Chapters Transcript Video Series Title: Contemporary Perspectives in Breast Biopsy and B3 Lesions. Episode Title: Perspectives on B3 Lesion Specimens Beyond the Textbook brought to you by the advanced clinical education and training team at BD. Follow and subscribe wherever you get your podcast to stay up to date with the latest expert conversations in clinical practice. This podcast is on behalf of Becton Dickinson and Company. The opinions and techniques presented herein are for informational purposes only, and the decision of which technique to use in a particular interventional application should be made by the physician based on the individual facts and circumstances of the patient and previous medical experience. The participating healthcare professionals have been compensated by Becton Dickinson and company to participate in this podcast. Welcome to Beyond the Textbook, the podcast where we explore real world clinical insights that go beyond guidelines to improve patient care. Today's episode, Perspectives on B3 lesion specimens, is the 2nd installment in our series Contemporary Perspectives in Breast Biopsy and B3 lesions. In this discussion, Doctor Shakiri is joined by Doctor Sharma and Doctor Shaban to explore the diagnostic challenges, histopathologic considerations, and clinical implications of B3 lesions with a focus on multidisciplinary decision making and patient management. It is our pleasure to introduce Doctor Shakiri, Doctor Sharma, and Doctor Shaban. Hello and welcome to the BD Advanced Clinical Education and Training podcast, Perspectives on B3 lesion specimen. I'm Shadi Aminolamashekeri. I'm a professor of radiology and the division chief of breast radiology at the University of California, Davis. Uh, and I have the great pleasure to have a discussion today with Doctor Nisha Sharma, consultant radiologist and director of the breast screening program for Leeds and Wakefield. She is, uh, an internationally recognized expert in breast screening, uh, breast radiology, and AI and breast cancer screening. Also joining us is Professor Abir Shaban, a consultant pathologist based at Queen Elizabeth Hospital, Birmingham from the UK and she is Honorary Professor in Cancer and Genomic Sciences at the University of Birmingham, UK. Welcome to both of you. I had the good fortune of being in the audience when I think it was the two of you who were giving a joint lecture actually a few years ago at a conference. Um, regarding the practices of, uh, how things have changed and how you have changed things for, uh, B3 lesions and how they're handled, uh, in your practices. And so I would like to, um, start out by asking Doctor Shaban from a pathology. Standpoint, would you tell our audience what exactly defines a B3 lesion and why are these um considered lesions of uncertain malignant potential? And for US um audiences, I will just mention briefly that B3 lesions are distinct. They are not referring to BIRAD's 3 lesions, but I'll let Doctor Chaban take it from here. Yeah, thank you. So yeah, we divide breast lesions on core biopsy on the diagnostic core biopsy or diagnostic vacuum assisted biopsy into a B coding categories, starting from B1, which is normal, to B5, which is malignant. In the middle, we have a group of lesions, which we call B3 or lesions of uncertain malignant potential. They are by definition, benign lesions, but they can harbor malignancy, can be associated with malignancy, and that's why we are interested in sampling them more to make sure that we've adequately sampled and exclude in situ or invasive disease. They are also known, some of them to be associated with a long term risk of breast cancer, but this risk is not that high to justify any intervention at the moment, and they are quite heterogeneous, so some of them will, uh, by definition have atypia, something like that, um, FEA ADH or lobular neoplasia, so these are atypical by definition. But some other lesions, such as intraductive papilloma, radial scar, can harbor atopia, and that's why your pathologist would include in their report whether these lesions are associated with atopia or not, and that's something that should be there and we look for. Other lesions that belong to this category are a fibroepithelial lesion. And some miscellaneous lesions, such as mucocele-like lesion, myofibroblastomas, adenomyofibromas, and also vascular lesions. Uh, for us pathologists, they are tricky. Normally, the straightforward benign is easy, the malignant is easy. Raison ones, and they suffer from uh some inter observer variability. And these are the lesions that we would show to each other, and we will get a consensus in difficult cases. Thank you for explaining that. Doctor Sharma, from a radiologist's perspective, um, what are your thoughts on B3 lesions? Well, when you're at a multidisciplinary meeting, and often it's because you've biopsied a mammographic abnormality in the screening setting. So often it's calcifications or it may be an architectural distortion. And when the pathologist says that it's a B3, it's a heart sink. So as a radiologist, you know that it's a B3, it's benign, but you need to do further sampling. And from a surgical perspective, it's a heart sink for them as well because depending on the type of B3 lesion, they either have to take it to surgery or not. So um So B3 lesions are difficult entities. They're difficult for pathology, they're difficult for radiologists, and um and they're challenging for, for the surgeons because actually it's how do you explain