Annals of Surgical Oncology

, Volume 24, Issue 12, pp 3549–3558 | Cite as

Flat Epithelial Atypia on Core Biopsy and Upgrade to Cancer: a Systematic Review and Meta-Analysis

  • Anatoliy V. Rudin
  • Tanya L. Hoskin
  • Aodhnait Fahy
  • Ann M. Farrell
  • Aziza Nassar
  • Karthik Ghosh
  • Amy C. Degnim
Breast Oncology



No consensus exists on whether flat epithelial atypia (FEA) diagnosed percutaneously should be surgically excised. A systematic review and meta-analysis of the frequency of upgrade to cancer or an atypical ductal hyperplasia (ADH) at surgical excision of FEA was performed.


Embase, MEDLINE, Scopus, and Web of Science databases from January 2003 to November 2015 were searched. The inclusion criteria required a manuscript in English with original data on FEA diagnosed percutaneously, data including the presence or absence of other concurrent high-risk lesions, and data including outcome of cancer at surgical excision. Studies were assessed for quality, and two reviewers extracted data. Random-effects meta-analysis was used to pool estimates. The impact of study-level characteristics was assessed by stratified meta-analysis and meta-regression.


The inclusion criteria was met by 32 studies. A total of 1966 core needle biopsies showed pure FEA, and 1517 (77%) showed surgical excision. The proportions of patients with upgrade to cancer varied from 0 to 42%, with an overall pooled estimate of 11.1%. Heterogeneity was observed, with the greatest impact based on whether a study included cases of FEA diagnosed before 2003. With restriction of the investigation to 16 higher-quality studies, the cancer upgrade pooled estimate was 7.5% (95% confidence interval [CI], 5.4–10.4%), and the rate of invasive cancer was 3% (95% CI 1.9–4.5%). For upgrade to ADH, data from 22 studies including 937 patients were analyzed. The proportion of patients upgraded to ADH ranged from 0 to 60%, with a pooled estimate of 17.9% overall and 18.6% among high-quality studies.


With patient management change potential for approximately 25% of patients, this analysis supports a general recommendation for surgical excision of FEA diagnosed by core biopsy.



We sincerely thank to Marilyn Churchward for assistance with manuscript preparation.

Conflict of interest

There are no conflicts of interest.

Supplementary material

10434_2017_6059_MOESM1_ESM.docx (42 kb)
Supplementary material 1 (DOCX 42 kb)


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Copyright information

© Society of Surgical Oncology 2017

Authors and Affiliations

  • Anatoliy V. Rudin
    • 1
  • Tanya L. Hoskin
    • 2
  • Aodhnait Fahy
    • 1
  • Ann M. Farrell
    • 3
  • Aziza Nassar
    • 4
  • Karthik Ghosh
    • 5
  • Amy C. Degnim
    • 1
  1. 1.Department of SurgeryMayo ClinicRochesterUSA
  2. 2.Biomedical Statistics and InformaticsMayo ClinicRochesterUSA
  3. 3.Mayo Clinic LibrariesMayo ClinicRochesterUSA
  4. 4.Laboratory Medicine and PathologyMayo ClinicJacksonvilleUSA
  5. 5.Breast Clinic, General Internal MedicineMayo ClinicRochesterUSA

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