This document discusses breast premalignant lesions, their imaging appearance, and diagnosis. It notes that while imaging cannot definitively diagnose premalignant lesions, it can provide diagnostic hypotheses and guidance for biopsy. Premalignant lesions like DCIS, ADH, ALH and LCIS can appear as masses, masses with calcifications, microcalcifications, or non-mass lesions. Biopsy is needed for histological diagnosis but underestimation of premalignant lesions is possible, especially with core needle biopsy. Careful radiologic-pathologic correlation is important to determine if surgical excision is needed.

1. !
Breast Premalignant lesions
imaging
diagnosis & interventional
Luc Rotenberg, Gregory Lenczner,
Jean Guigui, Catherine Beges, Mehdi Cadi
RPO – ISHH
Clinique Hartmann-CMC Ambroise Paré
26-27 bdVictor Hugo
92200 Neuilly Sur Seine - France
dr.rotenberg@radiologieparisouest.com
Du 5 au 8 nov 2015 / from nov 5th to 8th 2015
14è Edition Hanoï - Vietnam

2. !
Hard and spiculated = malignant ? Smooth and regular = benign ?
Conventional Wisdom in Breast imaging

3. !
Benign : mastopathy Malignant : IDC grade 3

4. !
Premalignant lesions imaging
DCIS, ADH, ALH, LCIS…
S Screening, detection or diagnosis :
S Mammography
S Full Digital Mammography
S 3D Digital Breast Tomosynthesis - DBT
S Sonography
S High frequency probe
S Doppler
S elastography
S MRI
S 1,5 or 3T magnet
S Morphologic and dynamic study, perfusion
S Diffusion
S Spectroscopy-MRI
S Goal = evaluation for a risk : BIRADS classification
S No specifity for premalignant lesion
PML prevalence out of DCIS
ADH 5 %
ALH/LCIS 0,9 to 2 %

5. !
Premalignant lesions imaging
DCIS, ADH, ALH, LCIS…
S Histological diagnosis by the pathologist always
mandatory
S No histological diagnosis on imaging !
S However, diagnostic hypotheses and indications of
action to be taken are welcome

6. !
Premalignant lesions imaging
DCIS, ADH, ALH, LCIS…
S All imaging pattern can be found
associated with PML
S Mass
S Mass with calcifications
S µcalcifications
S No mass lesion :
S focal density, desorganisation, ehancement

7. !
Breast Cancer Risk Factors
Risk Factor Min Max x
LCIS on biopsy 1.00 8.70 8.70
No. 1st degree relatives with breast cancer 1.00 6.80 6.80
Mammographic density 0.41 1.76 4.29
No. of biopsies 1.00 2.88 2.88
Tamoxifen 0.45 1.00 2.22
Biopsy with atypical hyperplasia 0.93 1.82 1.96
Oral contraceptives / Menop Horm Therapy 1.00 1.49 1.49
Alcohol use / Obesity 0.99 1.41 1.42
Early menarche / late menopause 1.00 1.21 1.21
From http://www.halls.md/breast/gailmods.htm

8. !
Unusual breast lesion?
S Patient
S High risk, young, anxious…
S Imaging pattern
S Location
S Pathologic findings
Unusual, uncommon, bizarre, strange or exceptional
is our daily work and practice
every patient is unique

9. !
BI-RADS
Breast Imaging Reporting and Data
System
2nd french edition
4th american edition
Indications

10. !
Birads 1 screening
Birads 2 screening
Birads 3 Follow up except high risk
Birads 4 a
Follow up except
progressive or high risk
Birads 4 b,c
LCB or VABB
diagnosis
Birads 5/6
LCB or VABB
diagnosis ou stategical

11. !
Probably benign
malignancy 0,2 à 5%
§ Follow up
§ No biopsy indication excepted for :
§ High risk patient
§ BRCA mutation
§ synchronous cancer
§ Impossible follow up
§ Cancerophobia
Bi-Rads 3

12. !
suspicious lesion
malignancy 5 to 95%
Biopsy indication
4 a ?
Bi-Rads 4

13. !
suspicious lesion
malignancy 5 to 95%
Biopsy indication
4 a ?
Bi-Rads 4

14. !
Very suspicious lesion for
malignancy
§ fine needle aspiration : no
more or sentinal lymph
nodes
§ Core biopsy 16 or 14 G
§ histology, HR, Her2...
§ Suspicious for recidive
§ after surgery
§ after radiotherapy
Bi-Rads 5 to 6

15. !
Birads 5
Strategical indications
1. Before surgery & sentinel
lymph node technique
2. Before surgery for extended
DCIS (mastectomy)
3. Multicentric and bilateral
lesion
Bi-Rads 5 to 6

16. !
Digital Breast Tomosynthesis

17. !

18. !

19. !

20. !
Breast US
diagnostic & balistic

21. !
US Biopsy & Wire Marking
Surgery : IDC grade 1, RH+, Her2 -
Large core 16g Biopsy Wire marker
LCB : DCIS High grade

22. !
Birads 5 bilatéral

23. !
50 y
Right consevative treatment1 998
BRAC1 Mutation - MRI screening
Courtesy of Dr Corinnne Balleyguier, IGR

24. !