to the patient. You know, when, when you have a patient and you tell them your diagnosis is benign, it's fine. When you tell them they've got a cancer, they know that they, they need treatment. But when you tell them that you've got a lesion, That may or may not turn out to be cancer, it becomes very, very difficult. So from a, an imaging perspective, it, it, it is a heart sink when you go to the multidisciplinary meeting and they tell you that we're dealing with a B3 lesion. But as I, we have tools to manage them. So we have the option of performing vacuum assisted excision. Where we can do further sampling through using a vacuum assisted biopsy needle rather than for these patients always going to surgery. Thank you. Uh, Doctor Choban, you know, when I was training, it seemed like, uh, pathology was the gold standard, and it, it felt like the pathologist has a, a golden wand to determine exactly the truth about tissues. And as we go through professionally in advance, we realize how difficult and challenging things can be. Can you tell our audience what makes B3 lesions so challenging to diagnose accurately, and how does sampling technique impact your ability as a pathologist to provide a definitive diagnosis? Yeah, for us pathologists, the more tissue we have, the better, because we can assess more features, we can, we like to assess the lesion as a whole, easier for us to have the excision and to look at the whole lesion, look at the margin and the architecture, and also the cytology of it. Because B3 lesions can harbor Ehiia, Ehiia is really difficult and difficult to get your baseline right. And I think when we all started looking at Ehiia, particularly in the context of the new pathway, and when we came to diagnose a new entity such as flat epithelial ethiia around 2010, 2011, we had a very low threshold. We anything that looked remotely, you know, worrying, we would call it atypical. And now with with confidence and we're seeing a lot, we have actually adjusted our threshold of calling anything atypical. Uh, B3 lesions as well are heterogeneous, and um we as pathologists refer to some um diagnostic help from special stains or immunists to chemistry, but the problem is it doesn't help with every B3 lesion. So we have, for example, Flat epithelial atypia, ADH, and low grade DCIS having exactly the same profile. So immunohistochemistry doesn't help us to make the diagnosis, and it is purely morphological. So we have to rely on our expertise in this. In addition, some of these lesions as well rely on the quantity of the lesions to decide whether, for example, it's ADH or DCIS, you need to see enough of the lesion, and we have, as you know, a cutoff of 2 millimeters or um two fully involved ducts to call it DCIS. The the definition changes actually in papilloma where ADH would be 3 millimeters or less. Above 3 millimeters is DCIS within a papilloma. The lesions as well can mimic other lesions, so papilloma and um um adenomyoepithelioma can look very similar, for example, and we also need to definitely classify lesions into the right category. For example, lobular neoplasia now is known to be uh comprising classical lobular, florid lobular and pleomorphic um LCIS. Each will have different implication and different management. So as pathologists, we try to do our best to get it right, and it's not always easy on a small biopsy. It really needs expertise and needs getting your confidence there and being able to see a lot, and the more you see, the more confident you become. And these are also the cases that we put in slight seminars and in conferences and discuss with each other and try to use our morphology and immunochemistry technique and anything and also our consistency. We try to assess regularly how consistent we are in the diagnosis of these lesions. Great. Thank you. I will mention for our audience, DCIS refers to ductal carcinoma in situ and ADH refers to atypical ductal hyperplasia. Um, thank you, and I know that providing um more samples is useful. And of course, as radiologists, we are always um trying to get through the procedure as accurately and providing patient safety. Um, and sometimes it's not, not so simple for us to stand there. Bring you, um, as many samples as we think would give you the easiest way to make the diagnosis. Um, any, uh, tips from you, Doctor Sharman, how to provide, um, the best samples for our pathologists so that we, uh, don't make their jobs any harder than it is? OK, I think because if we're doing vacuum assisted excision, then our aim is to take a large number of samples. And um and we want good quality samples. Now that's often dependent on the breast composition because when sometimes the breast is very fatty, the cores can be a bit friable and often if they are dense breasts, sometimes you can find that you don't get the same quality of samples because it's difficult to cut the tissue. Um, and again, with the vacuum assisted breast biopsy devices, what's really nice is that they do have different modes that we can use. So you can go into dense mode if you know that a woman has dense breast tissue to try and improve the quality of the sample. We can also, technically, if the lesion is superficial, we can use half notch where we don't need to use the full trough of the needle, but we can use half of it to be able to sample safely. But what I would say is it's very important to comment on the quality of the sampling. And we would always aim, now in the UK we have said 4 g of tissue. Mhm. Now if you're