Lobular Carcinoma In Situ Diagnosed By Core Needle Biopsy: When Should It Be Excised?

Abstract

Core needle biopsy is the preferred technique for evaluating breast masses and abnormal mammographic findings. The frequency of detection of noninvasive lobular lesions by core needle biopsy is increasing. Historically, the diagnosis of lobular carcinoma in situ has been considered a risk factor for the development of invasive carcinoma, and treatment has consisted of careful clinical follow-up with or without chemopreventive therapeutic agents such as tamoxifen citrate. We retrospectively reviewed core needle biopsy material with the primary diagnoses of lobular carcinoma in situ, atypical lobular hyperplasia, and lobular neoplasia in conjunction with clinical and radiographic findings to make recommendations as to when excision may be merited. We searched our database for core needle biopsy cases with lobular carcinoma in situ, atypical lobular hyperplasia, and lobular neoplasia as the primary diagnosis. Microcalcifications had been sampled with a stereotactically guided, 11 G Mammotome biopsy device, and masses had been sampled with an ultrasound guided, 18 G core needle. Glass slides were reviewed and histological parameters assessed. Mammographic findings were reviewed, and clinical information was obtained from the medical record. When available, excisional biopsy material was reviewed. The 2337 breast core needle biopsies performed from January 1995 to December 2001 included 35 (1.5%) with classic lobular carcinoma in situ (14), lobular neoplasia (4), and atypical lobular hyperplasia (17) as the primary diagnosis. Twelve of these 35 cases (34%) had histological evidence of microcalcifications directly associated with the lobular carcinoma in situ, lobular neoplasia, atypical lobular hyperplasia. Radiologic review revealed 21 calcifications, 6 ultrasonographic masses, and 8 mammographic masses and/or architectural distortions. Excisional biopsy had been performed in 17 cases (49%). In six cases diagnosed as in situ on core needle biopsy, excisional biopsy revealed invasive carcinoma. All of these patients had radiographically detectable masses. Eleven cases had excisional biopsies that showed histology similar to that of the core needle biopsies. The most important predictor of invasive carcinoma on excision was a synchronous mass lesion. Lobular carcinoma in situ involving adenosis and lobular carcinoma in situ with pagetoid spread on core needle biopsies did not show a histologically more aggressive lesion on excision and, therefore, may not require additional surgery. Histologically identified calcifications were associated with lobular lesions 34% of the time; however, their presence inside an in situ lobular lesion did not portend worse pathology on re-excision and should not be a criterion for excision. Based on these findings, we recommend excisional biopsy of lobular carcinoma in situ, atypical lobular hyperplasia or lobular neoplasia only when it is associated with a synchronous mass lesion. The increased use of screening mammography has resulted in an increasing number of image-guided breast biop...

Lobular neoplasia on core‐needle biopsy—Clinical significance

“…Overall, a review of the radiologic findings for the 16 patients who had a final diagnosis of breast carcinoma failed to reveal any consistent distinguishing features. Therefore, unlike Middleton et al, 30 we were unable to establish any criteria for ruling out follow-up excisional biopsy on the basis of initial mammographic findings.…”

“…Middleton et al 30 recently published a report on 35 patients diagnosed with LN on core biopsy. Seventeen of these patients subsequently underwent excisional biopsy.…”

Management of flat epithelial atypia on breast core biopsy may be individualized based on correlation with imaging studies

“…However, the radiology-pathology correlation data are either missing or incomplete in many studies. 4 Studies that have included radiology-pathology correlation for core biopsy cases with papillomas 22,23 and lobular neoplasia [24][25][26] tend to report lower upgrade rates and may argue against mandatory excision for these diagnoses on core biopsy. Similarly, our overall upgrade rate of 7% for cases with careful correlation is lower than the majority of published studies with 30 or more excisions (Table 4) and closer to the 9.5% reported by Bianchi et al 27 in a series of 589 cases from multiple hospitals in Italy.…”

“…In contrast, it seems prudent to offer excision to patients with a core biopsy diagnosis of flat epithelial atypia with limited sampling of the radiographic target or discordant imaging findings, similar to what has been proposed for solitary papillomas and lobular neoplasia diagnosed on core biopsy. [24][25][26] Most studies evaluating the upgrade rates of flat epithelial atypia on core biopsy have not reported the characteristics of the carcinoma upgrades identified on excision. As this study demonstrates, flat epithelial atypia is associated with other forms of low-grade atypia and low-grade estrogen receptorpositive carcinomas.…”

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.…”