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Atypical ductal hyperplasia: A way to minimize underestimation in vacuum-assisted breast biopsy?
ARTICLE IN PRESS THE BREAST The Breast 17 (2008) 6 www.elsevier.com/locate/breast
Letter to the Editor Atypical ductal hyperplasia: A way to minimize underestimation in vacuum-assisted breast biopsy?
Dear Sir The underestimation rate of atypical ductal hyperplasia (ADH) diagnosed via vacuum-assisted breast biopsy (VABB) is a crucial issue in the common clinical practice. Bedei et al. examined the underestimation of ADH diagnosis by VABB.1 Independently, our research team has evaluated putative ways of minimizing underestimation rate in preinvasive breast lesions.2,3 This letter summarizes our most recent results on ADH and presents them comparatively with the results by Bedei et al. More specifically, we have conducted a double blind study; women with non-palpable mammographic lesions were allocated either to the ‘‘standard’’ or to the ‘‘extended’’ protocol until November 2006. Afterwards, the extended protocol has been performed in the majority of cases. In the standard protocol, 24–36 cores were obtained, using one offset-main target and one-two additional offsets in the hypothetical center of microcalcifications. In the extended protocol, one offset-main target was defined in the center of the lesion and seven peripheral offsets were set, resulting in the excision of 96 cores. Subsequently, all women with a preoperative diagnosis of ADH (n=31) underwent open surgery under general anesthesia using a hook-wire localization. A second pathologist blind to the preoperative VABB diagnosis examined the tissue removed. The ADH underestimation rate in the standard protocol was 1/6. In the extended protocol, the underestimation rate was 0/25. Although underestimation in the extended protocol is lower than that reported by Bedei et al. (2/17 lesions), the difference did not reach statistical significance (p=0.158, Fisher’s exact test), probably due to the small sample size. It is worth mentioning that Bedei et al. excised 12 cores per lesion (range 6–36). In 2/6 (33.3%) cases of the standard protocol and in 23/25 (92%) cases of the extended protocol the excision may be considered as total, as the postoperative pathological examination did not recognize any ADH or carcinoma tissue. The 23/25 proportion is of special interest, since in our initial experience no precursor tissue was left in all ADH cases after VABB (6/6 cases).3 0960-9776/$ - see front matter r 2007 Elsevier Ltd. All rights reserved. doi:10.1016/j.breast.2007.10.002
In conclusion, it can be said that our results in the standard protocol are similar to those by Bedei et al.; however, in the extended protocol no underestimated ADH cases existed. Indeed, Bedei et al. have addressed the ‘‘adequacy of the specimens’’ as a putative predictor of ADH underestimation. Further studies, with larger samples, are needed to ascertain the present, promising findings.
References 1. Bedei L, Falcini F, Sanna PA, et al. Atypical ductal hyperplasia of the breast: the controversial management of a borderline lesion: experience of 47 cases diagnosed at vacuum-assisted biopsy. Breast 2006;15: 196–202. 2. Zografos GC, Zagouri F, Sergentanis TN, et al. Is zero underestimation feasible? Extended vacuum-assisted breast biopsy in solid lesions—a blind study. World J Surg Oncol 2007;5:53. 3. Zografos GC, Zagouri F, Sergentanis TN, et al. Minimizing underestimation rate of microcalcifications excised via vacuum-assisted breast biopsy: a blind study. Breast Cancer Res Treat 2007 July 26 [Epub ahead of print].
George C. Zografos Flora Zagouri Theodoros N. Sergentanis Breast Unit, 1st Department of Propaedeutic Surgery, Hippokratio Hospital, School of Medicine, University of Athens, 114, Vas Sofias Ave., Athens 116 27, Greece Aphrodite Nonni Department of Pathology, School of Medicine, University of Athens, Greece Dimitra Koulocheri John Bramis Breast Unit, 1st Department of Propaedeutic Surgery, Hippokratio Hospital, School of Medicine, University of Athens, 114, Vas Sofias Ave., Athens 116 27, Greece George C. Zografos University of Athens, 101, Vas Sofias Ave., Ampelokipi, Athens 11521, Greece E-mail address: [email protected]
Letter to the Editor Atypical ductal hyperplasia: A way to minimize underestimation in vacuum-assisted breast biopsy?