using a 7 gauge needle, approximately 300 mg per core, then you're talking about taking about 18 samples. And if they're good quality samples that would equate to about 4 g of tissue. We don't weigh the samples in our unit, but other people do weigh the tissue samples. One of the issues um is related to again the breast composition because if you have fatty tissue it won't weigh as much as a woman with dense breasts. So, um, so always aim to try and go for the bigger needle if you can, if you have access. And aim to take at least 18 cores if not more. Women are very tolerant of the sampling provided you get good local anesthesia. And again, that's really important, so to improve patient compliance, positioning is really key, so you have to make sure that the patient is comfortable. And then secondly, adequate analgesia will mean that the women will not move during the biopsy. And that therefore means that you've got the best chance of getting the samples that you need. But just sometimes, despite all your efforts, tissue composition, the course can not be the best quality. But we just need to inform the pathologist. And again, I think it's important to have that in your report so that the pathologists are aware that you have taken the number needed, but the sampling, the quality is what it is. So even if you were to repeat the sampling, you'd still end up with the same quality. So again, know your device. Know how you can make the best of the samples that you've got, understanding the breast tissue that you're sampling. Um, and that will help improve the quality of the samples. And the other thing that we do is if we are sampling calcifications, we will always separate the cores with calcifications and those without. Even though both will be analyzed by the pathologist, but that also helps. Um, in terms of the number of samples you have with calcifications and those without. So have you obtained representative sampling or not? So those are the tips that I would suggest to help improve the quality of the samples going to the pathologist. Wonderful tips. Thank you. I, that number 18 actually is very helpful for those of us starting to get into vacuum assisted excision. Thank you for that. Uh, Doctor Shaban, how would you say has, um, have things changed with the introduction of vacuum assisted biopsy and vacuum assisted excision in the way that a pathologist approaches B3 lesions? And you talked a little bit about, um, the tissue sampling sizes and numbers, but, uh, how, how does the size of the tissue sample affect your diagnostic confidence? Yeah, when we first started, obviously pathologists were a bit anxious. It's um a new technique, a new way of looking at samples, and a more difficult way of looking at it because we are now receiving the specimen piecemeal rather than intact. Um, it also highlighted the importance of communication between radiology and pathology. So we definitely rely on the imaging colleagues to tell us whether the sample is vacuum assisted biopsy for diagnosis or vacuum assisted excision. If it is VAE that's excision, there are things actually we would look for in the sample to confirm that we sampled the right area. For example, we would look for previous biopsy site, a reaction. We would look for the clip that was inserted before and see whether we can identify it or not, and we Look for the calcification, whether it's present or not, and if there is residual lesion or not. We always go back to the original biopsy and at least look up what the diagnosis was. So if we are, for example, looking for a papilloma, we would be searching for this or radial scar, we would be confirming presence or absence of residual. Um, one of the important issues of understanding what sample we're looking at is providing the B coding. So if the sample was diagnostic that, then we provide a B code. If it is the VAE, we do not provide a final B coding, because this is equivalent to a diagnostic excision for which we would not provide a B code. So that's also important for the communication. And discussion in the MDT meeting. Uh, another, um, pathological issue that has arisen after we've looked at that, and because our radiologists are really, really good and sample even very early lesions, is the complete excision of the lesion at the first biopsy. And you would come across that, it's not that common, but sometimes you would get a lesion, either calcification or a proper lesion that was completely excised in the first vap. And when you get a VAE there would be nothing. But again, we would look for Evidence of previous sampling or a clip to indicate that we have targeted the right lesion. Um, another important point for pathology as well is that when we receive the lesion piecemeal, we cannot comment on the adequacy of excision. We can only say that this is represented in the biopsy. We can say whether there is normal tissue present or not, but we cannot tell whether a lesion has been completely excised or not. And we do rely on you to assess and tell us that you're happy that you have excised the whole lesion. So we, yeah, so we came across different scenarios and and different challenges, uh, looking at VAEs compared with looking at a lesion intact. Oh, great insights. Um, Doctor Sharma, from a radiologist's standpoint, what have been the biggest challenges for integrating vacuum-assisted excision in routine practice? For example, margin assessment or just handling the, the specimens, 4 g of tissue. Um, can you tell us a little bit about