Research
Brief Report | RESIDENT'S FORUM
Determining Whether Excision of All Fibroepithelial Lesions of the Breast Is Needed to Exclude Phyllodes Tumor Upgrade Rate of Fibroepithelial Lesions of the Breast to Phyllodes Tumor Andrew D. Van Osdol, MD; Jeffrey Landercasper, MD; Jeremiah J. Andersen, MD; Richard L. Ellis, MD; Erin M. Gensch, MD; Jeanne M. Johnson, MD; Brooke De Maiffe, BA; Kristen A. Marcou; Mohammed Al-Hamadani, MBChB, MPH; Choua A. Vang, BS
Fibroepithelial lesions (FELs) are a common histologic finding on core needle biopsy (CNB) of the breast. Fibroepithelial lesions include fibroadenoma and phyllodes tumor, which can be difficult to distinguish with an initial CNB. An institutional experience was reviewed from February 12, 2001, to January 4, 2007, to determine the safety of selective rather than routine excision of FELs and to determine the factors associated with upgrading diagnosis of FELs to phyllodes tumors without definitive phyllodes tumor diagnosis by CNB. Of 313 patients, 261 (83%) with FELs diagnosed by CNB received observation with long-term follow-up (mean, 8 years). Of the observed patients, 3 (1%) were diagnosed with phyllodes tumor on follow-up. Eighteen of 52 patients (35%) who received excision had an upgrade of diagnosis to phyllodes tumor. Sensitivity and specificity of the pathologist’s comment of concern for phyllodes tumor on a CNB demonstrating FELs without definitive phyllodes tumor diagnosis were 82% and 93%, respectively. Our policy of selective excision of FELs without definitive phyllodes tumor diagnosis resulted in safe avoidance of many surgical procedures. JAMA Surg. 2014;149(10):1081-1085. doi:10.1001/jamasurg.2014.73 Published online August 27, 2014.
T
he goals of clinical and imaging evaluation of the breast are to find all cancers and avoid unnecessary diagnostic surgical procedures, if possible.1 Core needle biopsy (CNB) achieves these goals.2-5 Fibroepithelial lesions (FELs) are one of the most common lesions diagnosed by CNB.6 These include fibroadenomas and phyllodes tumors.7 Both are biphasic neoplasms containing a proliferation of epithelial and stromal components.7-9 Imaging and histologic characteristics of these lesions can overlap.7-11 When differentiation between them is difficult with CNB, the World Health Organization Working Group that convened in September 2011 in Lyon, France, favors a diagnosis of fibroadenoma to avoid overtreatment.7-9 On finding an FEL, the pathologist may designate it an FEL and then add a comment of concern, such as “cannot rule out phyllodes” or “increased stromal cellularity,” if features of phyllodes are present but not definitive.11 The exact character of an FEL is important owing to differences in recommended management ranging from observation to wide surgical resection.5,12 The purposes of this study were to determine our institutional rate of upgrading FEL diagnosis to phyllodes tumor without definitive phyllodes tumor diagnosis by CNB and to determine the factors predicting upgrade. We hypothesized
Author Affiliations: Author affiliations are listed at the end of this article. Corresponding Author: Jeffrey Landercasper, MD, Norma J. Vinger Center for Breast Care, Gundersen Lutheran Health System, 1900 S Ave, La Crosse, WI 54601 ([email protected]). Section Editor: Richard D. Schulick, MD, MBA; Pamela A. Lipsett, MD, MPHE.
that a policy of selective excision of FELs diagnosed by CNB would result in safe avoidance of many surgical procedures.
