My Biopsy Results: “Do I Have Cancer?”

Standard of care would recommend needle core biopsy as the best method to evaluate a breast mass, abnormal mammogram/ultrasound/MRI. There are many types of breast pathologies, which can be confusing. Understanding a pathology report is the key to understanding treatment options.

It is very important to understand your pathology report; even when the results are benign. Upstaging occurs when a needle biopsy underestimates the presence of a cancer. Surgical excision may be necessary to further evaluate a finding on breast imaging.

Pathology

Upstage Rate

HIGH RISK

Atypcial Ductal Hyperplasia (ADH)

Atypical Lobular Hyperplasia (ALH)

Flat Epithelial Atypic (FEA)

Papillary Lesions

10-20%

<5-50%

10-15%

10-35%

LOW RISK

Fibrocystic Changes

Usual Duct Hyperplasia

Duct Ectasia

Stromal Fibrosis

Can Surgical Excision Be Avoided?

In general, surgical excision is favored because the morbidity of surgical breast biopsy is judged to be lower than the cost of a missed cancer.
If surgical excision is not performed, short-term mammographic follow-up is necessary.
Clinical risk factors of the patient should be considered; eg, genetics/family history/history of chest wall radiation.
Some favorable subgroups have been identified in whom close surveillance rather than excision might be considered, with informed consent that there is a small ~5% or less chance of a missed cancer.

Avoid Excision if:

ADH: Lesions that might be observed: no mass lesion, and all or >95% of calcifications removed by core biopsy. Caution is advised because other recent studies have been unable to identify low-risk subgroups.
ALH: The primary criterion to omit excision is that the ALH finding is incidental.
Papillary lesions: Recent data suggests that papillary lesions without atypia may be followed with imaging surveillance, especially if imaging demonstrates that the lesion has been completely removed by needle biopsy. However, caution is advised for this approach, considering multiple previous reports demonstrating upgrade rates of 20-30%.

Why Should These Lesions Be Excised

When atypical ductal hyperplasia and papillary lesions are identified by core needle biopsy, they are associated with a significant rate of upgrade to cancer if the biopsy site is surgically excised.
This is primarily due to (1) sampling error of the core needle biopsy technique (removing only a portion of the lesion) and (2) the fact that these lesions are histologically difficult to discriminate from cancer when only fragments of the lesion are present in the biopsy tissue.
The goal of surgical excision is to remove the biopsy site and the original mammographic lesion that prompted the core needle biopsy in order to obtain a definitive diagnosis.