Sakoglu N, et al. Ann Surg Treat Res. 2026 Jun;110(6):405-415. https://doi.org/10.4174/astr.2026.110.6.405

Background/Objectives: This study aimed to evaluate the diagnostic performance and clinical decision-making impact of adding digital breast tomosynthesis (DBT) to two-dimensional digital mammography (2D DM) in a 100% biopsy-proven cohort of women with dense breast parenchyma (ACR types C and D), focusing on the relationship between tumor biology and radiologic conspicuity. Methods: This retrospective study analyzed 123 women (mean age 46.7 ± 9.9 years) with ACR type C (n = 67) or D (n = 56) breast density who underwent sequential 2D DM and DBT imaging, all with definitive histopathology (malignant, n = 78; high-risk, n = 8; benign, n = 37). A single expert radiologist performed independent readings of 2D DM alone and then the combined 2D DM + DBT dataset after a 4-week washout. Outcomes included sensitivity, specificity, PPV/NPV, lesion visibility (0–5 scale), and BI-RADS upgrade rate. Results: 2D DM + DBT significantly outperformed 2D DM alone in sensitivity (97.4% vs. 69.2%; p < 0.000001) and NPV (93.1% vs. 57.1%), with AUC improving from 0.727 to 0.922 (p < 0.001). Mean lesion visibility increased from 2.94 ± 1.19 to 4.52 ± 0.78 (p < 0.0001), with the largest gains for architectural distortion (100% sensitivity) and, notably, for Grade 1 tumors (delta +1.90), which reached the highest DBT visibility of any grade. Major BI-RADS upgrades occurred in 27 cases (22.0%; upgrade PPV 88.9%). Conclusions: In this biopsy-enriched ACR C/D cohort, adding DBT to 2D DM was diagnostically superior across all metrics. The disproportionate visibility gain for Grade 1 tumors is a hypothesis-generating finding relevant to the overdiagnosis debate, not proof that DBT reduces overdiagnosis. These findings support DBT as a valuable adjunct to 2D DM in dense breasts, pending prospective, multi-reader validation in unselected populations.

Background: Sclerosing adenosis (SA) is a benign, proliferative breast lesion that frequently mimics malignancy on multimodality imaging. The appropriate clinical management of SA diagnosed via core needle biopsy (CNB) remains a highly debated topic in breast oncology. This study aimed to evaluate the clinical, imaging, and histopathological characteristics of CNB-diagnosed SA-spectrum lesions and to determine the rate of, and factors associated with, pathological upgrade at the time of surgical excision in a symptomatic cohort. Methods: This retrospective, single-center study evaluated 34 symptomatic female patients who received a CNB diagnosis of SA. Patients were assessed using targeted ultrasound (US, n = 34), digital mammography (n = 19), and/or dynamic contrast-enhanced breast MRI (n = 17). Based on CNB findings, lesions were classified as isolated SA, complex/accompanied SA, or atypical SA. Patients subsequently underwent either definitive surgical excision or long-term imaging surveillance. Upgrades were defined as the presence of a high-risk B3 lesion not identified on CNB (Level 1) or overt malignancy, such as ductal carcinoma in situ or invasive carcinoma (Level 2), at final surgical pathology. Results: Twenty-one patients (61.8%) underwent surgical excision, while thirteen (38.2%) were managed with radiological follow-up (median surveillance 16 months, range 7–84). Within the surgical cohort, 9 of 21 patients (42.9%; 95% CI: 24.5–63.5%) demonstrated an upgrade: 6 (28.6%; 95% CI: 13.8–50.0%) to a B3-level lesion and 3 (14.3%; 95% CI: 5.0–34.6%) to malignancy. Notably, two of the three malignant upgrades originated from lesions initially classified as isolated SA without atypia on CNB. Due to the limited sample size, no single clinical or imaging variable (BI-RADS category, lesion size, or age) reached statistical significance as an independent predictor of upgrade (all p > 0.10). All patients managed with imaging surveillance remained radiologically stable. Conclusions: In stark contrast to the 1–2% upgrade rates traditionally reported in asymptomatic screening populations, symptomatic SA-spectrum lesions selected for surgical excision following CNB exhibited a substantially higher overall upgrade rate (42.9%) and malignant upgrade rate (14.3%) in our cohort, albeit with wide confidence intervals reflecting the modest surgical subgroup size. The occurrence of malignant upgrades from presumed isolated SA underscores the limitations of CNB sampling and highlights the necessity of multimodality imaging–pathology concordance. Because this estimate derives exclusively from patients already selected for surgery on the basis of clinical and imaging suspicion, it reflects the upgrade risk of this pre-selected, imaging-discordant subgroup and should not be extrapolated to the baseline risk of all CNB-diagnosed SA. Accordingly, these findings caution against extending non-operative management without further scrutiny to symptomatic SA cases showing a similar degree of imaging–pathology discordance: in such cohorts, surgical excision or large-volume vacuum-assisted excision may still merit consideration despite the absence of atypia on CNB, although this observation is drawn from a small, non-randomly selected surgical subgroup and should be interpreted with corresponding caution.

