Upgrade Rates of Variant Lobular Carcinoma In Situ Compared to Classic Lobular Carcinoma In Situ Diagnosed in Core Needle Biopsies: A 10-Year Single Institution Retrospective Study

The primary aim of this study was to determine the upgrade rates of variant lobular carcinoma in situ (V-LCIS, ie, combined florid [F-LCIS] and pleomorphic [P-LCIS]) compared with classic LCIS (C-LCIS) when diagnosed on core needle biopsy (CNB). The secondary goal was to determine the rate of progression/development of invasive carcinoma on long-term follow-up after primary excision. After institutional review board approval, our institutional pathology database was searched for patients with "pure" LCIS diagnosed on CNB who underwent subsequent excision. Radiologic findings were reviewed, radiologic-pathologic (rad-path) correlation was performed, and follow-up patient outcome data were obtained. One hundred twenty cases of LCIS were identified on CNB (C-LCIS = 97, F-LCIS = 18, and P-LCIS = 5). Overall upgrade rates after excision for C-LCIS, F-LCIS, and P-LCIS were 14% (14/97), 44% (8/18), and 40% (2/5), respectively. Of the total cases, 79 (66%) were deemed rad-path concordant. Of these, the upgrade rate after excision for C-LCIS, F-LCIS, and P-LCIS was 7.5% (5 of 66), 40% (4 of 10), and 0% (0 of 3), respectively. The overall upgrade rate for V-LCIS was higher than for C-LCIS (P = .004), even for the cases deemed rad-path concordant (P value: .036). Most upgraded cases (23 of 24) showed pT1a disease or lower. With an average follow-up of 83 months, invasive carcinoma in the ipsilateral breast was identified in 8/120 (7%) cases. Six patients had died: 2 of (contralateral) breast cancer and 4 of other causes. Because of a high upgrade rate, V-LCIS diagnosed on CNB should always be excised. The upgrade rate for C-LCIS (even when rad-path concordant) is higher than reported in many other studies. Rad-path concordance read, surgical consultation, and individualized decision making are recommended for C-LCIS cases. The risk of developing invasive carcinoma after LCIS diagnosis is small (7% with ∼7-year follow-up), but active surveillance is required to diagnose early-stage disease.

Imaging Spectrum of Lobular Carcinoma In Situ and Correlation with Pathology Findings

Background  Lobular carcinoma in situ (LCIS) is a noninvasive neoplasm that is known to have an increased relative risk for developing subsequent invasive breast carcinoma. Pure LCIS is usually an incidental finding on histopathological examination (HPE) of tissue samples. However, in the recent years, there has been an increasing trend seen in the diagnosis of LCIS.

Purpose  This article aims to bring out the spectrum of appearances on breast imaging in confirmed cases of pure LCIS on HPE and immunohistochemical.

Materials and Methods  Cases that were confirmed as pure LCIS on HPE from core or excision biopsy were retrospectively analyzed for abnormalities on breast imaging. Digital breast tomosynthesis mammography was performed with high-resolution ultrasound with elastography for all cases. Magnetic resonance imaging (MRI) was performed in cases wherever indicated, with dynamic postcontrast imaging after injecting intravenous gadolinium.

Conclusion  LCIS is recognized as an intermediate risk factor for the development of breast cancer. Pure LCIS has varied histology and imaging patterns on mammography, high-resolution ultrasound, and MRI. It is important to recognize the imaging appearances of these lesions to enable the radiologist to detect LCIS early for proper management.

Management of Lobular Neoplasia Found on Core Needle Biopsy Performed for Calcifications Using Precise Radiologic-Pathologic Correlation

OBJECTIVE. The purpose of our study was to evaluate the upgrade rate of calcified lobular neoplasia (LN) versus incidental noncalcified classic LN found on core needle biopsy performed for the evaluation of suspicious calcifications. MATERIALS AND METHODS. This retrospective study included 390 consecutive image-guided breast core needle biopsies with microcalcifications as the target that were performed between December 2009 and July 2017. In 81 of the 390 core biopsies, the highest-risk lesion was LN that then underwent either excision or imaging follow-up. Core biopsy results were compared with excision and imaging follow-up findings. An upgrade of LN was defined as ductal carcinoma in situ or invasive ductal or lobular carcinoma. RESULTS. Of 81 LN diagnosed on core biopsy performed for calcifications, 16 had calcifications within the LN. Fifteen of these 16 cases underwent surgical excision, and three (3/15, 20.0%) were upgraded on excision. Of the 64 core biopsies showing incidental noncalcified LN with benign concordant entities containing calcifications, 42 underwent surgical excision, and one LN (1/42, 2.4%) was upgraded. Twenty-three total lesions (one calcified LN and 22 noncalcified LN) were followed with imaging rather than excision. No cancers were detected among the follow-up group. One case was deemed to have discordant findings on radiologic-pathologic review and was sent for excision, which showed invasive cancer with tubulolobular and lobular features. CONCLUSION. Women undergoing stereotactic core needle biopsy for calcifications revealing noncalcified incidental classic LN and a benign concordant entity that could explain the presence of the target calcifications have a low risk of upgrade and may be followed with imaging. Surgical excision should be offered to women who have LN with calcifications.