that? So, yeah, I think one of the biggest challenges has been um when you adopt innovation, having historical thought processes. So with vacuum assisted excision, people were wanting to treat it like a surgical diagnostic biopsy. And it's not. So one was margin assessment, but if you're dealing with a benign lesion, margins are not assessed. Margins come to plea when you are dealing with malignancy. So, first thing is that margins are not assessed when you're dealing with a benign lesion and in particular with a B3 lesion. Secondly, people um are really focused on excision of a lesion in its entirety. But again, B3 lesions can represent mammographic abnormalities that can range in size from 2 millimeters to 5 centimeters in size. Now, when we're doing vacuum assisted excision, um, and particularly with calcifications, if we have calcifications more than 3 centimeters, we'll biopsy two separate areas. So that we get an idea of the spectrum of pathology that may be there regarding the calcifications. Now if that patient was to go for surgery because we have a B3 lesion, our surgeons would not remove all the calcifications. Because there is um they are mandated to take less than 20 g of tissue for a surgical diagnostic biopsy. And I think that's really important because remember, a woman has not been diagnosed with cancer. So why would you take lots of breast tissue? When you are not dealing with a cancer. And if you do have a cancer, they're often going to have to go back and repeat the operation to assess for margins. So the aim with a B3 lesion is one, first of all, further sampling to make sure you're not missing a coexistent cancer. And we can get the upgrade rate using vacuum assisted excision because our pathologist pathologists can diagnose ductal carcinoma in situ and invasive cancers. We are not there to entirely excise the lesion, if it's small we will, but if it's a larger lesion, what we're doing is representative sampling. And we can do that with vacuum assisted excision, and we do that with the surgical diagnostic biopsy. And margin assessments in the context of these three lesions should not be an issue. So I think when people first start out because they're anxious about a new innovation, they look at all the things that can stop them from adopting that innovation. And what they're doing is looking at historical practice. But what we've got to remember is with any new innovation, you've got to look at what is the innovation bringing to the table, what can you and cannot assess. And therefore, you develop a new set of rules as to how to manage that lesion in the context of using vacuum assisted excision. Thank you for that. I want to go back to the, to what you mentioned. So, if you have a group of calcifications that are, are 3 centimeters or more, you mentioned you would do two biopsies. So, you would do two cores. And if these were B3 lesions, would you do, Vacuum assisted excision at each of the areas that you biopsied. Yes, I see. So, so it's part of our assessment guidelines. So if you have calcifications more than 3 centimeters in size, you would biopsy in Two ends of the calcifications or you'd go for the worst looking calcifications, and if we were diagnosed, um, if they're diagnosed as being B3, we would then do vacuum assisted excision of both areas. Um, and then if you remain B3 we would discharge them back to routine screening, but if you upgrade to malignancy then they would go on to have an operation. Wonderful. OK. And on this note, actually, as pathologists, we noted that sometimes for B3 lesions with a new pathway, you get more than one biopsy. And it is good practice to use more than type shape clip for each, so you know what's what, because one might turn out to be malignant. What the other might not be. So we need really to know which area was biopsied and if we need to go back. For us and also pathologists, it's really important that we identify whether there is calcification or not, particularly if you have told us you have definitely sampled calcification. And I couldn't agree more with Nisha in the separation, of course, with and without calcifications. This is good practice and this helps the pathology team quite a lot to focus on the cores that are supposed to have radiological calcifications. So we sometimes do levels, we go deeper till we find the calcs, we polarize to look for calcium oxalate that might not be obvious, but sometimes at the end, we X-ray the whole block to see whether they are there or not, and confirm the absence or presence of calcification. If it is there, we would go through all the way to find it. So really, the communication between radiologists and pathologists is important. Wonderful. Thank you for making that point. And uh also, I'm, I'm a huge fan of using the different clips to identify different lesions for sure. Um, and, and we talked about upgrade risk, you brought that up. So, could you, Doctor Shaban, maybe explain this concept of upgrade risk for B3 lesions? What histological subtypes are most likely to be upgraded to malignancy? Yeah, so further sampling of B3 lesions can identify in situ or invasive disease in about 15 to 20% of all cases. So a recent systematic review and meta-analysis of the data available showed that the upgrade rate to in situ or invasive disease is 17%. And this means that the majority of the lesions will turn out to be benign, will not harbor malignancy, and malignancy also includes pleomorphic LCIS. So if you have lobular neoplasia, you can upgrade to PLCIS