25. !
DCIS excised in 2009, follow up
DCIS recurence in the scar

26. !
Evolution
2010 2011
Cystosteatonecrosis or recurence ? Stereotactic VABB
Cytosteatonecrosis

27. !
57 y, LCIS left UIQ 2005, progression µcal UQ left
cluster birads 4 Deep preaxillary
ACR4B
VABB/
Stereotactic
recurence
ILC G2

28. !
2005 DCIS - IDC low grade
Scar – fat cytosteatonecrosis

29. !
Right breast mammogram
DCIS

30. !
Mrs A. 40 y. Right IUQ cancer 1997
Breast cancer familiar history. No mutation
Follow up /6 month M+US/IRM
05/2011
SD
CNB 14g : ADH

31. !
§ local anesthesia
§ external procedure
§ Explanation +++
§ Time 15 to 40 mn
Vacuum Aspiration Breast biopsy
14 G 11 G 10 G 8 G
17 mg 95 mg 160 mg 300 mg

32. !
Specimens XRays

33. !
Discussion
S Underestimation rate
ADH, DCIS, LCIS
S Not eliminated with VABB
S >> PPV : malignant
S >> NPV : benign
S Surgical indication

34. !
DCIS
Roger J. Jackman & al, Radiology February 2001 218:497-502
Stereotactic Breast Biopsy of Nonpalpable Lesions: Determinants of
Ductal Carcinoma in Situ Underestimation Rates
S DCIS underestimation rates by biopsy device were
S 20.4% (76 of 373) at large-core biopsy
S 11.2% (107 of 953) at vacuum-assisted biopsy (P < .001)
S 24.3% (35 of 144) of masses
S 12.5% (148 of 1,182) of microcalcifications (P < .001)
S and by number of specimens per lesion
S 17.5% (88 of 502) with 10 or fewer specimens
S 11.5% (92 of 799) with greater than 10 (P < .02).
S DCIS underestimations increased with lesion size
1.9 times more frequent with masses
than with calcifications
1.8 times more frequent with LCB than
with VAB
1.5 times more frequent <10 or fewer
specimens per lesion than with ≥ 10
specimens per lesion.

35. !
Frederick R. Margolin1 Jessica W. T. Leung1,2 Richard P. Jacobs1 Susan R. Denny1
Percutaneous Imaging-Guided Core Breast Biopsy: 5 Years’ Experience in a Community
Hospital, AJR:177, September 2001
ADH

36. !
Peter R. Eby, Jennifer E. Ochsner, Wendy B. DeMartini & al, Frequency and Upgrade Rates of
Atypical Ductal Hyperplasia Diagnosed at Stereotactic Vacuum-Assisted Breast Biopsy: 9-
Versus 11-Gauge. AJR 2009; 192:229–234
ADH

37. !
ADH Prevalence
RJ Jackman, RL Birdwell, DM Ikeda, Atypical Ductal Hyperplasia: Can Some Lesions Be
Defined as Probably Benign after Stereotactic 11-gauge Vacuum- assisted Biopsy,
Eliminating the Recommendation for surgical exision ? Radiology 2002; 224:548–554

38. !
Radial Scars
R. James Brenner, Roger J. Jackman, Steve H. Parker & al, Percutaneous Core Needle Biopsy
of Radial Scars of the Breast: When Is Excision Necessary? AJR:179, November 2002
S Carcinoma was found at excision in
S 28% (8/29) of lesions with associated atypical hyperplasia
S 4% (5/128) of lesions without associated atypia
S In the latter group, carcinoma was found at excision in
S 3% (2/60) of masse
S 8% (3/40) of architectural distortions
S 0% (0/28) of microcalcification lesions
S Malignancy was missed in
S 9% (5/58) of lesions biopsied with a spring-loaded device LCB
S 0% (0/70) of lesions biopsied with a directional vacuum-assisted device VABB
S 8% (5/60) of lesions sampled with less than 12 specimens
S 0% (0/68) sampled with 12 or more specimens
S Lesion type, maximal lesion diameter, and type of imaging guidance (stereotactic or sonographic) were not significant factors in determining the
presence of malignancy
S CONCLUSION: Diagnosis of radial scar based on core needle biopsy is likely to be reliable when
S no associated atypical hyperplasia
S biopsy includes at least 12 specimens (VABB)
S mammographic findings are reconciled with histologic findings.
S If miss a criteria, excisional biopsy is indicated

