1.1%) 39 (22.8%)synchronous carcinoma

No EXC

TOTAL 2011 141 (7%)22/ 1818 (1.2%)

86/1818 (4.7%)1 PLCIS

253/ 1703 (15%)




Mercado 2006 36 2 (6%) 0 2 (5%) 8 (22%) none EXC


Lu 2012 66 4 (6%) 0 4 (6%) 8 (12%) none EXC

Fu 2012 203 34 (6%) 0 12 (5.9%) 41 (20%) none EXC

Tseng 2012 24 7 (29%) 2 (8%) 6 (25%) 0 none EXC

Rizzo 2012 234 21 (9%) 2 (0.9%) 19 (8.1%) 42 (17.9%) none EXC

Foley 2015 18827

(14.3%)7 (3.7%) 20 (10.6%) 21 (11%) older age EXC



Li 2012 370 7 (2%) 1 (0.3%)5 (1.3%)


No EXC (except*)



Kim 2016 141 6 (2.6%) 2 (0.8%) 4(1.8%) 8 (5.6%) none No EXC



No EXC

TOTAL 2011 141 (7%)22/ 1818 (1.2%)

86/1818 (4.7%)1 PLCIS

253/ 1703 (15%)




Mercado 2006 36 2 (6%) 0 2 (5%) 8 (22%) none EXC


Lu 2012 66 4 (6%) 0 4 (6%) 8 (12%) none EXC

Fu 2012 203 34 (6%) 0 12 (5.9%) 41 (20%) none EXC

Tseng 2012 24 7 (29%) 2 (8%) 6 (25%) 0 none EXC

Rizzo 2012 234 21 (9%) 2 (0.9%) 19 (8.1%) 42 (17.9%) none EXC

Foley 2015 18827

(14.3%)7 (3.7%) 20 (10.6%) 21 (11%) older age EXC



Li 2012 370 7 (2%) 1 (0.3%)5 (1.3%)


No EXC (except*)



Kim 2016 141 6 (2.6%) 2 (0.8%) 4(1.8%) 8 (5.6%) none No EXC



No EXC

TOTAL 2011 141 (7%)22/ 1818 (1.2%)

86/1818 (4.7%)1 PLCIS

253/ 1703 (15%)




Mercado 2006 36 2 (6%) 0 2 (5%) 8 (22%) none EXC


Lu 2012 66 4 (6%) 0 4 (6%) 8 (12%) none EXC

Fu 2012 203 34 (6%) 0 12 (5.9%) 41 (20%) none EXC

Tseng 2012 24 7 (29%) 2 (8%) 6 (25%) 0 none EXC

Rizzo 2012 234 21 (9%) 2 (0.9%) 19 (8.1%) 42 (17.9%) none EXC

Foley 2015 18827

(14.3%)7 (3.7%) 20 (10.6%) 21 (11%) older age EXC



Li 2012 370 7 (2%) 1 (0.3%)5 (1.3%)


No EXC (except*)



Kim 2016 141 6 (2.6%) 2 (0.8%) 4(1.8%) 8 (5.6%) none No EXC



No EXC

TOTAL 2011 141 (7%)22/ 1818 (1.2%)

86/1818 (4.7%)1 PLCIS

253/ 1703 (15%)

3/27/2017

3

papilloma w/o atypia at CNB: MSKCC Study

• MSKCC in‐house CNBs obtained 2003‐2013

• All CNB modalities

• CNB dx: “papilloma” or “papillary” lesion

• EXCLUDED: atypia, DCIS and/or invasive carcinoma

• All imaging studies and slides of CNB and EXC specimens re‐reviewed

• Rad‐path concordance reassessed for all cases

Pareja et al. Cancer. 2016;122(18):2819‐27.

