Cleveland Clinic Journal of MedicineSurgical De-escalation: Are We Ready for ‘Observation’ of Benign High-risk Breast Lesions Found on Core Needle Biopsy?

Imaging-guided CNB has been the standard of care for decades in the US, with an estimated 1-2 million benign and high-risk CNBs performed annually.

The new research article by Vegunta et al. seeks to discern if benign proliferative lesions such as atypical hyperplasia diagnosed on core needle biopsy (CNB) require surgical excision. It also probes into the question of an acceptable threshold for excision as the sensitivity of breast imaging improves.

Key Points:

• There’s ongoing debate about whether benign proliferative lesions diagnosed via CNB require surgical excision, a process that involves considerations of upgrade rates, patient preferences, and follow-up measures.
• De-escalation in surgical breast cancer treatment involves balancing oncologic outcomes with surgical morbidity and quality of life.
• The potential for upgrade to malignancy at surgical biopsy remains the primary reason for the excision of benign high-risk lesions detected on CNB.

Additional Points:

• The surgical management of breast cancer has seen a consistent trend of de-escalation from the early Halsted radical mastectomy to the simple mastectomy and breast conservation.
• Surveys have shown that patients often accept aggressive treatments with significant side effects for a minimal benefit in survival.
• The concept of radiologic-pathologic concordance in high-risk lesions is currently ambiguous and lacks consensus.
• Guidelines vary for surgical treatment vs. observation for benign high-risk lesions, leading to disagreements in practice.

Conclusion:

• Although the need for surgical excision of benign high-risk lesions detected on CNB is still debated, the authors suggest that the recommendation for observation of such lesions may not yet be ready for widespread implementation.

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Did You Know?
Women age 60 and older represent 59% of invasive breast cancer cases, with more than 30% occurring in women aged 70 and older.