Contrast-Enhanced Digital Mammography Screening for Intermediate-Risk Women With a History of Lobular Neoplasia

OBJECTIVE. The objective of this study was to assess to the role of contrast-enhanced digital mammography (CEDM) as a screening tool in women at intermediate risk for developing breast cancer due to a personal history of lobular neoplasia without additional risk factors. MATERIALS AND METHODS. In this institutional review board-approved, observational, retrospective study, we reviewed our radiology department database to identify patients with a personal history of breast biopsy yielding lobular neoplasia who underwent screening CEDM at our institution between December 2012 and February 2019. A total of 132 women who underwent 306 CEDM examinations were included. All CEDM examinations were interpreted by dedicated breast imaging radiologists in conjunction with a review of the patient's clinical history and available prior breast imaging. In statistical analysis, sensitivity, specificity, NPV, positive likelihood ratio, and accuracy of CEDM in detecting cancer were determined, with pathology or 12-month imaging follow-up serving as the reference standard. RESULTS. CEDM detected cancer in six patients and showed an overall sensitivity of 100%, specificity of 88% (95% CI, 84-92%), NPV of 100%, and accuracy of 88% (95% CI, 84-92%). The positive likelihood ratio of 8.33 suggested that CEDM findings are 8.3 times more likely to be positive in an individual with breast cancer when compared with an individual without the disease. CONCLUSION. CEDM shows promise as a breast cancer screening examination in patients with a personal history of lobular neoplasia. Continued investigation with a larger patient population is needed to determine the true sensitivity and positive predictive value of CEDM for these patients.

Impact of lobular carcinoma in situ on local recurrence in breast cancer treated with breast conservation therapy: a systematic review and meta-analysis

BACKGROUND

Lobular carcinoma in situ (LCIS) is a known risk factor for breast cancer of unclear significance when detected in association with invasive carcinoma. This meta-analysis aims to determine the impact of LCIS on local recurrence risk for individuals with breast cancer treated with breast conservation therapy to help guide appropriate management strategies.

METHODS

We identified relevant studies from five electronic databases. Studies were deemed suitable for inclusion where they compared patients with invasive breast cancer and concurrent LCIS to those with breast cancer alone, all patients underwent breast conservation therapy (lumpectomy with adjuvant radiation therapy) and local recurrence was evaluated. Recurrence data were pooled by use of a random-effects model.

RESULTS

From 1488 citations screened by our search, nine studies were deemed suitable for inclusion. These studies comprised 990 cases and 12 870 controls. Median follow-up time was 104 months. There was a significantly increased risk of overall local recurrence of breast cancer for individuals with LCIS in association with breast cancer following breast conservation therapy (pooled odds ratio (pOR) 1.73; 95% confidence interval (CI) 1.10-2.71; P = 0.018). The risk of local recurrence was not significantly increased at 5 years (pOR 1.00; 95% CI 0.49-2.04; P = 0.995) and 10 years (pOR 1.52; 95% CI 0.72-3.23; P = 0.275).

CONCLUSION

Individuals with LCIS in association with invasive breast cancer have an increased risk of local recurrence following breast conservation therapy. This supports consideration of increased medical surveillance and exploration of further risk reduction strategies for such patients.

Classical Lobular Carcinoma In Situ Arising From an Intraductal Papilloma of the Breast: A Case Report

Intraductal papilloma of the breast is a benign, mass-forming, proliferative lesion with a papillary architecture confined within a duct. Lobular neoplasia can rarely arise from an intraductal papilloma of the breast. In this article, we report the morphologic features of a rare case of classical LCIS (lobular carcinoma in situ) arising from an intraductal papilloma in a 76-year-old woman. The monomorphic dyscohesive cells were present between the myoepithelial and luminal epithelial layer in the periphery of the papilloma. These cells partially obliterated the spaces between the papillae forming solid sheets. The monomorphic dyscohesive cells showed lack of E-cadherin expression and uniform staining for estrogen receptor. We review the histologic differential diagnosis and stress the importance of correct classification to ensure optimal care for patients. We also propose a new criterion for the distinction of lobular neoplasia within a papilloma.

Lobular intraepithelial neoplasia: Outcomes and optimal management

INTRODUCTION

Lobular neoplasia is a term encompassing both atypical lobular hyperplasia and lobular carcinoma in situ. These pathological findings are of uncertain malignant potential and predispose to a higher lifetime risk of breast cancer. Debate surrounds the management of such lesions, with the rationale for diagnostic excision based on the possibility of upgrading to malignancy. In this study, we report the upgrade rate of these lesions and risk of subsequent development of breast cancer.

