How to lower rate of upgrade of screen-detected high risk B3 breast lesions at time of surgery: A new proposed pathway


Session type:


Amrita Kumar1,Chin Ng1,Mohsen Elgammal2
1Frimley Health,2



  • B3 lesions are traditionally benign but known to be associated with malignancy (25-33%). Literature review suggests that different B3 lesions have differing relative risks.
  • Current evidence shows that certain B3 lesions can be upgraded to invasive disease using 11G vacuum biopsy and as such, diagnostic excision can be avoided and therapeutic breast surgery undertaken.
  • The purpose of our study was to assess our departmental rate of upgrade against published figures to adapt and standardise our B3 high risk lesion management protocol


  • Retrospective analysis of the cancer data from a cohort of approximately 30,000 women screened via our institution which is part of the UK NHS breast screening programme during the course of 18 months, between April 2013 and August 2014.
  • Review of screening mammograms, ultrasound imaging and biopsy results.
  • Correlated with the lesion type and surgical pathology for both malignant invasive and non-invasive cancers.


  • The rate of upgrade of B3 lesions at time of diagnostic surgery was 15.6% (7/45) which is already ≈50% of current published data
    • low rate of upgrade is likely attributed to 11G vacuum assisted biopsy already in place. However now we have 9G vacuum assisted biopsy which will be prospectively audited.
  • Important incremental value in doing 2nd biopsy 11G VAB when 1st biopsy was US/stereo 14G CNB which led to half of the cancers being diagnosed.


  • All papillomas diagnosed on US/ stereo 14G should have repeat 12x cores 9G VAB
  • All ADH <10mm will have repeat 12x cores on 9G VAB
  • New B3 management pathway adapted from London Cancer Alliance Clinical Guidance from October 2013
    • This should lead to a lower rate of upgrade at time of surgery, thereby avoiding unnecessary and minimising open biopsy for B3 patients, while providing significant cost benefit.