Delhi State Chapter[ASI] Surgery Journal

Article Watch (DSC S-JAW)

Dr Kushica Chandra [ DNB 1],Dr Ratna Chopra [Moderator]

Hindu Rao Hospital and NDMC Medical College Delhi

Article
European guidelines for the diagnosis, treatment and follow-up of breast lesions
with uncertain malignant potential (B3 lesions) developed jointly by EUSOMA,
EUSOBI, ESP (BWG) and ESSO Isabel T. Rubio a,c,v,*, Lynda Wyld b,w,
Lorenza Marotti c, Alexandra Athanasiou d, Peter Regitnig e, Giuseppe
Catanuto f,g, Jan W. Schoones h, Marzia Zambon i, Julia Camps j, Donatella
Santini k, Jill Dietz l, Francesco Sardanelli m,n, Zsuzsanna Varga o, Marjolein
Smidt p,q, Nisha Sharma r, Abeer M. Shaaban s,t, Fiona Gilbert u,

European Journal of Surgical Oncology 50 (2024)

107292

Introduction
B3 is a group of non-malignant breast lesions with a heterogeneous risk of concurrent or
subsequent breast cancer diagnosis over time. Traditionally, B3 lesions have been treated with
diagnostic surgical open excision because of the risk of upgrade to malignant lesions. But
surgical excision should be reserved for discordant lesions, large lesions that are under-
sampled, and for ADH in many cases. However, many of them were downgraded to benign
lesions at final histology. Discordant report of breast core needle biopsy [CNB] or a B3 report
on biopsy is a challenge and invites further specialized evaluation and varied strategies of
management. The underlying reasons for special consideration in B3 lesions is possibility of
missed malignancy, a high risk lesion progressing to malignancy or a pure harmless benign
lesion. Contemporary management based on facilities available and patient involvement in
decision making, together range from expectant conservatism to upfront surgery, prevention
strategies and lifestyle changes.

PIP [Picture in Picture ] View of Article

The article in discussion discusses at length the challenging domains associated with B3
lesion. The guidelines developed and shared in the article provide practical recommendations
which can be applied in clinical practice which include recommendation grade and level of
evidence. The contents are a unique blend of consensus and Critique based on AGREE tool [
international Appraisal of Guidelines, Research and Evaluation (AGREE)] developed as
updated systemic literature review from discussions at a consensus meeting and a written
critique of experts
B3 lesions have been defined as lesions of uncertain malignant potential with an incidence of
3 and 21%. They may be classified as lesions with or without atypia, Those with atypia
include ADH [atypical ductal hyperplasia], ALH [atypical lobular hyperplasia] and those
without include, FEA [flat epithelial atypia], lobular neoplasia (LN), lobular carcinoma in
situ (LCIS), papillary lesions, [RS]radial scars [CSL]complex sclerosing lesions], [FEL]fibro-
epithelial lesions, and apocrine adenosis. Vacuum assisted biopsy [VAB} has shown co
existing malignancy in 0-25% cases. Modern practice [larger gauge core needles (14 G) and
vacuum-assisted biopsy (VAB) needles (up to 8 or 7 G) upgrade 5- 20% of all B3 lesions to
overtly malignant lesions. The stratified recommendations for B3 lesions are tabulated

Table of B3 breast proliferative lesions,

Representaive imaging, Histopathology
and Recommendations
Lesion Recommendation
Surgical excision Evidence/Grade 1 /A
1. ADH[Atypical Ductal VAB Evidence/Grade 111/B
Hyperplasia]

Clustered
Monotonous calcification
intradutal epithelial
lesions Special imaging
<2mm focus may aid[MRI/CE]
If VAB/VAR Concordance:
2. ALH, LCIS[Atypical lobular Surveillance, not surgery
Hyerplasia, Lobular Carcinoma Evidence/Grade11/B
In Imaging discordance: Surgical
in Situ]
Excision/ VAE
No B/L Mastectomy in the absence of
high risk factors 111/B
Patient information and shared decision
making
Discohesive, Non mass
Multifocal/Bilateral enhancement :MRI
LCIS Type A LCIS Type B
type A/ Type B occult/calcification
:small/ large nucleus outside lesion
cells
 3. FEA[Flat epithelial Atypia] In case of concordant imaging:
Surveillance 11/B
Columnar Cell
Concomitant with ADH on CNB:
Lesiona[CCL]
Surgical excision/VAE 11/B
Concomitant with ADH on VAB:
Residual calcification or discordant
imaging: Surgical excision/ VAE
111/B
Columnar cell Groupeg
Change{CCC]/Hyperpla amorphous
sia[CCH] calcifications

