Tomosynthesis-Guided Vacuum-Assisted Excision of B3 Breast Lesions: Reducing Overtreatment Without Compromising Safety.

OBJECTIVE

Breast lesions of uncertain malignant potential (B3) pose a diagnostic and management challenge. Surgical excision (SE) has traditionally been the standard for definitive diagnosis, but it may represent overtreatment. Percutaneous vacuum-assisted excision (VAE) offers a minimally invasive alternative. This study aimed to evaluate the safety and efficacy of VAE compared with SE for the management of B3 breast lesions, with the aim of reducing overtreatment.

MATERIALS AND

METHODS

This retrospective single-center study included 64 patients with histologically confirmed B3 lesions diagnosed by tomosynthesis-guided vacuum-assisted breast biopsy between January 2018 and January 2024. Patients were managed by SE, VAE, or imaging follow-up, based on multidisciplinary team recommendations. Imaging characteristics, histopathology, upgrade rates, and follow-up outcomes were analyzed.

RESULTS

Most lesions presented as microcalcifications (92%). The most common histological subtypes were atypical intraductal epithelial proliferation (37.5%) and lobular neoplasia (25%). SE was performed in 26 patients (40%), VAE in 22 (34%), and 16 (25%) underwent follow-up. Malignant upgrades occurred in 8 of 26 SE-treated lesions (30.8%), predominantly atypical intraductal epithelial proliferation, while no upgrades were observed in the VAE group (p = 0.007). Mean follow-up was longer for SE (42 months) than VAE (21 months, p = 0.036). One SE patient developed invasive carcinoma at 48 months; no malignant progression occurred after VAE.

CONCLUSION

VAE is a safe, minimally invasive and effective alternative to SE for carefully selected B3 lesions, particularly those without atypia and with imaging-pathology concordance, potentially reducing overtreatment. Multidisciplinary evaluation remains essential.