What To Do with the Incidental Finding of Lobular Neoplasia?
Abstract & Commentary
By William B. Ershler, MD, Editor
Synopsis: The management of an isolated core needle breast biopsy reading of lobular neoplasia (LN) is controversial. Although this finding is associated with an increased risk for cancer, the current belief is that it, itself, is not a pre-malignant lesion. In this report, a single institution's experience with LN over an 18 month period (98 cases) is detailed. More than half of the patients were followed carefully without surgical excision. Of the 45 patients who had surgical excision, all but 3 had LN alone (without malignant features) on the excised tissue. The authors make the case that this is a safe approach if there is confidence that follow-up (including imaging studies) will be maintained.
Source: Nagi CS, et al. Lobular neoplasia on core needle biopsy does not require excision. Cancer. 2008;112:2152-2158.
Atypical lobular hyperplasia (ALH) is a term that has evolved to describe lesions that are similar to lobular carcinoma in situ (LCIS) but falls short of reaching criteria for that diagnosis. Lobular neoplasia (LN) is a designation that encompasses ALH and LCIS. In most cases, LN occurs in the absence of any clearly discernable radiological abnormality and is often considered an incidental finding on core needle biopsies (CNBs). Under those circumstances it is not associated with a mass or even calcifications. On the other hand, LN can be found in association with mass lesions, fibrocystic lesions containing calcifications, atypical ductal hyperplasia, or ductal carcinoma in situ (DCIS) and therefore, although present as an incidental finding, LN may be considered a risk factor for breast carcinoma. Thus, there remains controversy regarding management decisions when a needle biopsy report comes back with a histologic diagnosis of LN.1,2
Nagi and colleagues at Mount Sinai reviewed their experience with 98 cases of LCIS and/or ALH. In each of these cases, strict criteria were used for diagnosis of LN, including those for distinguishing ALH.3 Cases containing LN accompanied by a second lesion mandating excision (eg, radial scar, atypical ductal hyperplasia [ADH]) and those failing to meet strict diagnostic criteria for LN (eg, atypical cells, mitoses, single-cell necrosis) were excluded. For the remainder, radiographic findings were correlated with their histologic counterparts in terms of size, number, and pattern. In all cases, after careful correlation of imaging studies and histology, those that fit criteria for LN were identified. Although some patients underwent surgical excision, others were followed clinically and radiologically, without surgery.
Ninety-one biopsies were performed for calcifications and 7 were performed for mass lesions. The ages of the patients ranged from 35 to 82 years. Fifty-three patients were followed radiologically without excision, 42 of whom had available clinical and radiologic information. The 45 patients who underwent excision were without disease at follow-up periods ranging from 1 to 8 years. Of these 45 patients, 42 (93%) had biopsy results demonstrating only LN. The remaining 3 patients had biopsies with the following findings: atypical ductal hyperplasia, infiltrating lobular carcinoma, and ductal carcinoma in situ admixed with LCIS.
The authors conclude that excision of LN is unnecessary provided that: 1) careful radiographic-pathologic correlation is performed; and 2) strict histologic criteria are adhered to when making the diagnosis. However, they caution that close radiologic and clinical follow-up is warranted.
Commentary
There remains no consensus on the optimal management of LN when discovered as an incidental finding on a needle biopsy specimen. These lesions are often multifocal and not infrequently are present in both breasts. Although their presence indicates an increased risk for cancer, the current belief is that, unlike atypical ductal hyperplasia or DCIS, LCIS is unlikely to evolve into an invasive carcinoma. Thus, a common approach is to follow carefully, with or without antiestrogenic therapy.3
The published report indicates that such an approach would be safe. However, success hinges on the initial histological evaluation and correlative radiographic procedures. There are variants of LCIS that may confer increased risk, such as the presence of large cells, cells with highly proliferative features or if there is any evidence for ductal proliferation. If not, their experience would indicate surveillance alone, without surgical excision would be sufficient and safe.
References
1. Bauer VP, et al. The management of lobular neoplasia identified on percutaneous core breast biopsy. Breast J. 2003;9(1):4-9.
2. Foster MC, et al. Lobular carcinoma in situ or atypical lobular hyperplasia at core-needle biopsy: is excisional biopsy necessary? Radiology. 2004;231(3):813-819.
3. Simpson PT, et al. The diagnosis and management of pre-invasive breast disease: pathology of atypical lobular hyperplasia and lobular carcinoma in situ. Breast Cancer Res. 2003;5(5):258-262.
The management of an isolated core needle breast biopsy reading of lobular neoplasia (LN) is controversial. Although this finding is associated with an increased risk for cancer, the current belief is that it, itself, is not a pre-malignant lesion.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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