Management of high-risk (B3) breast lesions in symptomatic practice: evidence review and practical recommendations for multidisciplinary care
Abstract
Borderline breast lesions (B3 lesions, also termed lesions of uncertain malignant potential or high-risk lesions) represent a heterogeneous group of entities associated with variable risks of malignancy. While the management of screen-detected B3 lesions has become increasingly standardised, no dedicated international recommendations exist for symptomatic B3 lesions, despite them posing a distinct clinical challenge. Symptomatic lesions differ from screen-detected lesions in their mode of presentation, lesion characteristics, biopsy techniques, and diagnostic objectives; consequently, management strategies derived from screening populations may not be directly applicable. This review summarises the current evidence and proposes a pragmatic management framework for B3 lesions encountered in the symptomatic setting (defined as those presenting with breast symptoms outside population-based screening programmes). This is particularly relevant for patients under 50 years of age, where the primary objective is to exclude malignancy at the index site rather than solely to stratify long-term cancer risk. Clinical-radiological-pathological concordance and multidisciplinary assessment are central to management decisions. Lesions presenting as palpable abnormalities (which are typically larger) or those demonstrating radiological-pathological discordance warrant a lower threshold for additional sampling or excision. Conversely, selected concordant lesions without atypia may be managed conservatively following adequate sampling. The long-term cancer risk associated with epithelial atypia should also be considered with subsequent risk-based surveillance implemented where appropriate. Overall, management requires a risk-adapted, multidisciplinary approach integrating pathological, radiological, and clinical factors alongside patient symptoms and quality-of-life considerations. Given the limited evidence, current recommendations rely on expert consensus and a proposed practical framework. They underscore the need for large-scale, high-quality studies with long-term follow-up to establish formal clinical guidelines.
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Authors: Emad A. Rakha, Abeer Shaaban, Giuseppe Floris, Grace Callagy, Nisha Sharma, Raghavan Vidya, Thomas Decker, Peter Regitnig, Yazan Masannat, Elena Provenzano, Rahul Deb, Jill R. Dietz, Basel Altrabulsi, William Teh, Muna A. Abuhejleh, Zsuzsanna Varga, P. van Diest, Gábor Cserni, Maria Pia Foschini, Carolien H. M. van Deurzen, Madhuri Warren, Yasmeen Mir, Emmanuelle Charafe‐Jauffret, Soha El Sheikh, Zsuzsanna Bagó-Horváth, Isabella Castellano, Stephen Grobmyer, Mieke R. Van Bockstal, Puay Hoon Tan, Cecily Quinn, Sarah Pinder
Institutions: University of Liverpool, KU Leuven, University of Nottingham, University College London, Inserm, University of Szeged, NYU Langone Health, Centre National de la Recherche Scientifique, Cliniques Universitaires Saint-Luc, Erasmus University Rotterdam, Erasmus MC, University Hospital Zurich, University of Birmingham, Ollscoil na Gaillimhe – University of Galway, University of Turin, Queen Mary University of London, Medical University of Graz, Medical University of Vienna, King's College London, Abu Dhabi Health Services, University Medical Center Utrecht, University of Derby, Addenbrooke's Hospital, St. Vincent's University Hospital, Queen Elizabeth Hospital Birmingham, Abu Dhabi National Oil (United Arab Emirates), The Royal Wolverhampton NHS Trust, Pathodiagnostik Berlin, Broomfield Hospital, Mid Essex Hospital Services NHS Trust, University Hospitals of Derby and Burton NHS Foundation Trust, Northwick Park Hospital, Ospedale Bellaria, Barts Health NHS Trust, Royal Liverpool University Hospital, Centre de Recherche en Cancérologie de Marseille