Core Biopsy of Atypical Micropapillary Hyperplasia and Need for Surgical Biopsy
Question: I had a stereotactic core biopsy of cluster of calcifications in the upper inner left breast. Path diagnosis columnar cell change and hyperplasia with focal atypical micropapillary hyperplasia with microcalcifications. surgicial excision is recommended. From my understanding this is not cancer but has the potential to be cancer down the road. I am not in favor of doing surgical excision. Is there any other alternative for this type of situation. Any advice would be helpful.
Answer: Thank you for your question. I’m sorry you are faced with this uncertainty. While it is true none of the findings you have mentioned are a “cancer”, the finding on core biopsy of atypical micropapillary hyperplasia (a type of atypical ductal hyperplasia) can be associated with a more significant lesion on excisional biopsy (such as ductal carcinoma in situ or even invasive carcinoma). The literature gives varying rates of “upgrades” from atypical ductal hyperplasia to ductal carcinoma in situ or invasive carcinoma, but in general the average is 20-30%. Thus, the standard of care is to proceed on to surgical excision.
Of note (and I fully support this idea), there has been some data in the breast literature suggesting that “focal” atypical ductal hyperplasia may not need to be excised. It is a very interesting area of research because it could help save a lot of women from an open surgical biopsy, but it requires meticulous correlation between pathology and radiology to determine if the area in question was likely fully excised. While promising, I have not seen enough data supporting that yet, so to my knowledge this is not widely accepted and the standard is still for surgical excision. It might be worthwhile to get a second opinion on the “focal atypical micropapillary hyperplasia” because otherwise simple columnar cell change, even with hyperplasia, does not necessarily need surgical excision.
Dear Dr. Lawton,
Thanks for your quick response. It’s very much appreciated. Who should I go to for the second opinion… Oncologist, Pathologist.
Please advise.
With Best Regards,
Sharon
Sharon–
I am not sure if you had a breast pathologist read your initial slides, so if you wanted a second opinion on your diagnosis, I would recommend getting a second opinion from a breast pathology specialist to either confirm the presence of atypical hyperplasia or not. It’s easy to get a copy of your pathology report and at the bottom of that report you can see the pathologist’s name and can search that person online. It is the pathologist’s diagnosis of “atypia” that is driving further surgical biopsy. Your radiologist or surgeon is simply responding to that diagnosis and the current standard of care.
Let me know if you need any more assistance.
Thomas J. Lawton MD
Dear Dr. Lawton,
I too have been given the same diagnosis as above with a core biopsy. I am wondering how does one determine how much tissue to excise? I am getting a different answer from the Surgeon I was referred to who says about the size of a golf ball (1/3 of my breast) vs the Dr who did the core biopsy who said much smaller.. like a large grape. I am confused… and not sure if a golf ball is normal or excessive. Thoughts?
Thanks,
Deb
I apologize for not responding earlier–some comments have not been getting to my mailbox and are being filtered out. Was the diagnosis on core made because of a mass or because of calcifications or another reason? If it was for a mass, the size of the mass would determine the amount of tissue to be taken. If it was for calcifications, then the radiologist would determine the extent of the calcifications and recommend with the surgeon how much tissue should be removed in order to make sure all of the suspicious calcifications are removed at surgery. I hope this helps–and again, apologies for the computer glitch. I hope all goes well for you.
I am very concerned with what seems to be a rush to excisional biopsy, where previous core biopsy shows ADH. The 20%-30% upgrade stats seem to be contradicted by more and more studies, indicating in actual practice, it may be 15%. Why not use F/u MRI and Mammo to monitor the breast for additional indications of carcinoma.
God Bless,
Michael
Michael–
I understand your concern. Over-treating patients is not the way to go. However, the distinction between ADH and DCIS is a pathologic one. Breast imaging (MRI/Mammo/Ultrasound) cannot distinguish the two. A core biopsy is just a sampling of the area that the breast imager thought was suspicious. Based on the data (and yes, the numbers do vary), there are many cases that are called ADH on core but when more tissue is taken there is DCIS.
The current standard of care is to surgically excise ADH when diagnosed on core biopsy. Your wife can obviously opt to not have that done, but please make sure she is aware that if there is DCIS in the breast that was not removed, there is data to suggest that could be a precursor to invasive cancer.
I hope this helps.