METHODS

This is a retrospective review of a prospectively maintained data base of all biopsies of breast screening-detected abnormalities in a single Irish breast-screening unit. We included all patients with lobular neoplasia on core needle biopsy who underwent diagnostic excision from 2005 to 2012. We excluded those who had concurrent high-risk lesions on biopsy. End points included upgrade rate and subsequent diagnosis of malignancy on follow-up.

RESULTS

During the study period, 66 patients met criteria for inclusion, with a mean age of 53.74 years. Upgrade rate following excision was 13.64% (n = 9/66). Of those not upgraded, 7.02% (n = 4/57) were subsequently diagnosed with malignancy. Median time to diagnosis was 59.61 months (range = 10.5-124.4).

CONCLUSION

There is a significant rate of upgrade following diagnostic excision of lobular neoplasia, supporting the practice of diagnostic excision. There is an increased lifetime risk of breast cancer for women with a diagnosis of lobular neoplasia, with many of these cancers occurring outside the standard five-year monitoring period, suggesting a potential benefit in extending surveillance.

Longitudinal study of breast cancer risk markers

Atypical hyperplasia (AH) and lobular carcinoma in situ (LCIS) are markers for an increased risk of breast cancer, yet outcomes for these diagnoses are not well-documented. In this study, all breast biopsies performed for radiologic abnormalities over a 10-year period were reviewed. Patients with AH or LCIS were followed for an additional 10 years to assess subsequent rates of cancer diagnosis. Long-term follow-up showed that 25 (7.8%) patients with AH and 5 patients with LCIS (5.7%) developed breast cancer over the follow-up period, a lower rate of breast cancer development than predicted by risk models.

Risk for Upgrade to Malignancy After Breast Core Needle Biopsy Diagnosis of Lobular Neoplasia: A Systematic Review and Meta-Analysis

PURPOSE

Lobular neoplasia (LN) detected on breast core needle biopsy is frequently managed with surgical excision because of concern for undersampled malignancy. The authors performed a systematic review and meta-analysis to estimate the risk for upgrade to malignancy in the setting of imaging-concordant classic LN diagnosed on core biopsy.

METHODS

PubMed and Embase were searched for original articles published from 1998 to 2020 that reported rates of upgrade to malignancy for classic LN, including atypical lobular hyperplasia (ALH) and classic lobular carcinoma in situ (LCIS). Two reviewers extracted study data and assessed the following quality criteria: exclusion of variant LCIS, exclusion of imaging-discordant lesions, and outcome reporting for ≥70% of lesions. For studies meeting all criteria, pooled risks for upgrade to any malignancy (invasive carcinoma or ductal carcinoma in situ) and invasive malignancy for all LN, ALH, and LCIS were estimated using random-effects models.

RESULTS

For 65 full-text articles included in the review, the risk for upgrade to any malignancy ranged from 0% to 45%. Among the 16 studies that met all quality criteria for the meta-analysis, pooled risks for upgrade to any malignancy were 3.1% (95% confidence interval [CI], 1.8%-5.2%) for all LN, 2.5% (95% CI, 1.6%-3.9%) for ALH, and 5.8% (95% CI, 2.9%-11.3%) for LCIS. Risks for upgrade to invasive malignancy were 1.3% (95% CI, 0.7%-2.4%) for all LN, 0.4% (95% CI, 0.0%-4.2%) for ALH, and 3.5% (95% CI, 2.0%-5.9%) for LCIS.

CONCLUSIONS

The risk for upgrade to malignancy for LN found on breast biopsy is low. Imaging surveillance can likely be offered as an alternative to surgical management for LN, particularly for ALH.

Breast Atypical Apocrine Adenosis: A Case Report and Literature Review

Atypical apocrine adenosis (AAA) is a benign lesion of the breast that is identified more frequently today than in the past when it was considered a rare diagnosis and commonly misdiagnosed as other malignant lesions of the breast. AAA is defined as the presence of apocrine cytology in a recognisable lobular unit associated with sclerosing adenosis. We present a case of an incidental finding of AAA and discuss diagnostic challenges and their implications on clinical management.

Atypical Lesions of the Breast and Lobular Carcinoma in Situ in Pregnancy - Surgeons' Practice

Objective

Approach to precancerous and high-risk breast lesions occurring in pregnancy has received little attention in the literature. We carried out a study to investigate the practice of surgeons in the management of these cases.

Materials and Methods

A short survey was sent to surgeons, including a multiple-choice questionnaire about their practice for atypical hyperplasia or lobular carcinoma in situ presenting in each trimester of pregnancy or at time of breastfeeding. Answer options included observation, immediate vacuum biopsy, immediate surgery, surgery in next trimester, surgery after delivery, and surgery after end of breastfeeding; based on the time of presentation.

Results

Out of the 671 practitioners invited, 97(14.5 %) responded to the survey. Participants were from 23 countries. Answers showed that management of gestational Atypical Ductal Hyperplasia (ADH) and Lobular Neoplasia (LN) was readily postponed by surgeons in favor of fetus safety while being cautious about risks of conservative management alone.

