Jacky Luiten
60 | Chapter 4 hampered by the use of different biopsy techniques and differences in the distribution of the subtypes of high‐risk lesions found at biopsy. As the proportion of high‐risk lesions being upgraded to malignancy remained stable over the years, the increased excision rate of these lesions resulted in an increasing number of women with a benign outcome after diagnostic surgical excision. Although a recent US study found that reattendance to a screening mammography program is not lower in women with benign surgical excision after recall, 6 the use of this type of excision for diagnostic purposes should be kept to a minimum as it lowers the sensitivity of future screening mammography for cancer detection. 27 Tumor characteristics were generally more favorable for high‐risk lesions upstaged to breast cancer than for cancers with an unequivocal diagnosis of malignancy at CNB, with a higher proportion of DCIS and the absence of lymph node positive invasive cancers in the first group in case of simultaneous sentinel lymph node biopsy. Tumor stage and grading of invasive cancers, as well as type of final surgical treatment, were comparable for both groups. Although almost half of the upstaged high‐risk lesions comprised low grade DCIS, the presence of intermediate grade and high grade invasive cancers on the other hand may lead surgical oncologists to decide for lesion excision rather than radiologic and clinical surveillance. With the changing opinion of surgical excision for low grade DCIS towards close surveillance in the near future, low grade DCIS could have been included as a high‐risk lesion in our study. However, the clinical trials comparing surgery with active surveillance of DCIS 28,29 are still ongoing and none have reported any results yet confirming the safety of active surveillance. As a consequence, surgical excision was and still is the most widely accepted treatment for low grade DCIS. Taking all of the aforementioned into account we felt that considering low grade DCIS as high‐risk lesions is not justified yet. However, considering the fact that close follow up of low grade DCIS currently is subject of several prospective studies, 28,29 our study shows that when a diagnostic surgical excision of high‐risk lesions at CNB is performed, more than 85% of all excisions (71% [120/169] benign pathology and 14.2% [24/169] low grade DCIS) may be preventable in the near future. In order to decrease this number of potentially unnecessary surgical excisions, one may opt for vacuum‐assisted excision of high‐risk lesions as an alternative to surgical excision. 30‐32 Our study has certain strengths and limitations. To the best of our knowledge, it is the first study that describes trends in the detection of high‐risk lesions in a screened population. Furthermore, two‐year follow‐up was virtually complete for all recalled women. On the other hand, comparison of the management and
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