Methods Institutional review board approval was obtained from Gundersen Health System for retrospective review of our prospective database for FEL diagnosed by CNB from February 12, 2001, through January 4, 2007. The mean (median) duration of follow-up in the observed and excised groups were 8 (8.3) and 7.2 (7.9) years, respectively. Of 313 patients, 16 (5%) were lost to follow-up after 6 months. Inclusion criteria included patients with CNB that demonstrated an FEL with the descriptor “fibroadenoma” (235 [75%]) or “any additional descriptor” (78 [25%]). Three patients with definitive phyllodes tumor diagnosed by CNB were excluded. All 3 were diagnosed with phyllodes tumor after excision. Uncertainty of exact classification of an FEL diagnosis by CNB was described with a comment of concern, and lesion classification was assigned after excision. 7,8 Selective excision of FELs identified by CNB was used.2,5,12 All CNBs were performed by breast specialty radiologists. The CNB specimens
jamasurgery.com
JAMA Surgery October 2014 Volume 149, Number 10
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archsurg.jamanetwork.com/ by a New York University User on 05/25/2015
1081
Research Brief Report
Excision of Fibroepithelial Lesions of the Breast
Figure. Outcomes of 313 Patients With Fibroepithelial Lesion of the Breast Identified on Core Needle Biopsy 313 Patients with ambiguous FEL on CNB: NCCN guideline compliant care of FELs Clinical, radiologic, and pathologic concordance assessment1-5,14
261 Received observation (83%)
52 Received surgical excisional biopsy (17%)
18 Had phyllodes tumor (35%)
Median follow-up, 8.3 ya
238 Received no further biopsy (91%)
23 Received surgical biopsy on follow-up (9%)
3 Had benign phyllodes tumor (1%)
17 Benign (94%)
1 Malignant (6%)
0 Had malignant phyllodes tumor (0%)
34 Had no cancer (65%)
Median follow-up, 7.9 y
1 Benign phyllodes tumor found on follow-up (2%)
Linear graph with biopsy results, patient care pathway, and results of long-term follow-up. CNB indicates core needle biopsy; FEL, fibroepithelial lesion; and NCCN, National Comprehensive Cancer Network. a
Eight of 261 observed patients (3%) were not followed up.
Table 1. Comparison of 313 Patients Who Received Excision for FELs of the Breast Diagnosed by CNB With Those Who Received Observationa FELs Diagnosed by CNB by Cohort, No. (%) Characteristic
Excisional Biopsy
Observation
Cases
52 (17)
261 (83)
Mean age, y
38.8
45.8
P Value .001
Method of detection Provider Self Screening
26 (50)
43 (16)
7 (13)
26 (10)
19 (37)
184 (70)
.001
Family history Yes
14 (27)
43 (16)
No
38 (73)
211 (81)
.09
Palpable Yes
34 (65)
88 (34)
No
18 (35)
168 (64)
Median size, mm
16
12
.001 .003
BI-RADS finding ≤3
18 (35)
98 (38)
≥4
33 (63)
139 (53)
.42
Biopsy Stereotactic Ultrasound guided
2 (4)
33 (13)
50 (96)
228 (87)
.06
Needle gauge >16
23 (44)
76 (29)
12-16
29 (56)
146 (56)
0 (0)
29 (11)
#1
44 (85)
172 (66)
#2
6 (11)
75 (29)
#3
2 (4)
14 (5)
No
17 (33)
258 (99)
Yes
35 (67)
3 (1)
16
15 (44)
8 (44)
12-16
19 (56)
10 (56)
#1
27 (79)
17 (94)
#2
5 (15)
1 (6)
#3
2 (6)
0 (0)
.98
Radiologist
Results The outcomes of 313 patients with FELs diagnosed by CNB are detailed in the Figure. A total of 261 (83%) received observation and 52 (17%) received excision. In the observed group, phyllodes was found in 3 patients (1%): 2 at 6 months and 1 at 18 months. Of the patients who received excision, 18 (35%) had phyllodes tumors. The proportion of patients with CNB demonstrating FEL with the descriptor “fibroadenoma” without any additional descriptor was higher in patients who received observation (223 of 261 [85%]) than in those who received excision (12 of 52 [23%]; P < .001). In univariate analysis, patients who received excision were younger (mean age, 38.8 vs 45.8 years; P = .001), had larger tumor size (mean, 16 vs 12 mm; P = .003), and more often had a pathologist comment of concern on CNB (mean, 67% vs 1%; P = .001). Other factors associated with excision in univariate analysis are detailed in Table 1. In multivariate analysis, comments by pathologists (odds ratio [OR], 612.99; 95% CI, 96.53-999.99), detection by providers (OR, 9.94; 95% CI, 3.05-32.41), tumor size larger than 20 mm (OR, 8.30; 95% CI, 2.46-28.0), and positive family history (OR, 3.74; 95% CI, 1.17-11.96) were associated with excision. Factors associated with an upgrade of diagnosis from FEL to phyllodes tumor without definitive phyllodes tumor diagnosis by CNB after excision in univariate analysis are detailed in Table 2. These patients were older (mean age, 43.5 vs 36.o years; P = .03) and more often had a pathologist comment of concern on CNB (18 of 18 vs 17 of 34; P < .001). No variable was significant in multivariate analysis.