or invasive lobular carcinoma. The lesion that is more likely to be upgraded, as we know, is atypical ductal hyperplasia or ADH. In the UK we call it atypical intraductal epithelial proliferation. It means exactly the same. And the upgrade varies in the literature to up to 50%, but it's around in the systematic review, around 28%, so at least a quarter can be upgraded. This is followed by lobular neuplasia and is higher for florid and pleomorphic LCIS, which we do not actually classify as B3 lesions, we think they are actually in situ disease, but the classic lobular carcinoma in the literature varies between 0 to up to 60%. Um, and, um, the upgrade rate is usually to low grade cancer, either low grade DCIS or a low grade type or ER positive, low grade invasive cancer. Um, so this begs the question, can we actually predict which lesions or which patients will be upgraded on further, um, uh, sampling, and there are lots of factors depending on the size of the lesions, the type, whether it's screening or symptomatic. But so far the most important predictor of upgrade is the presence of Ethiopia. And when pathologists say etyia, we mean either cytological etyia on their own, so that the cells themselves look abnormal, not enough to call them malignant, but they have changes like hyperchromasia, increased size, increased nuclear cytoplasmic ratio, or a combination of cytological and architectural etyia. Architectural ethiia means that you get uh abnormal architecture such as crib reform pattern, micropapillary, papillary pattern that you shouldn't get in normal lobules. And we always compare what we see with the normal. Control in the tissue, which is the um the normal breast tissue that is present for this woman. So we compare that. So ETP remains the most important predictor of upgrade on subsequent sampling. Thank you for that. Um, I, I want to change, uh, gears a little bit and talk about, uh, with Doctor Sharma, if you could talk a little bit about the current guidelines that recommended managing B3 lesions, uh, after vacuum-assisted excision. Can you touch upon some of the differences between the UK and the European, uh, and globally, what the recommendations are? So, um, when we developed our guidelines in the UK that were published in 2018 but adopted in 2016 by the National Breast Screening Program. We implemented vacuum assisted excision, but follow up we felt we didn't have enough evidence. So women with atypia were put on annual mammographic follow-up for 5 years and then returned to routine screening, which in the UK is every 3 years. But um we have a Sloan um database in the UK where they collect cases of um atypia, so B3 lesions with atypia. And um we did a review of the data to look at the up once you had diagnosed a B3 lesion with atypia either at surgery or with vacuum assisted excision, how many of them during surveillance go on to develop breast cancer? And this study was published at the beginning of 2024 and it was a really interesting publication because what it showed was that the B3 lesions we were diagnosing now were less aggressive than the B3 lesions we were diagnosing in the early 2000s. But also that when they did develop cancers, because we have a 3 yearly screening program, we would be able to detect them at 3 years, 6 years, 9 years. And that we actually didn't need to do annual mammographic follow-up. And that was important because As Doctor Schwan had said, they confer an increased risk of developing cancer over time. So that could be over 10 to 20 years. And really, when you think about it, the annual mammographic follow-up, I think was there to make sure we hadn't missed a cancer when we did the initial vacuum assisted excision. And the data showed that we weren't missing cancers. So I think with the advances in technology with our biopsy techniques, we are accurately sampling these B3 lesions with vacuum assisted excision and therefore at year one we're not missing any cancers. So with this information that the B3 lesions we're now diagnosing are less aggressive, they're more likely to be risk factors rather than being associated with malignancy. And the fact that um that these are often small and can be detected through the can the the screening program. We updated our assessment guidelines um at the in November 2025. And now all B3 lesions with atypia will go back to routine screening. So we've stopped the annual mammographic follow-up. Now B3 lesions without atypia, we never did follow up for them, so they all were, they were always discharged or back to routine screening. And this has been a really important next step for us. Because this was an area of contention, um, and were we really doing the right follow up for these women. But the other challenge we had was collecting data. Now, if these women are being monitored through your screening program, that means you'll get robust data in terms of screen detected cancers and missed cancers. So actually what we're doing is improving the data collection going forward, improving the quality of that. So this has been um a new change in our screening program. A change that has been welcomed by all the breast screening units, and I think also welcomed by patients because how anxious it must be for them to go every year for a mammogram. And then often we would call them back, but there would be false positive recalls. But now we can do that through the breast screening program. And when we published our paper we actually um had a a panel discussion with patient advocates