Conclusion

Various methods of treatment are selected by surgeons for managing high-risk breast lesions during pregnancy. In the absence of relevant literature, decision making in a multidisciplinary team would be the best approach in these cases.

Atypical Ductal Hyperplasia and Lobular Neoplasia: Update and Easing of Guidelines

OBJECTIVE. Atypical ductal hyperplasia (ADH), atypical lobular hyperplasia (ALH), and lobular carcinoma in situ (LCIS) are among high-risk lesions that have been previously recommended for surgical excision when diagnosed on core needle biopsy. Recent studies have examined whether imaging surveillance is a reasonable alternative to surgical management for these lesions. This article synthesizes the evidence regarding management of atypical hyperplasia and LCIS diagnosed on core needle biopsy and clinical implications of these diagnoses on future breast cancer risk as well as highlights areas of further research needed to improve practice guidelines for these high-risk lesions. CONCLUSION. Although surgical excision is still recommended after diagnosis of ADH on core needle biopsy, in specific circumstances ALH and LCIS can safely be managed by imaging surveillance.

Breast lesions with atypia in percutaneous biopsies, managed with surgery in the last 10 years

Introduction

The optimal management of breast lesions with atypia (BLA), detected in percutaneous biopsies after screening mammograms, is a controversial issue. The aim of this paper is to compare histological diagnosis by percutaneous biopsy with the results of the surgical biopsy of these lesions and to analyse the changes to clinical approach this would imply.

Method

A retrospective study was carried out on patients operated on between June 2007 and June 2017 with a diagnosis of BLA. One hundred and forty-seven patients were identified with a pre-operative diagnosis of flat epithelial atypia (FEA), atypical ductal hyperplasia (ADH), atypical lobular hyperplasia, lobular carcinoma in situ and other atypia.

Results

The average age at diagnosis of BLAs was 52 ± 9.4 years. Radiologically, the lesions presented as microcalcifications in 79%, nodules in 15.6% and other lesions 5.4%. 73.5% of these were biopsied by means of digital stereotaxis. All of the patients analysed underwent a partial mastectomy. Changes in a biologically high-risk lesion were observed in 26.5% of the surgical specimens, of which 75.5% corresponded with ADH and FEA. In the percutaneous biopsies consistent with ADH (40.1%), ductal carcinoma was discovered in 6.8% (5.1% in situ and 1.7% invasive), which implied specific, multi-disciplinary management. Of the FEAs, 84.8% required a second treatment (surgery and/or hormone therapy ± radiotherapy, depending on whether it concerned FEA 59.6%, ADH 21.2% or ductal carcinoma in situ 3.8%).

Conclusion

These data show the clinical relevance in the diagnosis of ADH and FEA in percutaneous biopsies. For the diagnosis of FEA in particular, the associated risk of biologically high-risk lesions and ductal carcinoma is made evident.

Malignant Epithelial Transformation in Phyllodes Tumor: A Population-Based Case Series

Background Phyllodes tumor (PT) of the breast is an uncommon fibroepithelial neoplasm. Malignant epithelial transformation in PT is rare. This study reports clinicopathologic characteristics and outcomes of patients with malignant epithelial transformation in PT. Methods From an institutional database of 183 patients with newly diagnosed PT referred to a Canadian provincial cancer institution between 1999 and 2014, 11 cases of PT with concomitant in situ or invasive carcinoma were identified. Descriptive analysis was performed to document the characteristics, treatment and outcomes of this cohort. Results Prevalence of malignant epithelial transformation in PT was 6.0%. Median (range) age was 54 (35-75) years. Types of carcinoma were ductal carcinoma in situ (DCIS) (n = 6), lobular carcinoma in situ (n = 4), and invasive ductal carcinoma (IDC) (n = 1). Median PT size was 5 (1-15) cm. Three PTs were classified as benign (27%), five as borderline (45%), and three as malignant (27%). Mastectomy was performed in six (55%) and breast conserving surgery in five (45%) patients. Hormonal therapy was used in two cases: one with a 1 cm, grade 2 DCIS, and one with an 11 cm, grade 1 IDC, the latter also receiving radiotherapy. Mean follow-up duration was 54 (6-175) months. None of the cases showed any evidence of disease after treatment at the time of their last follow-up. Conclusion This case series showed a higher prevalence of malignant epithelial transformation in PT than reported in previous literature. Outcomes were favourable despite the presence of either in situ or invasive carcinoma within PT.