Background: Lymph node metastasis (LNM) is a major determinant of prognosis in gastric adenocarcinoma. Although lymphovascular invasion (LVI) and perineural invasion (PNI) are established markers of aggressive tumor behavior, their combined association with nodal dissemination has not been systematically evaluated. This study investigated the relationship between invasive histopathologic features and LNM and developed a composite invasion score. Methods: This retrospective study included 395 patients with gastric adenocarcinoma. Clinicopathological analyses involving LNM were performed in the surgical resection cohort. A composite invasion score (0–2) was generated based on the presence of LVI and PNI. Associations with LNM, metastatic lymph node burden, and lymph node ratio (LNR) were evaluated using non-parametric tests and multivariable logistic regression. Predictive performance was assessed using receiver operating characteristic (ROC) analysis. An exploratory external transcriptomic analysis was performed using the GSE15459 dataset. Results: Both LVI and PNI were significantly associated with LNM (both p < 0.001). The composite invasion score showed a stepwise association with nodal dissemination, with median metastatic lymph node counts increasing from 0 in score-0 tumors to 3.5 in score-1 and 9 in score-2 tumors (p < 0.001). After adjustment for pathological T stage, histological grade, Lauren classification, age, and tumor location, the composite invasion score remained an independent predictor of LNM (OR = 4.53, 95% CI: 1.81–13.00, p = 0.002). LNR also increased significantly across score categories (p < 0.001). The composite invasion score demonstrated good discriminatory performance for LNM (AUC = 0.848, 95% CI: 0.773–0.923). The exploratory transcriptomic analysis demonstrated significant upregulation of MMP11, MMP14, and FAP in advanced-stage tumors, consistent with increased extracellular matrix remodeling and stromal activation. Conclusions: A simple composite invasion score integrating LVI and PNI is independently associated with lymph node metastasis and metastatic burden in gastric adenocarcinoma. The accompanying exploratory transcriptomic analysis provides biological context for these clinicopathological findings by demonstrating stage-associated extracellular matrix remodeling rather than direct molecular validation of the proposed score. These findings support the potential utility of the composite invasion score as a postoperative pathology-derived risk stratification tool.

Background: Collision tumors combining basal cell carcinoma (BCC) and melanoma are exceptionally rare, and their distinction from melanoma colonization remains controversial. Case Presentation: A 68-year-old man presented with a persistent ulcer on the lower lip, initially believed to represent BCC. Wedge resection revealed a 2.2 cm ulcerated lesion composed of BCC with malignant melanocyte colonization. Immunohistochemical analysis confirmed the biphasic nature: the melanocytic component was positive for S100, Melan-A, SOX10, and PRAME (with p16 loss), and the epithelial component was positive for p40 and Bcl-2. The melanoma measured 7.5 mm in Breslow thickness (pT4b) with ulceration and perineural invasion, but no lymphovascular involvement. Margins were negative. A sentinel lymph node biopsy was recommended but was declined by the patient. Conclusion: This case illustrates the diagnostic complexity and clinical effect of BCC–melanoma collision/colonization tumors. Prognosis is dictated by the melanoma component, underscoring the need for meticulous histopathologic evaluation and immunohistochemistry in guiding patient management.