What is a concise classification of breast diseases for general surgery oral boards?

From the Guidelines

Breast disease can be broken down into three broad categories for easy remembrance on general surgery oral boards: nonproliferative lesions, proliferative lesions without atypia, and proliferative lesions with atypia. These categories help in understanding the spectrum of breast diseases, from benign to potentially malignant conditions.

Key Categories of Breast Disease

• Nonproliferative lesions include conditions such as benign calcifications, fibrocystic changes, fibroadenomas, lipomas, fat necrosis, and nonsclerosing adenosis, which are generally not associated with an increased risk of breast cancer 1.
• Proliferative lesions without atypia encompass usual ductal hyperplasia, sclerosing adenosis, complex fibroadenomas, radial scars/complex sclerosing lesions, papillomas, and papillomatosis. These lesions have a slightly increased risk but are not typically considered precancerous 1.
• Proliferative lesions with atypia, including atypical ductal hyperplasia, atypical lobular hyperplasia, lobular carcinoma in situ (LCIS), and flat epithelial atypia, are associated with a higher risk of developing breast cancer, with one study indicating that up to 25% of women with these lesions may develop breast cancer 1.

Clinical Implications

Understanding these categories is crucial for managing patients with breast disease, as the risk of breast cancer varies significantly among them. It is essential to recognize that benign breast disease and breast tissue density are independent risk factors for developing breast cancer. Almost 30% of women with breast cancer have a history of benign breast disease, highlighting the importance of appropriate screening and follow-up 1.

Approach to Breast Disease

For general surgery oral boards, it's vital to have a structured approach to breast disease, including:

• Categorizing breast lesions based on their pathological characteristics
• Understanding the risk of malignancy associated with each category
• Knowing the appropriate management and follow-up for each type of lesion
• Being familiar with screening guidelines, including the role of imaging modalities like mammography, especially in women with a history of surgical excision for nonmalignant pathology 1.

From the FDA Drug Label

Disease characteristics included 90% infiltrating ductal histology, 38% T1, 91% nodal involvement, 27% intermediate and 66% high grade pathology, and 53% ER+ and/or PR+ tumors. Disease characteristics: 94% infiltrating ductal carcinoma, 50% ER+ and/or PgR+, 57% node positive, 32% node negative, and in 11% of patients, nodal status was not assessable due to prior neo-adjuvant chemotherapy To break down breast disease in an easy-to-remember way for general surgery oral boards, consider the following key points:

• Histology: 90% infiltrating ductal histology, 94% infiltrating ductal carcinoma
• Tumor size: 38% T1, tumor size > 2 cm in high-risk features
• Nodal involvement: 91% nodal involvement, 57% node positive, 32% node negative
• Grade: 27% intermediate, 66% high grade pathology, Grade 2 to 3 in high-risk features
• Hormone receptor status: 53% ER+ and/or PR+, 50% ER+ and/or PgR+ These breast disease characteristics can help you remember the key points for general surgery oral boards 2, 2.

From the Research

Breast Disease Breakdown

To break down breast disease in an easy-to-remember way for general surgery oral boards, consider the following key points:

• Benign entities:
  • Fibrocystic change (FCC) is a term used to describe several benign entities encountered in the breast, including proliferative lesions such as usual ductal hyperplasia and sclerosing adenosis, and nonproliferative lesions including cysts, apocrine metaplasia, and stromal fibrosis 3
  • Fibroadenomas (FAs) are common benign breast tumors that can be distinguished from phyllodes tumors (PTs) using mammography-based machine learning methods 4
• Malignant entities:
  • Breast cancers can be identified using breast MRI, which provides high sensitivity but modest positive predictive value, with approximately 75% of MRI-guided biopsies returning benign pathologies 3
• Imaging and diagnosis:
  • Breast MRI can show enhancement of benign entities, and recognizing the pathologic correlates of these enhancing lesions can help guide management after MRI-guided biopsy 3
  • Mammography-based radiomics features can be used to distinguish PTs from FAs, with a combined model yielding a high area under the curve (AUC) of 0.973 in the validation group 4
• Management and follow-up:
  • Following a benign concordant MRI-guided biopsy result, follow-up with MRI in 12 months is reasonable 3
  • Accurate radiologic-pathologic correlation can be achieved when careful review of histologic findings is carried out in the context of MRI features 3