MSKCC Study

196 rad‐path concordant CNB DX papilloma w/o atypia

171/196 (87%) cases with F/U EXC

25/196 (13%) cases No EXC‐ stable F/U

4 (2.3 %) cases withUPGRADE

167/171 (97.7%) cases with NO UPGRADE


Clinical characteristics of patients with upgrade

Case 1 Case 2 Case 3 Case 4

Age (years) 50 51 52 58

Personal Hx BrCa No Yes Yes Yes

laterality - Ipsilateral Ipsilateral Ipsilateral

time - 2 yrs prior Concurrent Concurrent

histology - IDC IDC IDC


Clinical characteristics of patients with upgrade

Case 1 Case 2 Case 3 Case 4

Age (years) 50 51 52 58

Personal Hx BrCa No Yes Yes Yes

laterality - Ipsilateral Ipsilateral Ipsilateral

time - 2 yrs prior Concurrent Concurrent

histology - IDC IDC IDC


Patient undergoing excision for concurrent carcinoma; consider excision of papilloma

Cases with UpgradeCase 1 Case 2 Case 3 Case 4

Imaging target massnon-mass

enhancementmass Ca2+

Carcinoma in EXC DCIS DCIS ILC, DCIS ILC

Size of carcinoma 2 mm 2 mmILC 1 mm

DCIS 1.5 mm2 mm

Nuclear Grade 1 2-3 1 2

Residual IDP (mm) 7 mm 0.7 mm 8 mm 4 mm

Involves IDP Yes No No No

Distance of carcinoma DCIS involves ILC: 8 mmPareja et al. Cancer. 2016;122(18):2819‐27.






DCIS 1.5 mm2 mm




Distance of carcinoma from IDP

DCIS involves IDP

11 mmILC: 8 mm

DCIS: >10 mm15 mm


3/27/2017

4






DCIS 1.5 mm2 mm





DCIS involves IDP

11 mmILC: 8 mm

DCIS: >10 mm15 mm







DCIS 1.5 mm2 mm





Type of UPGRADE

DCIS in IDP

TRUE

11 mm

Incidental

ILC: 8 mm DCIS: >10 mm

Incidental

15 mm

Incidental

Papilloma size – wide range

lobule

Some studies: no EXC for imaging target size up to 1 cm or 1.5 cm

At present, no lowest size cutoff for the DX of papilloma

Morphologic mimics of micropapilloma at CNB

myoepithelial hyperplasia papillary usual ductal hyperplasia

(Micro)papilloma completely excised at rad‐path concordant

CNB No EXCISION

3/27/2017

5

• The decision to excise a papillary lesion without atypia needs to be individualized based on risk, including such criteria as size; symptomatology, including palpability and presence of nipple discharge; and breast cancer risk factors. Those not excised should be followed closely with imaging. Palpability alone is not an absolute indication for excision.

CNB Dx of papillary lesion w/o atypiaGuidelines for management of high risk lesions American Society of Breast Surgeons

https://www.breastsurgeons.org/new_layout/about/statements/PDF_Statements/Concordance_and_High%20RiskLesions.pdf

Papillary lesions

Excision OR

clinical and imaging F/U

‐ Excise palpable lesions and those with atypia ‐ Incidental, benign papillary lesions can be followed

Patient Management following CNB Dx of papilloma without atypia @MSKCC

No excision required

• Rad‐path concordant findings

• No clinical symptoms

• Routine radiologic F/U planned

• (micro)papilloma completely removed by CNB

Excision Recommended

Rad‐path discordant findings

Patient is symptomatic (nipple discharge/ palpable mass)

Patient undergoing surgery for synchronous breast cancer

Guidelines for management of high risk lesions –Am Society of Breast SurgeonsLesion Recommendation Exceptions/ Notes

ADH EXCSmall volume ADH if completely excised on CNB may be observed based on risk factor assessment and multidisciplinary input

LCIS/ ALHEXC or observation with clinical and imaging F/U

Excision is necessary if pathology is discordant, limited sampling, or other high lesion present

Pleomorphic LCIS EXC Similar for necrosis and other non‐classical lesions

Pure FEA or CCHObservation with clinical and imaging F/U

EXC if concurrent ADH

Papillary lesionsEXC or clinical and imaging F/U

EXC palpable lesions and those with atypiaIncidental, benign papillomas can be followed

CSLs EXC Small, adequately sampled CLSs may be observed

Fibroadenoma EXC or clinical observation

FEL with concern for phyllodes

EXCConcerning features include stroma mitoses, overgrowth, pleomorphism, fragmentation, adipose tissue infiltration or other path concerns

Mucocele‐like lesion

EXC or F/UBenign MLLs can be observed if atypia would not alter pt management

Fibromatosis Wide local EXC High risk local recurrence

PASH Clinical observation

https://www.breastsurgeons.org/new_layout/about/statements/PDF_Statements/Concordance_and_High%20RiskLesions.pdf

brogi uscap isbp management of papillary lesions … · 3/27/2017 2 • type and size of the...

Documents