One of the talks I gave at the BGICC meeting in Cairo, Egypt, is about the management of B3 lesions. B3 lesions are a heterogeneous group of lesions that we call lesion of uncertain malignant potential. So although they are mostly benign, some of them will harbour some co-existing malignancy. Traditionally, these were managed by surgical diagnostic excision, so the lesions were excised and sampled. However, the recent guidelines recommend that we manage them by what we call vacuum-assisted excision, or VAE. It’s basically a radiological method of sucking the tissue by vacuum-assisted biopsy, so obtaining a representative sample of tissue to assess, not necessarily excising the whole lesion but sampling it well to exclude any associated in situ or invasive malignancy.

We went through the UK guidelines that were published in 2018 and we still work to these guidelines. Vacuum-assisted excision is considered the gold standard for the management of the majority of B3 lesions. However, some lesions still require surgical excision, particularly if there is pathological and radiological discordance. Other lesions within this category that require surgical excision include cellular fibroepithelial lesions where phyllodes tumour is suspected, and that is to excise the lesion and examine the margins of the tissue around it; papillary lesions with atypia require excision; and a small group of miscellaneous B3 lesions such as vascular lesions, spindle cell lesions, adenoameloblastoma and so on. 

So generally we try to recommend this approach that is also very well tolerated by patients. Instead of having surgery, anaesthesia and all the dangers associated with them and all the difficulties in follow up by mammography and radiology, we recommend a very fast, about 30-minute, procedure that’s tolerated by patients and is as effective in detecting malignancy as a surgical excision. 

We also went through other international guidelines and informed colleagues that there are new guidelines in development as well that are hopefully going to be available by spring this year.