Treatment and survival outcomes of lobular carcinoma in situ of the breast: a SEER population based study

Lobular carcinoma in situ (LCIS) represents 5.3% of in situ specimens, and is thought to carry a low risk for developing to the invasive lobular breast cancer (ILC). There is still no standard care approach for patients with LCIS. We aimed to define the impacts of surgical and radiation intervention on survival outcomes of LCIS. LCIS cases from 2004 to 2013 of the recent Surveillance, Epidemiology, and End Results (SEER) database were analyzed. Clinicopathologic features were analyzed in 16002 patients between 2004 and 2013. Treatment modalities included no surgery (NS), lumpectomy alone (LA), lumpectomy with radiation treatment (LRT), mastectomy alone (MA) and mastectomy with radiation treatment (MRT). The overall survival (OS) was calculated by the Kaplan-Meier method. Univariate and multivariate analyses were performed using the variables of treatment, race, hormone receptor status, grade and age. Among 16002 patients, median follow-up was 54 months. Patients treated with LA had superior OS for NS (P = 0.001), MA (P < 0.001) and MRT P = 0.018). LRT only had superior OS for MRT (P = 0.009). There was no statistically significance between LA and LRT (P = 0.317). Improved OS was also correlated with younger age (P < 0.001), progesterone receptor positive (P = 0.001). Black patients had the worst OS (P < 0.001). There was no obvious survival difference among grade groups (P = 0.536). The LCIS patients treated with LA or LRT had better survival comparing with other groups. Considering the medical expense and the risk of radiotherapy, LA may be the most appropriate therapy for patients with LCIS.

Carcinoma In Situ Involving Sclerosing Adenosis: Seeking the Salient Histological Characteristics to Prevent Overdiagnosis

Ductal or lobular carcinoma in situ (DCIS/LCIS) can rarely arise from sclerosing adenosis (SA). The combination of cytologically malignant cells and the infiltrative growth pattern may make it challenging to distinguish it from an invasive carcinoma. The authors reviewed 50 consecutive cases of CIS involving SA to seek the salient histologic characteristics in order to prevent overdiagnosis. The features commonly seen with CIS were the lobular configuration at low magnification (94%), uninvolved SA in neighboring tissue (84%), at least focally identifiable myoepithelial cells on H&E-stained sections (76%), separate foci of unequivocal CIS (58%), associated microcalcifications (54%), and hyaline basement membrane surrounding tumor cell nests (48%). The group of DCIS with high nuclear grade showed a tendency to occupy the entire lobule of SA, whereas those with non-high grade were more often partially involving the affected lobule. The presence of adjacent separate foci of CIS was more closely related to the DCIS lesions when compared to those of LCIS. The finding of an SA lobule entirely involved by CIS was signifi-cantly correlated with the presence of an invasive carcinoma; this should thus strongly prompt the pathologist to search for other evidence of invasion. Awareness of these features is an additional, useful tool for reaching a proper diagnosis.

Breast Cancer-Major changes in the American Joint Committee on Cancer eighth edition cancer staging manual

Answer questions and earn CME/CNE The revision of the eighth edition of the primary tumor, lymph node, and metastasis (TNM) classification of the American Joint Commission of Cancer (AJCC) for breast cancer was determined by a multidisciplinary team of breast cancer experts. The panel recognized the need to incorporate biologic factors, such as tumor grade, proliferation rate, estrogen and progesterone receptor expression, human epidermal growth factor 2 (HER2) expression, and gene expression prognostic panels into the staging system. AJCC levels of evidence and guidelines for all tumor types were followed as much as possible. The panel felt that, to maintain worldwide value, the tumor staging system should remain based on TNM anatomic factors. However, the recognition of the prognostic influence of grade, hormone receptor expression, and HER2 amplification mandated their inclusion into the staging system. The value of commercially available, gene-based assays was acknowledged and prognostic input added. Tumor biomarkers and low Oncotype DX recurrence scores can alter prognosis and stage. These updates are expected to provide additional precision and flexibility to the staging system and were based on the extent of published information and analysis of large, as yet unpublished databases. The eighth edition of the AJCC TNM staging system, thus, provides a flexible platform for prognostic classification based on traditional anatomic factors, which can be modified and enhanced using patient biomarkers and multifactorial prognostic panel data. The eighth edition remains the worldwide basis for breast cancer staging and will incorporate future online updates to remain timely and relevant. CA Cancer J Clin 2017;67:290-303. © 2017 American Cancer Society.

Lobular carcinoma in situ of the breast - correlation between minimally invasive biopsy and final pathology

INTRODUCTION

Lobular carcinoma in situ (LCIS) is regarded as a non-obligate precursor of invasive breast cancer (IBC). Hence, the optimal management of LCIS found on minimally invasive breast biopsy remains a subject of debate. The aim of this study was to evaluate the correlation of biopsy findings with postoperative histology and to identify risk factors for upstaging to IBC.

MATERIAL AND METHODS

Twenty-seven patients with pure LCIS diagnosed on image-guided biopsy (vacuum-assisted or core-needle) underwent subsequent surgery. Clinical, radiological and histological features were compared to the final pathology after surgical excision.