4. RS, CSL RS without Atypia: VAE 111/B

With Atypia: Surgical excision [ if
diagnosed on VAB, VAE may be
considered] 11/B

Stellate
Central fibroelastic
lesion/architectural
core that lacks
distorsion,
Stellate orientation, Radiolucent centre,
fibroelastic stroma no enhancement on
MRI

5. Papillary Intraductal papillary [IDP] without

Atypia: VAE 11/B
IDP with atypia: Surgical excision11/B
Mammography
Normal or can show
dilated ducts, a well-
defined retroareolar
mass or clustered
calcifications in 25%
of cases.

Fibrovascular
core, size<3mm
 Open excision to know the real nature
6. Apocrine Adenosis of lesion. Upgrade rate is 16.7-25%
Resembles Low
Grade DCIS

Resembles DCIS, Her

2<3+

In case of concordance in pathology

7. Mucocele like lesions and imaging, and if mucinous
carcinoma has been excluded both
Not available in excision and VAB can be excluded
the article

Features of
malignancy to
Mucus pools without be ruled out
epithelial cells

8. Fibroepithelial lesions Excision is recommended in view of

inability to rule out phyllodes tumour
Histpathology Image not Not available especially if size is greater than 3 cm or
available rate of growth is fast
Features of
Both epithelial and stromal malignancy to
components be ruled out
Fibroadenoma, Phyllodes

Differentiation difficult

Preventive strategies [ after risk assessment and formal counselling,

medical evaluation]

1. Premenopausal Tamoxifen 5mg for 5 years with no risk

factors for thromboembolism or
endometrial cancer. Evidence/grade
1/A
2. Post menopausal Anastrazole/ Exemestane with bone
density monitoring Evidence/Grade
1/A
 Lifestyle Changes

1. Physical Activity Dose-effect relationship, increase in

exercise is advisable
Meta-analyses of prospective
observational studies show that
adequate physical activity (by most
definitions 30 min per day or 150 min
per week of moderate-to-vigorous
exercise) is associated with a lower risk
of BC, with an RR of approximately
0.88.
2. Alcohol Drinking one unit per day, the lifetime
risk is increased by 7–10%
Not for BRCA ½
No B3 related data available
Increased risk 11/B
3. Smoking Epidemiological evidence of increase
in risk of 1.11.2 of developing breast
cancer 11/B
4. Obesity Independent risk factor, increased risk
of >30% of ER Positive tumours
Increased risk Evidence/Grade 11/B

Concluding remarks
1. VAB can upgrade the reports received on CNB
2. Treatment based on VAB report is likely to decrease surgical interventions
3. Discordant biopsy and imaging favor surgical excision
4. Large Fibroepithelial lesions may be excised in view of suspicion of phyllodes tumour
and chances of recurrence
5. In view of lack of facilities of VAB, patient factors especially compliance with respect
to follow up, especially in low resource set ups,surgical excision is a viable option
with ongoing efforts to upgrade technology to be able to safely reduce surgical
excisions
6. Preventive strategies incorporated in clinical practice are a useful tool to decrease
cancer burden

Suggested further read

1. Amin AL, Wagner JL. Contemporary management of atypical breast lesions
identified on percutaneous biopsy: a narrative review. Ann Breast Surg 2021;5:9.
2. Bellini C, Jacopo Nori Cucchiari, Federica Di Naro, Diego De Benedetto, Giulia
Bicchierai, Franconeri A, et al. Breast Lesions of Uncertain Malignant Potential (B3)
and the Risk of Breast Cancer Development: A Long-Term Follow-Up Study.
Cancers. 2023 Jul 6