Borderline and High-Risk Core Needle Biopsy Findings: Now What?

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Core needle biopsy of abnormal lesions on breast imaging is used to answer the question: "what is it?" While all women and men would like to be told they have a non-cancerous lesion, sometimes the biopsy results can come back as a "borderline" or high-risk lesion. These lesions may:

  • place a patient at higher risk for developing breast cancer in the future.
  • lead to recommendation of further breast imaging, such as breast MRI.
  • require an excisional biopsy to make sure a cancer is not lurking nearby.

Common borderline lesions include:

  • Columnar cell lesions
  • Complex sclerosing lesions, including radial scars
  • Fibroepithelial lesions 
  • Mucocele-like lesions
  • PASH (pseudoangiomatous stromal hyperplasia), a benign lesion that may present as a painless mass
  • Papillary lesions

The surgeon, radiologist and pathologist will evaluate the breast imaging that led to the biopsy, the physical findings (such as a mass or nipple discharge) and the amount of tissue that was obtained during the biopsy. A recommendation of further surgery (excisional biopsy), advanced breast imaging or close follow-up will be made by putting all these factors together.

If the imaging, physical findings and pathology all fit, the biopsy results are concordant.

If the pathology results do not fit with the imaging and physical findings, the biopsy results are discordant. A discordant result leads to the recommendation of an excisional biopsy (removing the entire area of concern by an open surgical biopsy).

Some lesions, like PASH, can be observed with excision recommended if the area enlarges. Common borderline lesions that have been removed by the core needle biopsy may be observed if the biopsy results are concordant.

High-risk lesions include:

  • Atypical ductal hyperplasia (ADH)
  • Pleomorphic lobular carcinoma in-situ (LCIS)
  • Atypical lobular hyperplasia (ALH)
  • LCIS
  • Lobular neoplasia

The finding of ADH will lead to the recommendation of surgical excision, except in some special circumstances where there was a small amount of ADH found on the biopsy results and the imaging lesion in question has been completely removed the core needle biopsy. Pleomorphic LCIS requires a surgical excision as a nearby cancer will frequently be found at the subsequent operation.

Lobular neoplasia, ALH and LCIS are all lesions that indicate an increased risk for developing breast cancer anywhere in either breast. Often advanced breast imaging, such as breast MRI, will be advised to find potential  "hidden" cancers. Medications, such as Tamoxifen, Evista and Exemestane, may be recommended to reduce risk of breast cancer.

More information about Core Needle Biopsy and borderline and high-risk lesion management may be obtained from the American Society of Breast Surgeons Consensus Guideline.