.32
Pathologist comment No
17 (50)
0 (0)
Yes
17 (50)
18 (100)
#1
18 (53)
14 (78)
#2
16 (47)
4 (22)
Brief Report | RESIDENT'S FORUM
Determining Whether Excision of All Fibroepithelial Lesions of the Breast Is Needed to Exclude Phyllodes Tumor Upgrade Rate of Fibroepithelial Lesions of the Breast to Phyllodes Tumor Andrew D. Van Osdol, MD; Jeffrey Landercasper, MD; Jeremiah J. Andersen, MD; Richard L. Ellis, MD; Erin M. Gensch, MD; Jeanne M. Johnson, MD; Brooke De Maiffe, BA; Kristen A. Marcou; Mohammed Al-Hamadani, MBChB, MPH; Choua A. Vang, BS
Fibroepithelial lesions (FELs) are a common histologic finding on core needle biopsy (CNB) of the breast. Fibroepithelial lesions include fibroadenoma and phyllodes tumor, which can be difficult to distinguish with an initial CNB. An institutional experience was reviewed from February 12, 2001, to January 4, 2007, to determine the safety of selective rather than routine excision of FELs and to determine the factors associated with upgrading diagnosis of FELs to phyllodes tumors without definitive phyllodes tumor diagnosis by CNB. Of 313 patients, 261 (83%) with FELs diagnosed by CNB received observation with long-term follow-up (mean, 8 years). Of the observed patients, 3 (1%) were diagnosed with phyllodes tumor on follow-up. Eighteen of 52 patients (35%) who received excision had an upgrade of diagnosis to phyllodes tumor. Sensitivity and specificity of the pathologist’s comment of concern for phyllodes tumor on a CNB demonstrating FELs without definitive phyllodes tumor diagnosis were 82% and 93%, respectively. Our policy of selective excision of FELs without definitive phyllodes tumor diagnosis resulted in safe avoidance of many surgical procedures. JAMA Surg. 2014;149(10):1081-1085. doi:10.1001/jamasurg.2014.73 Published online August 27, 2014.
T
he goals of clinical and imaging evaluation of the breast are to find all cancers and avoid unnecessary diagnostic surgical procedures, if possible.1 Core needle biopsy (CNB) achieves these goals.2-5 Fibroepithelial lesions (FELs) are one of the most common lesions diagnosed by CNB.6 These include fibroadenomas and phyllodes tumors.7 Both are biphasic neoplasms containing a proliferation of epithelial and stromal components.7-9 Imaging and histologic characteristics of these lesions can overlap.7-11 When differentiation between them is difficult with CNB, the World Health Organization Working Group that convened in September 2011 in Lyon, France, favors a diagnosis of fibroadenoma to avoid overtreatment.7-9 On finding an FEL, the pathologist may designate it an FEL and then add a comment of concern, such as “cannot rule out phyllodes” or “increased stromal cellularity,” if features of phyllodes are present but not definitive.11 The exact character of an FEL is important owing to differences in recommended management ranging from observation to wide surgical resection.5,12 The purposes of this study were to determine our institutional rate of upgrading FEL diagnosis to phyllodes tumor without definitive phyllodes tumor diagnosis by CNB and to determine the factors predicting upgrade. We hypothesized
Author Affiliations: Author affiliations are listed at the end of this article. Corresponding Author: Jeffrey Landercasper, MD, Norma J. Vinger Center for Breast Care, Gundersen Lutheran Health System, 1900 S Ave, La Crosse, WI 54601 ([email protected]). Section Editor: Richard D. Schulick, MD, MBA; Pamela A. Lipsett, MD, MPHE.
that a policy of selective excision of FELs diagnosed by CNB would result in safe avoidance of many surgical procedures.
