Lobular In-Situ Neoplasia on Breast Core Needle Biopsy: Imaging Indication and Pathologic Extent Can Identify Which Patients Require Excisional Biopsy

Abstract

Women with a CNB diagnosis of LN for calcifications found on routine, normal-risk mammographic screening have a negligible risk of upgrade and may not require excisional biopsy. However, excisional biopsy should be offered to women undergoing imaging for other indications or with >4 foci of LN on CNB.

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.…”

Pathologic Upgrade Rates on Subsequent Excision When Lobular Carcinoma In Situ Is the Primary Diagnosis in the Needle Core Biopsy With Special Attention to the Radiographic Target

“…Moreover, some studies include cases containing concurrent atypical duct hyperplasia, a diagnosis that would independently lead to excisional biopsy, thus contributing to further selection bias. [14][15][16][17] Furthermore, the inherent subjectivity in rendering a morphologic diagnosis of LCIS can represent an additional variable, and many studies have used the term lobular neoplasia to encompass LCIS and ALH lesions. Finally, radiologic-pathologic correlation, a routine exercise when evaluating pathologic findings in a needle core biopsy, has varied in published reports.…”

“…Two of twenty-six cases (8%) were characterized as diffuse in their study, both of which were upgraded on excision. Rendi et al 15 reported extensive involvement of lobular neoplasia on core biopsy to correlate with the risk of pathologic upgrade on excision. Extensive lobular neoplasia was defined as greater than 4 foci of lobular neoplasia on core biopsy, and 21% (6 of 29) of the cases with extensive lobular neoplasia were upgraded on excision, whereas 2.2% (1 of 46) of nonextensive cases were subsequently upgraded.…”

“…However, in cases in which classic LCIS is identified as an incidental finding in patients undergoing routine screening, particularly if LCIS is focal in the biopsy, an argument can be made for close clinical and radiologic follow-up because studies, including the current one, have shown low pathologic upgrade rates in these patients. [15][16][17]31 In summary, finding LCIS as the most significant pathologic lesion in a needle core biopsy is uncommon. The optimal management of patients with LCIS/ALH on needle core biopsy continues to be debated.…”