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Controversies in Pathology

High-risk and selected benign breast lesions diagnosed on core needle biopsy: Evidence for and against immediate surgical excision


The vast majority of image-detected breast abnormalities are diagnosed by percutaneous core needle biopsy (CNB) in contemporary practice. For frankly malignant lesions diagnosed by CNB, the standard practice of excision and multimodality therapy have been well-defined. However, for high-risk and selected benign lesions diagnosed by CNB, there is less consensus on optimal patient management and the need for immediate surgical excision. Here we outline the arguments for and against the practice of routine surgical excision of commonly encountered high-risk and selected benign breast lesions diagnosed by CNB. The entities reviewed include atypical ductal hyperplasia, atypical lobular hyperplasia, lobular carcinoma in situ, intraductal papillomas, and radial scars. The data in the peer-reviewed literature confirm the benefits of a patient-centered, multidisciplinary approach that moves away from the reflexive “yes” or “no” for routine excision for a given pathologic diagnosis.

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Fig. 1: Atypical Ductal Hyperplasia (ADH).
Fig. 2: Pleomorphic Lobular Carcinoma in Situ (LCIS).
Fig. 3: Low power view of a Radial Scar from a surgical excision, H&E 20X. H&E shows this benign sclerosing lesion with stellate architecture.
Fig. 4: Images from a Core Needle Biopsy (CNB) of a Radial Scar, all H&E images.
Fig. 5: Images from a Core Needle Biopsy (CNB) of a benign intraductal papilloma.


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The Introduction and Discussion were written jointly by the authors. The sections arguing for immediate surgical excision of high-risk and selected benign lesions were written by AH and HG. The sections proposing nonoperative management of selected patients with high-risk and selected benign lesions were written by BC.

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Correspondence to Benjamin C. Calhoun.

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Dr. Calhoun is a Member of the Oncology Advisory Board for Luminex Corp. Dr. Gilmore is a Consultant for Agendia, Inc. and a Member of the Digital Pathology Advisory Board for Sectra. Dr. Harbhajanka has no financial relationships to disclose.

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Harbhajanka, A., Gilmore, H.L. & Calhoun, B.C. High-risk and selected benign breast lesions diagnosed on core needle biopsy: Evidence for and against immediate surgical excision. Mod Pathol (2022).

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