High-risk lesions diagnosed at MRI-guided vacuum-assisted breast biopsy: imaging characteristics, outcome of surgical excision or imaging follow-up

Background To evaluate imaging characteristics, outcome of surgical excision or imaging follow-up on high-risk lesions diagnosed at MRI-guided vacuum-assisted breast biopsy (MRI-VABB). Methods We retrospectively reviewed 598 lesions undergoing 9-gauge MRI-VABB from January 2015 to April 2018 to identify high risk breast lesions. We collected patient demographics, breast MRI BI-RADS descriptors, histopathological diagnosis at MRI-VABB and surgical excision, frequency of upgrade to malignancy and imaging follow-up of high-risk lesions. The x(2) test and Fisher exact tests were performed for univariate analysis. Results 114 patients with 124/598 findings (20.7%) had high-risk lesions at MRI-VABB, including atypical ductal hyperplasia (ADH) (21/124, 16.9%), lobular neoplasia (40/124, 32.3%), radial scar/complex sclerosing lesion (RS/CSL) (13/124, 10.5%), papillary lesions (49/124, 39.5%), and flat epithelial atypia (FEA) (1/124, 0.8%). 84/124 (67.7%) high-risk lesions were excised. 19/84 (22.6%) were upgraded to malignancy (7 invasive cancer, 12 DCIS). The upgrade rate for ADH and lobular neoplasia was 7/18 (38.9%) and 9/31 (29.0%), respectively. The upgrade rate for RS/CSL was 1/10 (10%). Of the 25 papillary lesions excised, 2 (8%) demonstrated pathologic atypia and were upgraded to DCIS. The other 23 papillary lesions had no upgrade or atypia. Excised high-risk lesions showing upgrade varied from 0.4 to 6 cm in length (mean 1.6 cm). There was a non-significant trend (p = 0.054) between larger lesion and upgrade to malignancy; however, there were no other specific imaging features to predict malignancy upgrade. Conclusions There were no specific MRI imaging characteristics of high-risk lesions to predict malignancy upgrade. Therefore, surgical excision is recommended for high-risk lesions, especially ADH or lobular neoplasia.