and experts within the breast screening program to see. Should we adopt the change of moving from annual mammographic surveillance to going to routine screening? And what they felt was that the evidence was strong enough to support this. But the caveat is, and the caveat that we say to our colleagues in the UK is this only applies to women of screening age. It does not apply to the younger population because we don't have the data. Mhm. Wow Evidence-based, innovative work to make things better for our patients and for our healthcare overall, um, really amazing. And, uh, you know, it's, it's also obvious that, uh, it takes a team approach as both of you have touched on. I, this is something I was struck by when I watched your talk, the joint talk that you both gave, uh, several years ago that I was watching. Uh, can you both, uh, maybe touch on the importance of communication between the different specialists, radiologists, pathologists, surgeons, um, in managing these cases? What does an ideal workflow look like? Yeah, I think to start this pathway, you have to have the buying in from all the team, and particularly surgeons, because you are taking basically work from surgeons to be done by the radiologist. And everywhere we actually spoke to, and we were very lucky to work together and and and work on this setup together, that our surgeons were really keen. They were keen to focus their uh Their energy and work on managing cancer patients rather than benign lesions and to make efficient use of their time and the operative theater lists as well. So first, we need all to come together and believe in that pathway. Uh, really, really helpful to improve the communication, as, as we said, we need to know, uh, are we taking one or more biopsies, where they are, are the biopsies representative or not? Did you find, did you really sample calcs or not? Are we looking at a stroma lesion or a deformity, a mass or calx, and whether the the specimen is a vacuum assisted biopsy or vacuum assisted excision. And at the heart of it, it is a multidisciplinary discussion. So we, we're not saying that we will get rid completely of the diagnostic excision. In fact, if there is still a radiological pathological discordance, even after we've done the VAE, we are still allowed after MDT discussion to go for surgical excision if we're not satisfied. So we always have this pathological radiological discussion and whether we're all happy that we've sampled adequately or not. We try to assess the amount of tissue taken as well by VAE. Is it 4 g, or is it are the number of cores enough to allow us to have a representative sample or not. So MDT discussion all the way, and um the pathway doesn't doesn't completely negate diagnostic excision when needed. And in the guide, it's always also important to have the guidelines there to follow, and based on the evidence, change the guidelines. Uh, radiologists and pathologists love their guidelines. We love something to follow and to know what we are doing. And, um, and also when you have something in the guidelines, you can actually enforce the change and support and, and acquire the, the, um, education, and the the equipment to do it if it is already embedded there in the guidelines. Right. I mean I, I would just add as well that um the communication is important because as a team if you're aligned then the information that the patient gets is consistent and that's really really important because I think sometimes one of the challenges we can have is that patients are often given different information because we do have clinician bias. And therefore dependent on who they see, they will be given an opinion and then they hear a different opinion and then they don't know which is the right opinion. Um, so therefore, as a team, if you are aligned and you and you've agreed to implement a new pathway, then what that means is whether the patient is speaking to the radiologist or the patient is speaking to the surgeon or the oncologist, the information that's flowing is the same and consistent. And that builds confidence for the patient in the clinical team. And that's why I think it's really, really important that the, the dialogues are open, they're transparent, and we have those difficult conversations so that when we're patient facing, we are aligned. And I think naturally important. Yes, so important, especially with the um eye on making things better for the patient and unifying the message. Um, and, and MDT referring to multidisciplinary team discussions, of course. Wonderful. Um, how do both of you see the future of B3 lesion management? Where do you see it going? Are there emerging techniques or molecular markers that could reduce uncertainty? I'd love to hear from both of you. Yeah, there has been um lots of attempts to try to identify which lesions can will be upgraded. Uh, so some relied on the size of the lesion, uh, and some, for example, if you have multiple foci of atyia ADH, uh, some investigators showed that those are more likely to be upgraded. Some tried to look at the tumor microenvironment, and the latest, as in radiology, we have AIs in pathology as well, and whether actually artificial intelligence can help us to diagnose these lesions. Unfortunately, this hasn't helped. In fact, the data from the literature has shown that AI in pathology is more likely to overestimate Atyia. So your pathologist will be diagnosing less than the AI because it is a tricky area and and to standardize um atyia for an AI to be trained on