Methods Institutional review board approval was obtained from Gundersen Health System for retrospective review of our prospective database for FEL diagnosed by CNB from February 12, 2001, through January 4, 2007. The mean (median) duration of follow-up in the observed and excised groups were 8 (8.3) and 7.2 (7.9) years, respectively. Of 313 patients, 16 (5%) were lost to follow-up after 6 months. Inclusion criteria included patients with CNB that demonstrated an FEL with the descriptor “fibroadenoma” (235 [75%]) or “any additional descriptor” (78 [25%]). Three patients with definitive phyllodes tumor diagnosed by CNB were excluded. All 3 were diagnosed with phyllodes tumor after excision. Uncertainty of exact classification of an FEL diagnosis by CNB was described with a comment of concern, and lesion classification was assigned after excision. 7,8 Selective excision of FELs identified by CNB was used.2,5,12 All CNBs were performed by breast specialty radiologists. The CNB specimens
jamasurgery.com
JAMA Surgery October 2014 Volume 149, Number 10
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archsurg.jamanetwork.com/ by a New York University User on 05/25/2015
1081
Research Brief Report
Excision of Fibroepithelial Lesions of the Breast
Figure. Outcomes of 313 Patients With Fibroepithelial Lesion of the Breast Identified on Core Needle Biopsy 313 Patients with ambiguous FEL on CNB: NCCN guideline compliant care of FELs Clinical, radiologic, and pathologic concordance assessment1-5,14
261 Received observation (83%)
52 Received surgical excisional biopsy (17%)
18 Had phyllodes tumor (35%)
Median follow-up, 8.3 ya
238 Received no further biopsy (91%)
23 Received surgical biopsy on follow-up (9%)
3 Had benign phyllodes tumor (1%)
17 Benign (94%)
1 Malignant (6%)
0 Had malignant phyllodes tumor (0%)
34 Had no cancer (65%)
Median follow-up, 7.9 y
1 Benign phyllodes tumor found on follow-up (2%)
Linear graph with biopsy results, patient care pathway, and results of long-term follow-up. CNB indicates core needle biopsy; FEL, fibroepithelial lesion; and NCCN, National Comprehensive Cancer Network. a
Eight of 261 observed patients (3%) were not followed up.
Table 1. Comparison of 313 Patients Who Received Excision for FELs of the Breast Diagnosed by CNB With Those Who Received Observationa FELs Diagnosed by CNB by Cohort, No. (%) Characteristic
Excisional Biopsy
Observation
Cases
52 (17)
261 (83)
Mean age, y
38.8
45.8
P Value .001
Method of detection Provider Self Screening
26 (50)
43 (16)
7 (13)
26 (10)
19 (37)
184 (70)
.001
Family history Yes
14 (27)
43 (16)
No
38 (73)
211 (81)
.09
Palpable Yes
34 (65)
88 (34)
No
18 (35)
168 (64)
Median size, mm
16
12
.001 .003
BI-RADS finding ≤3
18 (35)
98 (38)
≥4
33 (63)
139 (53)
.42
Biopsy Stereotactic Ultrasound guided
2 (4)
33 (13)
50 (96)
228 (87)
.06
Needle gauge >16
23 (44)
76 (29)
12-16
29 (56)
146 (56)
0 (0)
29 (11)
#1
44 (85)
172 (66)
#2
6 (11)
75 (29)
#3
2 (4)
14 (5)
No
17 (33)
258 (99)
Yes
35 (67)
3 (1)
16
15 (44)
8 (44)
12-16
19 (56)
10 (56)
#1
27 (79)
17 (94)
#2
5 (15)
1 (6)
#3
2 (6)
0 (0)
.98
Radiologist
Results The outcomes of 313 patients with FELs diagnosed by CNB are detailed in the Figure. A total of 261 (83%) received observation and 52 (17%) received excision. In the observed group, phyllodes was found in 3 patients (1%): 2 at 6 months and 1 at 18 months. Of the patients who received excision, 18 (35%) had phyllodes tumors. The proportion of patients with CNB demonstrating FEL with the descriptor “fibroadenoma” without any additional descriptor was higher in patients who received observation (223 of 261 [85%]) than in those who received excision (12 of 52 [23%]; P < .001). In univariate analysis, patients who received excision were younger (mean age, 38.8 vs 45.8 years; P = .001), had larger tumor size (mean, 16 vs 12 mm; P = .003), and more often had a pathologist comment of concern on CNB (mean, 67% vs 1%; P = .001). Other factors associated with excision in univariate analysis are detailed in Table 1. In multivariate analysis, comments by pathologists (odds ratio [OR], 612.99; 95% CI, 96.53-999.99), detection by providers (OR, 9.94; 95% CI, 3.05-32.41), tumor size larger than 20 mm (OR, 8.30; 95% CI, 2.46-28.0), and positive family history (OR, 3.74; 95% CI, 1.17-11.96) were associated with excision. Factors associated with an upgrade of diagnosis from FEL to phyllodes tumor without definitive phyllodes tumor diagnosis by CNB after excision in univariate analysis are detailed in Table 2. These patients were older (mean age, 43.5 vs 36.o years; P = .03) and more often had a pathologist comment of concern on CNB (18 of 18 vs 17 of 34; P < .001). No variable was significant in multivariate analysis.
.32
Pathologist comment No
17 (50)
0 (0)
Yes
17 (50)
18 (100)
#1
18 (53)
14 (78)
#2
16 (47)
4 (22)
