Factors Indicating Surgical Excision in Classical Type of Lobular Neoplasia of the Breast

Abstract

<b><i>Purpose:</i></b> Classical type of lobular neoplasia (LN) encompassing both atypical lobular hyperplasia and classical lobular carcinoma in situ of the breast is a lesion with uncertain malignant potential and has been the topic of several studies with conflicting outcome results. The aim of our study was to clarify outcome-relevant factors and treatment options of classical LN. <b><i>Methods:</i></b> We performed a pathological re-evaluation of the preoperative biopsy specimens and a retrospective clinical and radiological data analysis of 160 patients with LN from the Breast Center Zurich. Open surgery was performed in 65 patients, vacuum-assisted biopsy (VAB) in 79 patients, and surveillance after breast core needle biopsy (CNB) in 16 patients. <b><i>Results:</i></b> The upgrade rate into ductal carcinoma in situ/invasive cancer was the highest in case of imaging/histology discordance (40%). If the number of foci in the biopsy specimen was ≥3, the upgrade rate in the consecutive surgical specimens was increased (<i>p</i> = 0.01). The association of classical LN with histological microcalcification correlated with shortened disease-free survival (<i>p</i> < 0.01), whereas other factors showed no impact on follow-up. <b><i>Conclusions:</i></b> Surveillance or subsequent VAB after CNB of LN is sufficient in most cases. Careful consideration of individual radiological and histological factors is required to identify patients with a high risk of upgrade into malignancy. In those cases, surgical excision is indicated.

Third International Consensus Conference on lesions of uncertain malignant potential in the breast (B3 lesions)

“…This is true despite the variable risk for an upgrade which can be as high as 20% in the presence of certain risk factors. Current data imply a more individualized decision, e.g., under consideration of the number of LN foci in the biopsy specimen [38]. We found no significant difference in the diagnostic and therapeutic recommendation from the panelists if the B3 lesion was completely removed by VAB on clinical imaging; in FEA (100% voted for no further intervention compared to 97% in 2018), PL (100% no further intervention compared to 98% in 2018), and RS (82% no further intervention versus 89% in 2018).…”

“…An upgrade into DCIS or invasive cancer is observed on an average of 20% of cases, with a wide range from 4 to 67% within the current literature [4,38]. However, if the target imaging lesion is assigned to another histological entity and not to LN following pathological-radiological concordance, the upgrade rate is significantly lower [4,36,[38][39][40].…”

“…Regarding the upgrade rate, the majority of studies do not differentiate between ALH and classical LCIS. The greatest indicator of an upgrade into invasive cancer, however, is a radiological discrepancy, such as a spiculated mass in clinical imaging and a histopathologic diagnosis of LN in the biopsy specimen of the same lesion [4,36,[38][39][40][41]. After a mammographic-guided VAB with a 7-G needle, the upgrade rate is substantially lower (4%) [38,40,42].…”

B3-Läsionen der Mamma: Histologische, klinische und epidemiologische Aspekte

“…Die aktuelle Datenlage zeigt ein variables Unterschätzungsrisiko bei einer klassischen LN-Diagnose. Die Upgraderate am nachfolgendem Operationspräparat variiert in der Literatur in Abhängigkeit von Studie und Nomenklatur zwischen 0 und 60 % [ 9 , 18 , 25 , 55 ]. Vor allem bei fehlender radiologisch-pathologischer Korrelation ist mit höheren Upgraderaten zu rechnen, weshalb die radiologisch-pathologische Diskordanz bis dato als wichtigster Risikofaktor für die Unterschätzung angesehen wird [ 9 , 12 , 23 , 49 , 55 ].…”

“…Die Upgraderate am nachfolgendem Operationspräparat variiert in der Literatur in Abhängigkeit von Studie und Nomenklatur zwischen 0 und 60 % [ 9 , 18 , 25 , 55 ]. Vor allem bei fehlender radiologisch-pathologischer Korrelation ist mit höheren Upgraderaten zu rechnen, weshalb die radiologisch-pathologische Diskordanz bis dato als wichtigster Risikofaktor für die Unterschätzung angesehen wird [ 9 , 12 , 23 , 49 , 55 ]. Das relative Risiko, später an Brustkrebs zu erkranken, ist bei Patientinnen mit klassischem LCIS 8‑ bis 10-mal höher als in der Allgemeinbevölkerung.…”