is also difficult. So unfortunately, it doesn't. help at the moment, and we are still relying, I mean, immunohistochemistry can can help in some, for example, lesions that are um uniformly are positive can be managed, for example, by endocrine therapy, preventive. Um, therapy. Um, if a lesion is HER2 positive, we would indicate that this is a high grade lesion. It's actually likely to be DCIS, a ductal carcinoma in situ rather than atypical intraductal proliferation. But we still rely on the good old histopathology in uh diagnosis of atyia to um predict the upgrade. I mean, what, what I would add to that, so I, I think as you said, um, I think advancements in being able to predict upgrade are not there yet but may come in the future. But I think really what what I would like to see is standardization in the management of B3 lesions across all disciplines. Because I think one of the important things that we have done by creating guidelines for B3s is that we have created standardization and pathology in terms of reporting. And we are creating standardized pathways in how to manage them so that actually if a woman were to walk into any hospital, the care that she would get would be the same. And I think that's really important. So I think we're not quite there yet. I think there still has to be work done in terms of standardizing reporting and management of B3 lesions, but for people to also recognize that these are benign entities. So we have to be careful that we minimize overtreatment. Because they are inevitable and as technology advances and we do more biopsies, we will pick up these three lesions, but let's not be overzealous in how we manage them. So that's what I would like to see going forward, but I do think that collectively if we could create a pathology, digital pathology database, an imaging database, and then have really clever data analysts and informatics and use AI, the The future we could get there by creating algorithms that can help stream out our pathways even further. So I think the future's exciting. I don't think we're there yet, but I think the key thing for me would be to standardize the current pathway and stop women from going for surgery unnecessarily. Wow, this has really been an, an illuminating conversation on how um collaboration among specialists can really be uh so successful and bring innovation ultimately for making things better for our patients and for the healthcare systems overall. Um, if you were to give one or two key messages about B3 lesions, their pathology, their management, and vacuum-assisted excision, what would it be? Um, I think we have emphasized the communication that it is a team approach, and we have all to work together, uh, and also having the pathways and clear guidance. That all teams adhere to for pathology, for imaging for the surgeons. So we are all singing from the same hymn sheet. And my add-on message to that would be that atypical ductal hyperplasia is a benign entity. We have shown evidence that vacuum assisted excision can be used to upgrade these lesions so that women can go for the right operation. And we've also had a paper published that shows that actually if you use vacuum assisted breast biopsy first line. You can reduce the upgrade rates for those patients where you are doing surgery to malignancy, so we need to get it right first time. So let's use the tools that we have to hand by doing the right biopsy initially to make a diagnosis and then using the right interventional techniques for treatment and management. Surgery is not always the answer. And in relation to ADH it is a benign entity and it can be managed with vacuum assisted excision. Wonderful. Well, Doctor Sharma, every time I listen to you, I'm motivated to go back to my practice and change something. And Doctor Shaba, now hearing from you, it's really been a pleasure, and I've learned so much from you. Um, I've really enjoyed moderating this session. I'd like to thank you both, Doctor Shaban and Doctor Sharma, for sharing your expertise and practical insights. Your perspectives have been incredibly valuable, and we truly appreciate you taking the time to join us, um, here today. I'd also like to thank our audience Audience for listening. I hope that today's conversation has provided useful takeaways that um you as the audience could apply in your own practice and that it sparked um something for you to uh continue your learning and discussions. I know it has for me. Thank you so much. Thank you to Doctor Shakiri, Doctor Sharma, and Doctor Shaban for sharing your time, expertise, and perspectives. This discussion highlights the importance of multidisciplinary collaboration in the evaluation and management of B3 lesions, bringing together radiologic, pathologic, and clinical perspectives to support informed decision making. We invite you to join us for the 3rd and final episode in the series Contemporary Perspectives in Breast Biopsy and B3 Lesion featuring Doctor Shakiri and Doctor Heather Richardson as they discuss a comprehensive approach to vacuum assisted excision guidance for clinical practice. Thanks for being part of the BD Advanced Community. This podcast is intended for educational purposes only. Follow and subscribe so you never miss an episode. For more clinical education, visit advancedEDU.BD.com. We look forward to continuing the conversation in our next episode. BD and the BD logo are trademarks of Becton Dickinson and Company or its affiliates. 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