39. !
Lobular Neoplasia : ALH & LCIS
at Percutaneous Breast Biopsy: Variables Associated with Carcinoma at Surgical Excision
Rachel F. Brem, Mary C. Lechner, Roger J. Jackman
AJR 2008; 190:637–641
S OBJECTIVE. better define the rate and variables associated with cancer underestimation when lobular
neoplasia is found at breast biopsy. ALH or LCIS
S MATERIALS AND METHODS.
S The records of 32,420 patients who underwent imaging- guided needle biopsy from 1988 to 2000
retrospectively reviewed.
S 278 cases in which lobular neoplasia was the highest-risk lesion at biopsy were included.
S 164 proceeded to surgical excision, allowing calculation of rates of underestimation from minimally
invasive biopsy.
S RESULTS
S lobular neoplasia was found in 278 = 0.9%
S 164/278 (59%) continued to surgical excision
S cancer confirmed in 38 = 23%
S No difference underestimation rates LCIS = 25%, 17 of 67 / ALH = 22%, 21 of 97 lesions
S Statistically significant underestimation
S masses (with or without associated µcalcifications) > µcalcifications only
S higher BI-RADS category
S core biopsy device rather than a vacuum device
S obtaining fewer specimens
S CONCLUSION
S all patients with lobular neoplasia at core or vacuum-assisted biopsy should
undergo surgical excision until further differentiating criteria can be
determined.

40. !
Lobular carcinoma in situ/atypical lobular hyperplasia on breast needle
biopsies: does it warrant surgical excisional biopsy? A study of 27 cases
O’Neil M, Madan R, Tawfik OW, Thomas PA, Fan F. Ann Diagn Pathol 2010;14(4):251–255
S 3163 breast core needle biopsies were retrieved from the surgical pathology files between 2003 and 2009
S among them, 56 (1.8%) cases were identified with a diagnosis of ALH or LCIS
S Eleven cases were excluded because of the presence of a concurrent more severe lesion in the biopsies
that mandated excision
S The remaining 45 cases contained only ALH or LCIS
S 27 had surgical excision follow-up
S In the surgical excision specimens, 5 (19%) of 27 (11% of 45) cases showed more severe lesions or
were "upgraded »
S 3 invasive ductal carcinomas
S 1 invasive lobular carcinoma
S 1 ductal carcinoma in situ
S Histologic features of the lobular neoplasia on the core were found to have no predictive value for
a more severe lesion in the subsequent excision
S We suggest that patients with LCIS/ALH on core needle biopsy should be considered for
surgical excision to rule out a more significant lesion regardless of the histologic features.

41. !
Atypical Lobular Hyperplasia and Lobular Carcinoma in Situ at Core Breast Biopsy:
Use of Careful Radiologic-Pathologic Correlation to Recommend Excision or
Observation
Kristen A. Atkins, Michael A. Cohen, Brandi Nicholson, Sandra Rao.
Northwestern Memorial Hospital, Prentice Women’s Hospital, Chicago.
Radiology, 2013, Vol.269: 340-347, 10.1148/radiol.13121730
Flow diagram of total number of cases partitioned into radiologic and histologic concordance or discordance. IC = invasive carcinoma.

42. !
Atypical Lobular Hyperplasia and Lobular Carcinoma in Situ at Core Breast Biopsy:
Use of Careful Radiologic-Pathologic Correlation to Recommend Excision or
Observation
Kristen A. Atkins, Michael A. Cohen, Brandi Nicholson, Sandra Rao.
Northwestern Memorial Hospital, Prentice Women’s Hospital, Chicago.
Radiology, 2013, Vol.269: 340-347, 10.1148/radiol.13121730
S Advance in Knowledge
S When careful radiologic-pathologic correlation is conducted in the setting of a
breast core biopsy with atypical lobular hyperplasia or lobular carcinoma in situ
some women can be safely triaged to observation
S of the 43 benign concordant cases, none were upgraded at
surgery or extended follow-up
S Implication for Patient Care
S Focused and complete radiologic-pathologic correlation may
obviate excisional biopsy in patients with benign concordant biopsy
findings
S Additional validation of this is required before this approach can be
universally applied
• None of the 43 (95% CI: 0%, 8%) benign concordant cases were
upgraded at subsequent surgical excision or extended imaging
follow-up
• which suggests that arbitrary excision in all cases of ALH or LCIS
may not be necessary.

43. !
Discussion
to excise or to sample ?
— Excision for probably benign
lesion + clip
S Birads 3
S Birads 4a
— Sample for suspicious or
malignant lesion
S Birads 4 b & c
S Birads 5 & 6

44. !
Minimal invasive diagnosisMinimal invasive treatment ?
• Benign lesion
• Malignant lesion ?
• Premalignant lesions ???
• New paradigme
• New guideline
• Most studies • Overdiagnosis
• Overtreatment

45. !
Local Treatment
Surgery / Minimaly treatment US procedures

46. !
Intact system

47. !
Intact system

48. !
S No imaging specificity for PML
S Histology correlation for all Birads 4 and 5 lesions
S PML prevalence out of DCIS
S ADH 5 %
S ALH/LCIS 0,9 to 2 %
S Under-estimation rate
S ≈ 10 % VABB
S ≈ 20 % LCNB
S PML refered for surgical excision
S ALH ?...
S Present & Next Futur :
S Minimal invasive therapy/ patient selection
S Benign
S Premalignant and Malignant ?
Take home message