Breast Mri Assists In Decision-making For Surgical Excision Of Atypical Ductal Hyperplasia
*Amanda L Amin1, *Matthew Johnson2, *Brandon Stanczak2, *Onalisa D Winblad3
1University Hospitals, Cleveland, OH;2University of Kansas Medical Center, Kansas City, KS;3The University of Kansas Health System, Kansas City, KS
Surgical excision is frequently performed for atypical ductal hyperplasia (ADH) diagnosed on percutaneous biopsy (CNB) to rule out underlying breast cancer (BC). Upgrade ranges from 10-53%. Attempting to limit excision to those with highest upgrade risk, imaging and pathology features have been explored to stratify patients, but high-risk features are not reproducible between studies. There is a paucity of data on magnetic resonance imaging (MRI) value in determining ADH upgrade risk. In this study, we sought to define MRI presentation of ADH and assess its accuracy in predicting BC at ADH site.METHODS:A database was queried for female patients >18 years with ADH on CNB who had MRI from 2008-2020. Patient demographics including the presence of a concurrent ipsilateral or contralateral BC, imaging presentation including biopsy technique and MRI enhancement kinetic curves, and pathology features were captured. Categorical variables analyzed using Fisher’s exact tests to test for association between variables and upgrade. Continuous variables were analyzed using t-tests.RESULTS:125 CNB with ADH had MRI performed, 67 after and 58 before ADH diagnosis. 34% had a concurrent ipsilateral BC. Most were pure ADH (n=97, 77.6%) and the remainder were ADH involving a papilloma, radial scar, or fibroadenoma. On MRI, the ADH site had no enhancement in 45 (36%), non-mass enhancement (NME) in 50 (40%), and mass enhancement in 30 (24%). 28% had ADH diagnosed by MR guided CNB. Surgical excision was performed for 96 (76.8%) and 15 (15.6%) upgraded (11 DCIS and 4 invasive BC). The lowest risk for upgrade was in pure ADH and no MR enhancement (0%, n=25). All 15 upgrades had enhancement. Any kinetic pattern enhancement was significantly associated with upgrade (p=0.009) with a trend toward type III washout kinetics more strongly associated with upgrade (p=0.06).CONCLUSIONS:Active monitoring may be safely offered to women with pure ADH on CNB when MRI shows no enhancement. Any enhancement at ADH site, particularly type III washout kinetics, should continue to undergo excision to rule out underlying BC.
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