Follow-up Surgical Excision Is Indicated When Breast Core Needle Biopsies Show Atypical Lobular Hyperplasia or Lobular Carcinoma In Situ

Abstract

Atypical lobular hyperplasia (ALH) and lobular carcinoma in situ (LCIS) diagnosed in core needle biopsy (CNB) are generally regarded as risk indicators for developing invasive ductal or lobular carcinoma in either breast. Currently, there are no well-established guidelines for management of these patients. The most common management options are careful observation and endocrine chemoprophylaxis for high-risk patients. Previous studies had contradicting recommendations regarding follow-up surgical excision (FSE) of CNB yielding ALH or LCIS. These studies, unfortunately, have been limited by their retrospective nature, small number of patients examined, and association with other high-risk lesions. Only CNB diagnosed as pure LCIS or ALH (not associated with other high-risk lesions such as ADH, radial scar, or papilloma) were included in the study. We reviewed 33 CNB (20 ALH and 13 LCIS) with subsequent FSE from 33 patients (age range, 30-83 years; mean, 58 years). Eighteen of these patients were prospectively analyzed, where FSE was performed in an unselected fashion. All CNBs were obtained by mammotome (11-gauge, 30 cases; and 14-gauge, 3 cases). Mammography identified calcifications in 29 cases (88%) and a mass in 4 cases (12%). FSE revealed infiltrating ductal and/or lobular carcinoma in 4 of 13 LCIS (31%). FSE of 20 ALH revealed cancer in 5 cases (25%), including 4 ductal carcinoma in situ (DCIS) and 1 invasive lobular carcinoma. Seven of these nine cancers were associated with calcifications, and two presented as masses. Sampling error and underestimation of cancer (DCIS or invasive carcinoma) was associated with CNB diagnosis of LCIS or ALH in 27% of all cases. Underestimation of cancer was seen in 28% of prospectively examined patients, including 20% of ALH and 38% of LCIS. CNB associated with mass lesions or that showed histologic features of pleomorphic LCIS or extensive classic LCIS had a higher rate of cancer underestimation. Despite removal of all abnormal mammographic calcifications by CNB in 6 patients, one cancer was detected on FSE. To the best of our knowledge, this is the largest study reported to date, and the only one to include prospectively examined patients with no pre-selection bias. Our data strongly suggests that subsequent FSE is warranted in all patients with CNB diagnoses of LCIS or ALH, to exclude the presence of cancer.

Borderline breast core needle histology: predictive values for malignancy in lesions of uncertain malignant potential (B3)

“…Our PPV estimates show the highest lesion-specific risk of malignancy in association with LIN (ALH and LCIS) with a higher likelihood of malignancy for this category than reported in other series (Lee et al, 2003;Elsheikh and Silverman, 2005). The evidence on, and the management of, lobular neoplasia continues to be contradictory and controversial (Lakhani et al, 2006) and a detailed discussion of this lesion category is beyond the scope of this paper.…”

“…The evidence on, and the management of, lobular neoplasia continues to be contradictory and controversial (Lakhani et al, 2006) and a detailed discussion of this lesion category is beyond the scope of this paper. The largest published series that examined pure lobular neoplasia (based on 33 subjects) emphasised that all CNB diagnoses of ALH and LCIS warrant surgical excision because of a high risk of malignancy on excision histology (Elsheikh and Silverman, 2005). We also point out that most other series of lobular neoplasia on CNB have been based on very few subjects with many subjects not progressing to excision biopsy (Jacobs Borderline (B3) breast core needle histology N Houssami et al et al, 2002).…”

Atypical lobular hyperplasia and classic lobular carcinoma in situ in core biopsy specimens: routine excision is not necessary

“…The number of cases included in previously published studies (combining atypical lobular hyperplasia and lobular carcinoma in situ) varies from less than 10 up to 92 cases of lobular neoplasia followed by immediate excision. [22][23][24][25][26][27][28][29][30][31][32][33][34][35][36][37][38] In comparison, our study includes a relatively high number of cases (87 cases of lobular neoplasia followed by immediate excision). Another limitation in our study and others is that it is retrospective and may suffer from selection bias regarding the patients that underwent excision.…”

Invasive lobular carcinoma of the breast: MRI pathological correlation following bilateral total mastectomy

“…Our aim was indeed not to determine the prevalence of contra-lateral lesion, but rather to confirm the known sensitivity of breast MRI in ILC detection not only on biopsy or follow-up data. This selection bias could explain in part the low contralateral PPV of breast MRI for ILC detection (17%) in our study (14)(15)(16)(17)21). Furthermore, we focused solely on the detection of ILC, and not all neoplastic lesions, which further lowered the contralateral PPV, DCIS being considered as a false-positive finding.…”

“…On CNB, it can be difficult to distinguish ILC from lobular neoplasia (LN), which comprises two subtypes, namely lobular carcinoma in situ (LCIS) and atypical lobular hyperplasia (ALH). In Brem et al study, 23% of 164 lesions classified as lobular neoplasia on CNB in fact corresponded to true neoplastic lesions (DCIS or ILC) after surgical excision (15), and some authors thus recommend excision biopsy when LN is diagnosed on CNB (11,16,17).…”