Purpose: Management of atypical ductal hyperplasia (ADH) has historically included surgical excision to evaluate for associated malignancy. Recent data has shown a subset of ADH may be safe to undergo imaging surveillance and spare patients the anxiety, stress, cost, and potential complications of an invasive surgery.
Stereotactic biopsies targeting calcifications that revealed ADH at time of percutaneous biopsy were evaluated to identify imaging features associated with a decreased chance of upgrade at time of surgical excision, and thus, may be safely observed.
Materials and Methods: A retrospective review was performed with the inclusion criteria of 1.) patients undergoing evaluation at Oregon Health and Science University between 2017 and 2021 2.) who underwent a stereotactic core needle biopsy targeting calcifications yielding ADH without malignancy 3.) and subsequently underwent surgical excision. All imaging was interpreted by breast/women’s imaging fellowship-trained radiologists or radiologists with more than 20 years of experience in women’s imaging. Imaging reports were reviewed to identify features associated with decreased risk of malignancy upgrade at the time of excision
Results: A total of 32 cases met inclusion criteria. Six of these demonstrated either ductal carcinoma in situ (DCIS) or microinvasive carcinoma at the time of excision, yielding a 23% upgrade rate. The remaining 26 cases did not upgrade to malignancy at the time of surgery. The calcification morphology in 14 of 26 non-upgraded cases were described as amorphous. A single case of amorphous calcifications yielding ADH at biopsy upgraded to malignancy at excision. However, at the time of diagnostic evaluation, a possible mass associated with the calcifications was noted.
Conclusion: No cases of amorphous calcifications without other suspicious imaging features that demonstrated ADH at the time of biopsy upgraded to malignancy at excision. While this study is ongoing and the sample size is small, these preliminary results offer insight into prospective selection of high risk/atypical lesions that may safely undergo observation and defer an invasive surgical procedure. Additional results will continue to help build an institutional management algorithm for this subset of patients.
Clinical Relevance Statement: Prospective identification of cases of ADH that have a lower chance of upgrade to malignancy at the time of surgical excision can help safely determine patients who are candidates for imaging surveillance rather than surgical excision.
