Massachusetts Chapter of the American College of Surgeons

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The Effect of Timing of Excisional Biopsy on Upgrade Rate for Atypical Ductal Hyperplasia, Flat Epithelial Atypia, Intraductal Papilloma, and Radial Scar
Jesse Casaubon, DO, Shiva Niakan, DO, Aixa Perez Coulter, MS, MPH, Danielle Lipoff, DO, Holly Mason, MD
Baystate Health, Springfield, MA

When Core Needle Biopsy (CNB) demonstrates Atypical Ductal Hyperplasia (ADH), Flat Epithelial Atypia (FEA), Intraductal Papilloma (IDP) or Radial Scar (RS), surgical excision (SE) is often performed to rule out malignancy, with a 1-20% expected rate of upstage.

We performed an IRB approved retrospective analysis of women who underwent CNB then SE between 2017-2021 using an IRB approved repository. Upstage was compared by time between CNB and SE.

We identified 501 patients. 28 were excluded for not meeting inclusion criteria leaving 473. 55 were upstaged to cancer (11.6%). 178 had ADH on CNB with 37 upstaged (20.8%). 50 had FEA with 3 upstaged (6%). 132 patients had IDP with 7 upstaged (5.3%). 98 had RS with 1 upstaged (1%). 15 patients had a combination of diagnoses: 4 with ADH+IDP, 3 with ADH+RS, 1 with ADH+palpable mass, 3 with RS+lobular neoplasia, 2 with RS+FEA, 1 with RS+atypia, 1 with IDP+atypia. 7 were upstaged (46.7%). 39 of 55 upstages (70.9%) were to ductal carcinoma in-situ (DCIS), 6 (10.9%) invasive ductal carcinoma (IDC), 3 (5.5%) invasive lobular carcinoma (ILC), and 1 (1.8%) pleomorphic lobular carcinoma in-situ. There was no difference in rate of upstage associated with increasing elapsed time (10.9% for <60 days, 14.8% for 60-90 days, 7% for 90-120 days, and 12.8% for >120 days, p = 0.54).

Surgical delay was not associated with increased risk for upstage. Patients with a combination of diagnoses had the highest rate of upstage (46.7 vs 11.6%).

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