Purpose The increased breast cancer risk conferred by a diagnosis of lobular carcinoma in situ (LCIS) is poorly understood. Here we review our 29-year longitudinal experience with LCIS to evaluate factors associated with breast cancer risk. Methods Patients participating in surveillance following an LCIS diagnosis are followed in a prospectively maintained database. Comparisons were made among women choosing surveillance, with or without chemoprevention, and those undergoing bilateral prophylactic mastectomies between 1980 and 2009. Results 1060 patients with LCIS without concurrent breast cancer were identified. Median age at LCIS diagnosis was 50 years (range, 27–83). 56 (5%) underwent bilateral prophylactic mastectomy; 1004 chose surveillance with (n=173) or without (n=831) chemoprevention. At a median follow-up of 81 months (6–368 months), 150 patients developed 168 breast cancers (63% ipsilateral, 25% contralateral, 12% bilateral), with no dominant histology (ductal carcinoma in situ 35%, infiltrating ductal carcinoma 29%, infiltrating lobular carcinoma 27%, other 9%). Breast cancer incidence was significantly reduced in women taking chemoprevention (10-year cumulative risk: 7% chemoprevention; 21% no chemoprevention, p<.0001). In multivariate analysis, chemoprevention was the only clinical factor associated with breast cancer risk (hazard ratio 0.27, 95% confidence interval 0.15–0.50). In a subgroup nested case-control analysis, volume of disease defined as the ratio of slides with LCIS to total number of slides reviewed was also associated with breast cancer development (p=0.008). Conclusion We observed a 2% annual incidence of breast cancer among women with LCIS. Common clinical factors used for risk prediction including age and family history were not associated with breast cancer risk. The lower breast cancer incidence in women opting for chemoprevention highlights the potential for risk reduction in this population.
Background ACOSOG Z0011 defined clinical node negativity by physical exam alone. Although axillary US with biopsy has a positive predictive value for lymph node (LN) metastases approaching 100%, it may not appropriately identify clinically node-negative women with ≥3 positive LNs (+LNs) who require ALND. We sought to identify the total number of +LNs in women presenting with cT1-2N0 breast carcinoma with a positive preoperative LN biopsy to evaluate the potential for overtreatment when ALND is performed on the basis of a positive needle biopsy in patients who otherwise meet ACOSOG Z0011 eligibility criteria. Methods Patients with cT1-2N0 breast cancer by physical exam with a positive preoperative LN biopsy were identified from a prospective institutional database. Clinicopathologic characteristics and axillary imaging results were compared between women with 1-2 total +LNs and ≥3 total +LNs. Results Between 5/2006-12/2013, 141 women with cT1-2N0 breast cancer had abnormal axillary imaging and a preoperative +LN biopsy (median patient age: 51yrs, median tumor size:2.4cm,86% ductal histology,79% ER+). 66 (47%) women had 1-2 total +LNs, 75 (53%) had ≥3 total +LNs. Women with ≥3 total +LNs had larger tumors (2.4 vs 2.2cm, p=0.03), fewer tumors with ductal histology (79% vs 94%, p=0.01), more lymphovascular invasion (80% vs 61%,p=0.01) and higher median BMI (29.2 vs 27.1,p=0.04). Having >1 abnormal LN on axillary imaging was significantly associated with having ≥3 total +LNs on final pathology (68% vs 43% p=0.003). Conclusions Axillary imaging with preoperative LN biopsy does not accurately discriminate low-versus high-volume nodal disease in clinically node-negative patients.
BackgroundCurrent breast cancer care is based on high-level evidence from randomized, controlled trials. Despite these data, there continues to be variability of breast cancer care, including overutilization of some tests and operations. To reduce overutilization, the American Board of Internal Medicine Choosing Wisely® Campaign recommends that professional organizations provide patients and providers with a list of care practices that may not be necessary. Shared decision making regarding these services is encouraged.MethodsThe Patient Safety and Quality Committee of the American Society of Breast Surgeons (ASBrS) solicited candidate measures for the Choosing Wisely® Campaign. The resulting list of “appropriateness” measures of care was ranked by a modified Delphi appropriateness methodology. The highest-ranked measures were submitted to and later approved by the ASBrS Board of Directors. They are listed below.Results(1) Don’t routinely order breast magnetic resonance imaging in new breast cancer patients. (2) Don’t routinely excise all the lymph nodes beneath the arm in patients having lumpectomy for breast cancer. (3) Don’t routinely order specialized tumor gene testing in all new breast cancer patients. (4) Don’t routinely reoperate on patients with invasive cancer if the cancer is close to the edge of the excised lumpectomy tissue. (5) Don’t routinely perform a double mastectomy in patients who have a single breast with cancer.ConclusionsThe ASBrS list for the Choosing Wisely® campaign is easily accessible to breast cancer patients online. These measures provide surgeons and their patients with a starting point for shared decision making regarding potentially unnecessary testing and operations.
Purpose The natural history of pleomorphic lobular carcinoma in situ (PLCIS) remains largely unknown. Methods A pathology database search (1995–2012) was performed to identify patients diagnosed with an LCIS variant. Patients with synchronous breast cancer and/or no evidence of pleomorphism were excluded. Original slides were re-evaluated by 3 pathologists to identify a consensus cohort of PLCIS. Borderline lesions with focal atypia were classified as LCIS with pleomorphic features (LCIS-PF). Clinical data were obtained from medical records. Results From 233 patients, we identified 32 with an LCIS variant diagnosis and no concurrent breast cancer. Following review, 16 cases were excluded due to lack of pleomorphism. The remaining 16 were classified as PLCIS (n=11) and LCIS-PF (n=5). 12/16 patients were treated with surgical excision +/− chemoprevention. Patients with a prior breast cancer history and those having mastectomy were excluded from outcome analysis. Among the remaining 7 patients with PLCIS/LCIS-PF, 4/7 (57%) developed ipsilateral breast cancer at a median follow-up of 67 months. Median age at the time of breast cancer diagnosis was 56 years old and median time from PLCIS/LCIS-PF to cancer diagnosis was 59 months (range, 45–66 months). The 4 cancers included 1 invasive lobular carcinoma (ILC), 1 microinvasive ILC, 1 invasive ductal carcinoma and 1 ductal carcinoma in situ. Conclusions We confirm that PLCIS in isolation is indeed a rare entity, further contributing to the difficulty in determining the actual risk conferred by this lesion. Long-term follow-up data on larger cohorts is needed to define standardized management and outcomes for patients with PLCIS.
The ASBrS Choosing Wisely measures that address benign breast disease management are easily accessible to patients via the internet. Consensus was reached by PSQC regarding these recommendations. These measures provide guidance for shared decision-making.
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