RESULTS

Median age of patients was 56 years while median size of LCIS was 15 mm. Final examination demonstrated IBC foci in 29.6% of lesions. Upstaged patients were younger and had larger lesions but without statistical significance (p = 0.07 and p = 0.09, respectively). Palpable tumours (p = 0.0004), BIRADS 5 lesions (p = 0.0001), masses (p = 0.016) and pleomorphic LCIS (p = 0.0001) had a significantly increased rate of upstaging. Guidance of the procedure (ultrasound vs. stereotactic) was significantly associated with the upstaging risk (p = 0.016), while the importance of the biopsy technique (core-needle vs. vacuum-assisted) was not confirmed (p = 0.37). After excluding pleomorphic LCIS and mass-forming classic LCIS, there was no risk of upstaging for lesions with BIRADS 4 mammographic abnormalities.

CONCLUSIONS

Pleomorphic histology, mass formation and BIRADS 5 category reflect more aggressive behaviour of LCIS and identify patients who need subsequent surgery. For other patients, close follow-up could be a safe alternative.

Pleomorphic lobular carcinoma in situ: Current evidence and a systemic review

Pleomorphic lobular carcinoma in situ (PLCIS) has only recently been identified as a distinct pathological entity within classic lobular carcinoma in situ (CLCIS). As such, there is currently no consensus among clinicians regarding the optimal treatment of this disease. The present study determined the risk of concomitant invasive disease and ductal carcinoma in situ (DCIS) if PLCIS is observed on core needle biopsy (CNB) and collated the evidence regarding the risk of recurrence in relation to surgical margins and adjuvant therapy. In addition, the pertinent literature available through MedLine, PubMed, the WHO Clinical Trials Registry Platform and Google Scholar using appropriate keywords was reviewed. The pooled results of studies in the literature demonstrated a concomitant presence of invasive disease of 40%, and 15% for DCIS. The studies that examined recurrence rates indicated that the risk is reduced with ample resection margins (>2 mm) and adjuvant radiotherapy. However, recent studies raise concerns regarding breast conservation when pursuing clear margins. No level 1 evidence from prospective studies, randomized controlled trials (RCTs), or meta-analyses based on such RCTs was identified. This is a clinical issue that warrants investigation in appropriately powered well designed prospective studies for a satisfactory resolution of all concerns.

Core Breast Biopsies Showing Lobular Carcinoma In Situ Should Be Excised and Surveillance Is Reasonable for Atypical Lobular Hyperplasia

OBJECTIVE

The purpose of this article is to determine the upgrade rate to ductal carcinoma in situ (DCIS) or invasive carcinoma at excision at the same site after percutaneous breast biopsy findings of atypical lobular hyperplasia (ALH) or lobular carcinoma in situ (LCIS) using current imaging and strict pathologic criteria.

MATERIALS AND METHODS

From January 2006 through September 2013, 32,960 breast core biopsies were performed; 1084 (3.3%) core biopsies found ALH or classic LCIS. For 447 lesions in 433 women, this was the only high-risk lesion at that site, with no ipsilateral malignancy, and results of excision were available.

RESULTS

Among the 447 lesions, 22 (4.9%) were malignant at excision, including 10 invasive carcinomas (two grade 2 and eight grade 1; all node negative) and 12 DCIS. The upgrade rate of LCIS was 9.3% (10/108; 95% CI, 5.1-16.2%) and that of ALH was 3.5% (12/339; 95% CI, 2.0-6.1%; p = 0.02). After excluding five cases with radiologic-pathologic discordance and reclassifying one core from ALH to LCIS at review, the upgrade rate for LCIS remained higher (8.4%; 9/107; 95% CI, 4.5-15.2%) than that for ALH (2.4%; 8/335; 95% CI, 1.2-4.6%; p = 0.01).

CONCLUSION

Excision is recommended for LCIS on core biopsy because of its 8.4-9.3% upgrade rate. Excluding discordant cases, patients with other high-risk lesions or concurrent malignancy, the risk of upgrade of ALH was 2.4%. Surveillance at 6, 12, and 24 months can be performed in lieu of excision because a short delay in diagnosis of the few malignancies is not expected to cause harm.

Atypical epithelial hyperplasia of the breast: state of the art

INTRODUCTION

Atypical epithelial hyperplasia (AEH) of the breast is considered benign histological lesions with breast cancer risk. This review focuses on clinical signification and management of AEH that remains controversial.

AREAS COVERED

A review of published studies was performed using medline database. In this review, we fully describe the current evidence available. In particular, we describe 1) data from immunohistochemistry and molecular studies that suggest AEH is a precursor of breast cancer; 2) epidemiological studies demonstrate low rate of breast cancer in women with AEH; 3) surgical excision is necessary after diagnosis of AEH, such as lobular carcinoma in situ or atypical ductal hyperplasia, on core needle biopsy; 4) although current recommendations are evolving to fewer (if not no) excisions for flat epithelial with atypia and classic lobular neoplasia found on percutaneous biopsy (without radiologic indications for excision). Expert commentary: HEA management steel need prospective evidences, but recent retrospective data give some clue for less invasive management for some of HEA.

Atypical lobular hyperplasia and lobular carcinoma in situ at core needle biopsy of the breast: An incidental finding or are there characteristic imaging findings?