Dear Sir The underestimation rate of atypical ductal hyperplasia (ADH) diagnosed via vacuum-assisted breast biopsy (VABB) is a crucial issue in the common clinical practice. Bedei et al. examined the underestimation of ADH diagnosis by VABB.1 Independently, our research team has evaluated putative ways of minimizing underestimation rate in preinvasive breast lesions.2,3 This letter summarizes our most recent results on ADH and presents them comparatively with the results by Bedei et al. More specifically, we have conducted a double blind study; women with non-palpable mammographic lesions were allocated either to the ‘‘standard’’ or to the ‘‘extended’’ protocol until November 2006. Afterwards, the extended protocol has been performed in the majority of cases. In the standard protocol, 24–36 cores were obtained, using one offset-main target and one-two additional offsets in the hypothetical center of microcalcifications. In the extended protocol, one offset-main target was defined in the center of the lesion and seven peripheral offsets were set, resulting in the excision of 96 cores. Subsequently, all women with a preoperative diagnosis of ADH (n=31) underwent open surgery under general anesthesia using a hook-wire localization. A second pathologist blind to the preoperative VABB diagnosis examined the tissue removed. The ADH underestimation rate in the standard protocol was 1/6. In the extended protocol, the underestimation rate was 0/25. Although underestimation in the extended protocol is lower than that reported by Bedei et al. (2/17 lesions), the difference did not reach statistical significance (p=0.158, Fisher’s exact test), probably due to the small sample size. It is worth mentioning that Bedei et al. excised 12 cores per lesion (range 6–36). In 2/6 (33.3%) cases of the standard protocol and in 23/25 (92%) cases of the extended protocol the excision may be considered as total, as the postoperative pathological examination did not recognize any ADH or carcinoma tissue. The 23/25 proportion is of special interest, since in our initial experience no precursor tissue was left in all ADH cases after VABB (6/6 cases).3 0960-9776/$ - see front matter r 2007 Elsevier Ltd. All rights reserved. doi:10.1016/j.breast.2007.10.002
In conclusion, it can be said that our results in the standard protocol are similar to those by Bedei et al.; however, in the extended protocol no underestimated ADH cases existed. Indeed, Bedei et al. have addressed the ‘‘adequacy of the specimens’’ as a putative predictor of ADH underestimation. Further studies, with larger samples, are needed to ascertain the present, promising findings.
References 1. Bedei L, Falcini F, Sanna PA, et al. Atypical ductal hyperplasia of the breast: the controversial management of a borderline lesion: experience of 47 cases diagnosed at vacuum-assisted biopsy. Breast 2006;15: 196–202. 2. Zografos GC, Zagouri F, Sergentanis TN, et al. Is zero underestimation feasible? Extended vacuum-assisted breast biopsy in solid lesions—a blind study. World J Surg Oncol 2007;5:53. 3. Zografos GC, Zagouri F, Sergentanis TN, et al. Minimizing underestimation rate of microcalcifications excised via vacuum-assisted breast biopsy: a blind study. Breast Cancer Res Treat 2007 July 26 [Epub ahead of print].
George C. Zografos Flora Zagouri Theodoros N. Sergentanis Breast Unit, 1st Department of Propaedeutic Surgery, Hippokratio Hospital, School of Medicine, University of Athens, 114, Vas Sofias Ave., Athens 116 27, Greece Aphrodite Nonni Department of Pathology, School of Medicine, University of Athens, Greece Dimitra Koulocheri John Bramis Breast Unit, 1st Department of Propaedeutic Surgery, Hippokratio Hospital, School of Medicine, University of Athens, 114, Vas Sofias Ave., Athens 116 27, Greece George C. Zografos University of Athens, 101, Vas Sofias Ave., Ampelokipi, Athens 11521, Greece E-mail address: [email protected]