Jacky Luiten

42 | Chapter 3 A sharp decline in the use of primary excision biopsy was observed over the past two decades. Currently, primary excision biopsy has been replaced by percutaneous core biopsy in almost all patients, which was also demonstrated in this study. 15 ‐ 17 Although it has been postulated that, with the introduction and widespread use of (S)CNB, an excisional biopsy would become an obsolete procedure, an ongoing significant increase was observed over the last few years, comprising mainly secondary excisional biopsies due to an increase in the number of suspicious findings at percutaneous biopsy. In daily practice, most secondary biopsies are performed if percutaneous biopsy yields an inconclusive histopathologic diagnosis, implying malignancy cannot be ruled out completely or when a discordance between radiologic and histopathologic findings persists after (repeated) percutaneous biopsy. This discordance is known to be related to an increased likelihood of upgrading to carcinoma. 18 The recent increase in secondary excision biopsies is probably related to the introduction of full‐field digital mammography, revealing smaller breast lesions due to the higher sensitivity of digital mammography compared to screen‐film mammography. 19,20 These changes in imaging techniques and diagnosis revealing lesions of unknown significance have had an impact on the types of specimens in which radiologists and pathologists encounter high‐risk lesions. 21 This poses clinicians for therapeutic dilemmas for which either subsequent need for additional secondary excision biopsy or mammographic surveillance is imposed depending on the level of agreement in multidisciplinary tumor boards. 22,23 These lesions include, for example, atypical ductal hyperplasia (with the differential diagnosis of ductal carcinoma in‐situ), papillary lesions, atypical lobular hyperplasia and flat epithelial atypia. 24 Since surgical excision is still regarded as the gold standard to obtain a definitive histopathologic diagnosis, surgical excision of the these lesions may be considered in order to minimize the risk of missing out malignant disease. 22 However, Mercado et al ., in 2006 demonstrated that approximately 80% of all papillary lesions consist of benign pathology at secondary surgical excision. 25 Another study, by Sen et al ., in 2016, also demonstrated that 97.6% of all atypical lobular hyperplasia was benign at secondary surgical excision. 26 Consequently, mammographic surveillance can be performed safely for some subtypes of high‐ risk lesions, without the risk of a significant underdiagnoses and ‐treatment. 13,26 In the Netherlands and many other countries, pathology results of diagnostic core biopsies are discussed in a multidisciplinary tumor board. Secondary excision biopsy, preceded by percutaneous biopsy in almost all cases, appears to be the necessary following step in case of persistent uncertainty. Still, it can be questioned