AJR: Confusion reigns over recommendations for high-risk breast lesions

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Disagreement over management of four high-risk breast lesions—lobular neoplasia, benign papilloma, radial scar and flat epithelial atypia—demonstrate the need for a prospective trial as current recommendations are not well substantiated, according to an article published in the February issue of the American Journal of Roentgenology.

“Controversies exist in the management after core biopsy of each of these lesions—whether to perform immediate surgical excision so as not to miss an associated malignancy or imaging follow-up because concomitant malignancy is low,” wrote authors Dianne Georgian-Smith, MD, of Brigham and Women’s Hospital in Boston, and Thomas J. Lawton, MD, of Seattle Breast Pathology Consultants in Seattle.

A review of the relevant literature for each lesion revealed much disagreement, with large studies often disagreeing over the recommendation for excision or for follow-up. What’s more, Georgian-Smith and Lawton noted that current rates of underestimation of malignancy for these high-risk lesions are inaccurate because most are derived from retrospective studies with limitations. Most studies did not achieve statistical significance due to low patient numbers, and follow-up of patients not excised is lacking.

Practice guidelines from the American College of Radiology indicate that it is the radiologist performing the biopsy, not the pathologist, who is responsible for determining the radiology-pathology concordance, according to the authors.

“Pathologists should not be interpreting radiographic images, just as radiologists should not be interpreting pathology slides,” they wrote. “We think this could hinder appropriate treatment of the patient by ‘forcing the hand’ of the radiologist to recommend surgery and of the surgeon to perform an open biopsy when the pathology results could be concordant on the basis of the radiologist’s interpretation of the imaging findings.”

While an absence of direct relationships between radiologists and pathologist is the norm in many hospitals and breast centers, Georgian-Smith and Lawton believe that more communication between the disciplines is needed, especially when discussing follow-up surgery.

To demonstrate the confusion among practicing radiologists over recommendations for these lesions, the authors shared the results of an audience survey they administered during the 2010 American Roentgen Ray Society annual meeting. After the audience was updated on the current literature, they were asked whether their management of high-risk lesions would change. Of 83 respondents, 24 percent said they would either definitely change or consider changing, while 42 percent said they would not. Thirty-four percent, however, responded that they were “now completely confused.”

“These answers reflect the state of current medical practice—confusion. For those who were anticipating answers as to what to do, we have none to share. Whether women undergo immediate surgical excision or follow-up is random,” wrote the authors. “Prospective trials to achieve statistical significance are badly needed.”