Ductal vs. Lobular may be a problem in pagetoid or complete involvement of ducts by LCIS, in solid low grade DCIS, or in lobular involvement by DCIS cells (cancerization of lobules)
LCIS requires that all the acini in at least one lobular unit be completely filled and that half the acini in that unit must be expanded
If either of the above features is lacking, designate as ALH
Clinical
Lobular carcinoma in situ is considered to be a marker of increased risk of invasive carcinoma it can be a precursor lesion
The increased risk applies to both breasts in most studies
Recent data suggest 2/3 of subsequent carcinomas are in the ipsilateral breast
In the past there has been no consensus about management of patients with LCIS in a core biopsy
A recent study provides data indicating that patients with LCIS in a core should have an excision
We particularly consider its presence in a core biopsy to be an indication for excisional biopsy in the following situations:
If there is discordance between the mammographic and pathologic findings
If another lesion such as atypical ductal hyperplasia is present
If the lobular nature of the cells is at all equivocal
If the LCIS is extensive
In an excisional biopsy:
We suggest excision with clear margins if florid/extensive, pleomorphic, extensively necrotic or predominantly signet ring
Otherwise, margins are not relevant if LCIS is the only lesion
Nevertheless, we generally report margin status to satisfy those who want the information
Relative risk for development of invasive breast carcinoma
No increased risk
Non-proliferative fibrocystic change
Fibroadenoma
Solitary papilloma
Slightly increased risk (1.5 to 2 times)
Proliferative fibrocystic change
Usual ductal hyperplasia
Sclerosing adenosis (florid)
Radial scar
Complex fibroadenoma (approximately 3 times risk)
Moderately increased risk (4 to 5 times)
Atypical ductal hyperplasia (no family history)
Atypical lobular hyperplasia
High risk (8 to 10 times)
Ductal carcinoma in situ, low grade
Lobular carcinoma in situ
Atypical ductal hyperplasia, if history of carcinoma in primary relatives
Very high risk (precise level not known)
Ductal carcinoma in situ, high grade
Grading / Staging / Report
Grading is not applicable
Staging is not applicable
The surgical pathology report should contain or address the following:
Type of resection or biopsy and location
Results of any supplementary studies performed
Extent of LCIS
(Margins of excision are not relevant)
Bibliography
Acs G, Lawton TJ, Rebbeck TR, LiVolsi VA, Zhang PJ. Differential expression of E-cadherin in lobular and ductal neoplasms of the breast and its biologic and diagnostic implications. Am J Clin Pathol. 2001 Jan;115(1):85-98.
Bentz JS, Yassa N, Clayton F. Pleomorphic lobular carcinoma of the breast: clinicopathologic features of 12 cases. Mod Pathol. 1998 Sep;11(9):814-22.
Bratthauer GL, Moinfar F, Stamatakos MD, Mezzetti TP, Shekitka KM, Man YG, Tavassoli FA. Combined E-cadherin and high molecular weight cytokeratin immunoprofile differentiates lobular, ductal, and hybrid mammary intraepithelial neoplasias. Hum Pathol. 2002 Jun;33(6):620-7.
Crisi GM, Mandavilli S, Cronin E, Ricci A Jr. Invasive mammary carcinoma after immediate and short-term follow-up for lobular neoplasia on core biopsy. Am J Surg Pathol. 2003 Mar;27(3):325-33.
Elsheikh TM, Silverman JF. Follow-up surgical excision is indicated when breast core needle biopsies show atypical lobular hyperplasia or lobular carcinoma in situ: a correlative study of 33 patients with review of the literature. Am J Surg Pathol. 2005 Apr;29(4):534-43.
Fisher ER, Costantino J, Fisher B, Palekar AS, Paik SM, Suarez CM, Wolmark N. Pathologic findings from the National Surgical Adjuvant Breast Project (NSABP) Protocol B-17. Five-year observations concerning lobular carcinoma in situ. Cancer. 1996 Oct 1;78(7):1403-16.
Goldstein NS, Bassi D, Watts JC, Layfield LJ, Yaziji H, Gown AM. E-cadherin reactivity of 95 noninvasive ductal and lobular lesions of the breast. Implications for the interpretation of problematic lesions. Am J Clin Pathol. 2001 Apr;115(4):534-42.
Jacobs TW, Connolly JL, Schnitt SJ. Nonmalignant lesions in breast core needle biopsies: to excise or not to excise? Am J Surg Pathol. 2002 Sep;26(9):1095-110.
Jacobs TW, Pliss N, Kouria G, Schnitt SJ. Carcinomas in situ of the breast with indeterminate features: role of E-cadherin staining in categorization. Am J Surg Pathol. 2001 Feb;25(2):229-36.
Lehr HA, Folpe A, Yaziji H, Kommoss F, Gown AM. Cytokeratin 8 immunostaining pattern and E-cadherin expression distinguish lobular from ductal breast carcinoma. Am J Clin Pathol. 2000 Aug;114(2):190-6.
Liberman L, Sama M, Susnik B, Rosen PP, LaTrenta LR, Morris EA, Abramson AF, Dershaw DD. Lobular carcinoma in situ at percutaneous breast biopsy: surgical biopsy findings. AJR Am J Roentgenol. 1999 Aug;173(2):291-9.
Maluf HM, Swanson PE, Koerner FC. Solid low-grade in situ carcinoma of the breast: role of associated lesions and E-cadherin in differential diagnosis. Am J Surg Pathol. 2001 Feb;25(2):237-44.
Middleton LP, Palacios DM, Bryant BR, Krebs P, Otis CN, Merino MJ. Pleomorphic lobular carcinoma: morphology, immunohistochemistry, and molecular analysis. Am J Surg Pathol. 2000 Dec;24(12):1650-6.
Ottesen GL, Graversen HP, Blichert-Toft M, Christensen IJ, Andersen JA. Carcinoma in situ of the female breast. 10 year follow-up results of a prospective nationwide study. Breast Cancer Res Treat. 2000 Aug;62(3):197-210.
Page DL, Schuyler PA, Dupont WD, Jensen RA, Plummer WD Jr, Simpson JF. Atypical lobular hyperplasia as a unilateral predictor of breast cancer risk: a retrospective cohort study. Lancet. 2003 Jan 11;361(9352):125-9.
Schnitt SJ, Morrow M. Lobular carcinoma in situ: current concepts and controversies. Semin Diagn Pathol. 1999 Aug;16(3):209-23.
Simpson PT, Gale T, Fulford LG, Reis-Filho JS, Lakhani SR. 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):258-62.
Sneige N, Wang J, Baker BA, Krishnamurthy S, Middleton LP. Clinical, histopathologic, and biologic features of pleomorphic lobular (ductal-lobular) carcinoma in situ of the breast: a report of 24 cases. Mod Pathol. 2002 Oct;15(10):1044-50.