BACKGROUND

Atypical lobular hyperplasia and classic-type lobular carcinoma in situ, collectively known as lobular neoplasia, are classically described as incidental findings found on breast core-needle biopsy without distinguishing imaging characteristics.

OBJECTIVE

The purpose of this study was to investigate concordant imaging findings of lobular neoplasia identified at core-needle biopsy after careful radiologic-pathologic correlation.

METHODS

The pathology database was searched from October 1, 2006 to October 1, 2013 for breast biopsies yielding lobular neoplasia not associated with a coexistent malignancy or other high risk lesion in the biopsy specimen.

RESULTS

Of the 482 biopsies performed containing lobular neoplasia, 65 cases had lobular neoplasia as the highest risk lesion at core-needle biopsy. Of the 65 total cases in which lobular neoplasia was the highest risk lesion, 18 (28%) cases had concordant imaging correlates. 13 of 18 (72%) cases presented as calcifications on mammography and 5 of 18 (28%) presented on magnetic resonance imaging as a focus (n = 2) or non-mass enhancement (n = 3).

CONCLUSION

With careful radiologic-pathologic correlation, mammographically detected calcifications and foci or non-mass enhancement on magnetic resonance imaging can be considered concordant imaging findings of lobular neoplasia after breast core-needle biopsy.

Cancer statistics: Breast cancer in situ

An estimated 60,290 new cases of breast carcinoma in situ are expected to be diagnosed in 2015, and approximately 1 in 33 women is likely to receive an in situ breast cancer diagnosis in her lifetime. Although in situ breast cancers are relatively common, their clinical significance and optimal treatment are topics of uncertainty and concern for both patients and clinicians. In this article, the American Cancer Society provides information about occurrence and treatment patterns for the 2 major subtypes of in situ breast cancer in the United States-ductal carcinoma in situ and lobular carcinoma in situ-using data from the North American Association of Central Cancer Registries and the 13 oldest Surveillance, Epidemiology, and End Results registries. The authors also present an overview of in situ breast cancer detection, treatment, risk factors, and prevention and discuss research needs and initiatives.

Fibroadenoma with an unexpected lobular carcinoma in situ: A case report and review of the literature

Fibroadenoma (FA) is the most common type of breast lesion in young female individuals. Although malignant transformation in FA is rare, there is evidence of an association with breast carcinoma, particularly in middle-aged females with associated risk factors, such as a strong family history and/or BRCA-1/2 mutations. The current study presents the case of a 44-year-old female exhibiting lobular carcinoma in situ (LCIS) arising within an FA. Over the previous 20 years, numerous lumps were detected in the patient's breasts, all of which were clinically diagnosed as FA and expectantly managed. One year prior to presentation, the patient's father was diagnosed with esophageal cancer, older sister with kidney cancer and the patient herself with a benign ovarian teratoma. The patient presented with one lump in each breast and monitoring was performed using ultrasonography (US). US detected an increase in the size of the two lumps and analysis of the images was used to propose a diagnosis of FA. Therefore, a lumpectomy was performed. Analysis of the frozen section indicated a diagnosis of FA in the right breast, however, a 5-mm LCIS was identified within the FA of the left breast. Subsequent to the identification of three additional lumps in the left breast, a left mastectomy was performed. During a five-year follow-up period, no local recurrence or contralateral breast carcinoma occurred. The present study showed that FAs containing foci of carcinoma in situ can be indistinguishable from benign lesions following imaging, therefore, despite the incidence of carcinoma within FA is estimated at 0.1-0.3%, it should be considered a long-term risk factor for invasive breast cancer. The present describes a case of LCIS arising within an FA and conducts a review of the relevant literature.

Most lobular carcinoma in situ and atypical lobular hyperplasia diagnosed on core needle biopsy can be managed clinically with radiologic follow-up in a multidisciplinary setting

We evaluated the efficacy of using standard radiologic and histologic criteria to guide the follow-up of patients with lobular carcinoma in situ (LCIS), lobular neoplasia (LN), or atypical lobular hyperplasia (ALH). Patients with high-risk benign lesions diagnosed on biopsy were presented and reviewed in a multidisciplinary clinical management conference from 1 November 2003 through September 2011. Associations between patient characteristics and rates of upgrade were determined by univariate and multivariate logistic models, and times to diagnosis carcinoma were calculated. Of 853 cases reviewed, 124 (14.5%) were lobular neoplasms. In all, 104 patients were clinically and/or radiographically monitored. In 20 patients, who were found to have LN on core biopsy and were recommended to have immediate surgical excision, a more significant lesion was identified in 8 (40%) of the excised specimens. Factors associated with a more significant lesion on excisional biopsy included whether the lobular lesion had been targeted for biopsy and whether the extent of disease involved three or more terminal duct lobular units. Of the 104 patients radiographically and clinically monitored, the median follow-up time was 3.4 years with a range of 0.44–8.6 years. Five patients under surveillance were subsequently diagnosed with breast malignancy (three of the five at a site unrelated to the initial biopsy). Patients with incidental lobular lesions identified on percutaneous core needle biopsy have a small risk of upgrade and may not require an excisional biopsy. Clinical management of low-volume lobular lesions in a multidisciplinary setting is an efficacious alternative to surgical excision when radiologic and histologic characteristics are well-defined.

