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Letters to the Editor |
Department of Radiology, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215
e-mail: fhall{at}bidmc.harvard.edu
Editor:
In the March 2006 issue of Radiology, Dr Mercado and colleagues (1) report 43 benign papillary lesions diagnosed at core-needle biopsy, with subsequent surgical resection of 36 lesions and long-term uneventful follow-up of seven. Two of the 36 surgically resected lesions showed well-differentiated ductal carcinoma in situ (DCIS), while eight of 36 revealed atypical ductal hyperplasia (ADH). No invasive carcinoma was found.
These authors conclude that their "results strongly suggest that papillary lesions diagnosed as benign at core-needle biopsy should be surgically excised because a substantial number of lesions were upgraded to ADH and DCIS at excision." I respectfully question this conclusion.
In their discussion Dr Mercado and colleagues (1) state that "the relative and/or absolute risk for the development of invasive breast carcinoma in patients with a history of ADH or DCIS at breast biopsy has been well documented." The implication that ADH is a "true precursor" of cancer has, to my knowledge, never been shown. What has been established is that ADH is a risk factor for the development of subsequent breast cancer, just as is the diagnosis of a papillary lesion or atypical lobular hyperplasia. Patients with the diagnosis of ADH at core-needle biopsy have surgical resection recommended because of the documented increased incidence of invasive and in situ carcinoma found. However, none of the papillomas reported by Dr Mercado and colleagues (1) had associated ADH at initial core biopsy.
What is currently felt is that nearly all invasive breast cancers arise from in situ cancers and these entities share a clonal evolutionary relationship with similar chromosomal changes (2). Dr Mercado and colleagues (1) make the valid point that DCIS in 4.6% (two of 43) of their papillomas is a higher rate than the average 2% incidence of carcinoma found in the Breast Imaging Reporting and Data System (BI-RADS) 3 category for which follow-up is usually recommended. However, with only two women having DCIS, these findings are hardly statistically significant.
The two patients with DCIS reported by Dr Mercado and colleagues (1) both had initial biopsy performed for suspicious calcifications, without associated mass. However, in two-thirds of the 43 papillary lesions in their series, biopsy was performed only for a mass, with no calcifications. This suggests that papillomas diagnosed at core-needle biopsy, that are not associated with calcifications, do not require surgical resection.
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Departments of Radiology*
Pathology,NYU Clinical Cancer Center, 160 East 34th Street, 3rd Floor, New York, NY 10016
e-mail: cecilia.mercado{at}med.nyu.edu
In response to the comments by Dr Hall, we acknowledge that ADH is a risk factor for the development of subsequent breast cancer. While patients with ADH at core biopsy are recommended for surgical resection because of the increased risk of in situ and invasive carcinoma, knowledge of the presence of ADH at resection for a benign papillary lesion is also important, because these patients would be considered for chemoprevention with tamoxifen.
To address Dr Hall's concerns regarding our conclusions (1), we have shown that even if we excluded the group with ADH at surgical excision after the diagnosis of a benign papillary lesion at percutaneous core-needle biopsy, the upgrade rate to DCIS among patients in whom surgical excision was performed would still be 5.7%. This rate as stated within our article is higher than the average 2% incidence of carcinoma found in the BI-RADS category 3 probably benign lesions, and thus the recommendation for surgical excision is valid.
In reference to the suggestion that papillomas appearing as calcifications at imaging and diagnosed at core-needle biopsy may not require surgical resection, it is an interesting observation. Unfortunately many of the other published articles failed to indicate the radiographic findings in cases that contained carcinoma at excision; thus, this observation cannot be confirmed. Further studies may be useful.
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