Invasive pleomorphic lobular carcinoma, negative for ER, PR and Her/2neu--a case report

Pleomorphic variant of lobular carcinoma is a recently described variant of invasive lobular carcinoma. It is reported to be positive for estrogen receptors and progesterone receptors and over express Her2/neu in most cases. We present here a case of invasive variant of pleomorphic lobular carcinoma with coexisting classic and pleomorphic variants of lobular carcinoma in situ along with focal ductal carcinoma in situ. The immunohistochemical results on hormone receptors and high molecular weight cytokeratins in all the above components of the tumor are presented. The invasive tumor was negative for estrogen receptors, progesterone receptors and Her2/neu. Most foci of lobular carcinoma in situ showed morphogenic heterogeneity and a corresponding heterogeneous staining for hormone receptors. The high molecular weight cytokeratins (CK5/6 and CK 903) were non contributory in establishing diagnosis.

Molecular genetics of solid tumours: translating research into clinical practice. What we could do now: breast cancer

Breast cancer is a common solid malignancy in women. Over the past decade, much progress has been made in understanding the biology of breast cancer. The use of molecular and immunohistochemical techniques is providing insights that will allow us to tailor the management of patients with breast cancer. In this review, progress in the understanding of lobular carcinoma in situ and atypical ductal hyperplasia, the use of the molecular marker CerbB2, and information gained from the morphological analysis of tumours arising in patients with BRCA1 and BRCA2 mutations is discussed.

Disparate E-cadherin mutations in LCIS and associated invasive breast carcinomas

AIMS

The relation between lobular carcinoma in situ (LCIS) and invasive breast cancer is unresolved. In an attempt to establish whether LCIS is a precursor of invasive cancer the mutational status and the expression of E-cadherin was analysed in LCIS and associated invasive breast carcinoma in 23 patients.

METHODS

Foci of LCIS and associated invasive carcinoma were individually microdissected from tissue from 23 patients. Exons 4-16 of the E-cadherin gene were analysed using single strand conformation polymorphism (SSCP); protein expression and the localisation of E-cadherin and beta-catenin were assessed with the use of immunohistochemistry.

RESULTS

Immunohistochemistry revealed a lack of expression of E-cadherin and beta-catenin in most LCIS samples and invasive foci. In all but four cases, the staining pattern was identical in the LCIS and associated invasive areas. When E-cadherin was absent, beta-catenin was also undetected, suggesting a lack of expression of alternative classic cadherin members in these lesions. Coincident E-cadherin mutations in LCIS and associated invasive carcinoma were not identified in this series of patients. However, mutational analysis of E-cadherin in multiple foci of carcinoma in situ surrounding an invasive lesion provided evidence to support ductal carcinoma in situ as a precursor of invasive ductal carcinoma.

CONCLUSION

These data support the hypothesis that LCIS is not a precursor of invasive breast carcinoma but a marker of increased risk of developing invasive disease.

Genetic relation of lobular carcinoma in situ, ductal carcinoma in situ, and associated invasive carcinoma of the breast

AIMS

The mutual relation of lobular carcinoma in situ (LCIS) and ductal carcinoma in situ (DCIS) of the breast, as accepted precursor lesions of invasive breast cancer, is controversial. Because they display genetic heterogeneity, it is not clear how genetically advanced these entities are and what causes the transition to an invasive carcinoma.

METHODS

Six cases of LCIS, four of them with associated lobular invasive carcinoma, four cases of intermediately differentiated DCIS with an associated invasive lobular carcinoma, and nine cases of intermediately and poorly differentiated DCIS with associated ductal invasive carcinoma were investigated by means of comparative genomic hybridisation (CGH) after microdissection and immunohistochemical staining of E-cadherin.

RESULTS

LCIS was characterised by a low average rate of copy number changes, no evidence of amplifications, and a high rate of gains and losses of chromosomal material at 1q and 16q, respectively. A high degree of genetic homology with well differentiated DCIS was obvious, as reported previously. The cases of intermediately differentiated DCIS with associated lobular invasive components and lobular differentiation revealed striking homologies, and a significant difference of E-cadherin expression. The comparison of preinvasive and invasive breast lesions, irrespective of differentiation within the same patient, revealed no specific alteration that might be associated with invasion. Genetic alterations seen in invasive carcinoma were not necessarily seen in the adjacent precursor lesions.

CONCLUSIONS

These results provide strong evidence that invasive breast cancer is a disease with multiple cytogenetic subclones already present in preinvasive lesions. Moreover, specific CGH alterations associated with invasion were not observed. Furthermore, the close genetic association between well differentiated and a subgroup of intermediately differentiated DCIS and LCIS led to the hypothesis that LCIS and a subgroup of DCIS are different phenotypic forms of a common genotype.