Figure 3 - uploaded by Karin Wang
Content may be subject to copyright.
![Case of incidental lobular carcinoma in situ (LCIS) on core biopsy with pathologic upgrade on excision. A, The needle core biopsy performed for a nodule showed a complex fibroadenoma. B, Classic LCIS was identified in the breast tissue adjacent to the complex fibroadenoma and was considered incidental in nature (negative E-cadherin stain, inset). C, Excisional biopsy showed a 0.25-cm focus of cribriform ductal carcinoma in situ (DCIS) involving the fibroadenoma (left). Lobular carcinoma in situ was present in the fibroadenoma (right) as well as in surrounding breast tissue (not shown). D, An E-cadherin immunostain shows membranous reactivity in DCIS cells (left) and absence of staining in LCIS cells (right) (hematoxylin-eosin, original magnifications 3 40 [A through C]; original magnifications 3 40 [inset and D]) .](profile/Karin-Wang/publication/243964820/figure/fig2/AS:298501620682756@1448179741088/Case-of-incidental-lobular-carcinoma-in-situ-LCIS-on-core-biopsy-with-pathologic.png)
Case of incidental lobular carcinoma in situ (LCIS) on core biopsy with pathologic upgrade on excision. A, The needle core biopsy performed for a nodule showed a complex fibroadenoma. B, Classic LCIS was identified in the breast tissue adjacent to the complex fibroadenoma and was considered incidental in nature (negative E-cadherin stain, inset). C, Excisional biopsy showed a 0.25-cm focus of cribriform ductal carcinoma in situ (DCIS) involving the fibroadenoma (left). Lobular carcinoma in situ was present in the fibroadenoma (right) as well as in surrounding breast tissue (not shown). D, An E-cadherin immunostain shows membranous reactivity in DCIS cells (left) and absence of staining in LCIS cells (right) (hematoxylin-eosin, original magnifications 3 40 [A through C]; original magnifications 3 40 [inset and D]) .
Source publication
Context:
Lobular carcinoma in situ (LCIS) as the primary pathologic diagnosis in a needle core biopsy is an infrequent finding, and the management of patients in this setting is controversial.
Objective:
To determine the rate of pathologic upgrade (defined as the presence of a clinically more-significant lesion in the subsequent excision) in pat...
Contexts in source publication
Context 1
... were present within the LCIS in 38 of the 61 cases (62%). Of the 38 cases containing calcifications within LCIS, 5 cases (13%) showed a Figure 3). pathologic upgrade on excision, which was not a statistically significant association. ...
Context 2
... that case, LCIS was present amid extensive nodular sclerosing adenosis, which was considered the imaging abnormality, and LCIS was considered incidental in this case. Of the 24 cases where LCIS was considered an incidental microscopic finding on needle core biopsy, 1 case (4%) showed a pathologic upgrade on excision (Figure 3). In that case, the core biopsy was performed for a 1.1 cm nodule detected on screening imaging. ...
Similar publications
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 conf...
Citations
... For pleomorphic and florid LCIS, available studies show a high rate of upgrade to invasive carcinoma and DCIS on surgical excision (40% and 15%, respectively). 57,82 Therefore, surgical resection is recommended for nonclassical types of LCIS. The range of upgrade rates in classic LCIS is wide, although recent, well-powered studies have suggested that the upgrade rate at surgical excision is lower than once believed when pure classic LCIS is identified on core needle biopsy, radiologic and pathologic diagnoses are concordant, and no other lesions requiring excision are present. ...
Benign breast diseases, which are commonly seen in clinical practice, have various clinical presentations and implications, as well as management strategies. This article describes common benign breast lesions, presentations of these lesions, and typical radiographic and histologic findings. Also included in this review are the most recent data and guideline-based recommendations for the management of benign breast diseases at diagnosis, including surgical referral, medical management, and ongoing surveillance.
... Vacuum-assisted excision as a minimally invasive procedure for removal of an imaging target is uncommon in the USA and Canada. In most contemporary series from North-American institutions, the upgrade rate at follow-up surgical excision of radiology-pathology concordant CNBs yielding C-LN (ALH or C-LCIS) as the highest risk lesion ranges between 1% and 4% [35][36][37][38][39][40]. In a few series, excision of C-LCIS yielded >5% rate of upgrade [41,42] and some groups have suggested that surgical excision is not required for ALH but is recommended for C-LCIS [42]. ...
... In most studies, C-LN was identified in the CNB material of a mammographic or sonographic lesion [35][36][37][38][39][40][41][42]. Magnetic resonance imaging (MRI) technology, however, may detect foci of C-LCIS and ALH that are not associated with another lesion and are mammographically and sonographically occult [35,[45][46]. ...
Lobular carcinoma in situ (LCIS) is a non-invasive proliferation of atypical dyscohesive epithelial cells characterized by loss or functional alteration of E-cadherin-mediated cell adhesion. The morphologic spectrum of LCIS encompasses classic (C-LCIS), florid (F-LCIS) and pleomorphic LCIS (P-LCIS), as recently defined by the World Health Organization (WHO) Expert Consensus Group. Atypical lobular hyperplasia (ALH) is also part of this spectrum.
This article highlights the morphologic and immunohistochemical features of the three forms of LCIS and summarizes their management implications and prognosis, with emphasis on F-LCIS and P-LCIS.
... A shared hallmark of each of these three aggressive LN subtypes is their propensity to calcify, which makes them detectable on mammography and thus amenable to stereotactic core biopsy. Identifying calcifications on core biopsy specimens yielding LN has been reported to occur between 8% and 72% of the time and to be highest when studies isolate cal- cifications as the sampling target as opposed to including additional targets such as masses, asymmetries, or areas showing MRI enhancement [25]. ...
... Summarizing the aforementioned findings, the presence of calcifications within LCIS likely indicates the presence of one of the LCIS variants, and each variant justifiably raises concern for concurrent carcinoma at a rate in excess of that associated with incidental noncalcified classic LCIS encountered at core biopsy. D'Alfonso et al. [25] similarly described 50 cases of calcifications targeted at stereotactic biopsy. Of the 36 cases histologically determined to have calcifications within LCIS, there were 5 (14%) upgrades at subsequent surgery. ...
... Of the 36 cases histologically determined to have calcifications within LCIS, there were 5 (14%) upgrades at subsequent surgery. In the remaining 14 cases in which the LCIS was noncalcified and thus incidental to a benign calcifying process, there were no upgrades [25]. Our series falls in line with this report by showing an upgrade rate of 20.0% (3/15) in all calcified LN core biopsies (12 calcified LCIS + 4 calcified ALH) and of 25.0% (3/12) in core biopsies if only LCIS is considered. ...
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.
... CLCIS, first described by Foote and Stewart in 1941 as the morphologic precursor of invasive lobular carcinoma (3), is currently considered both a risk indicator and nonobligate precursor for breast cancer (4)(5)(6). Contemporary studies have shown that when CLCIS is the highest risk finding on core needle biospy (CNB) excision can be spared if the pathologic and imaging findings are concordant (7)(8)(9)(10). PLCIS (1,11) and more recently FLCIS (1) have been recognized as morphologic subtypes of LCIS but their clinical behavior and optimal management have not been fully characterized. ...
... In addition, most series published before 2019 classified all cases as PLCIS, even though they included lesions that today qualify as FLCIS (41). Only few groups have used diagnostic criteria consistent with the criteria recently codified in the WHO 2019 Classification of Tumours of the Breast(1) and reported separately the upgrade rates of FLCIS and PLCIS (10,21,29). ...
Lobular carcinoma in situ (LCIS) is currently classified as classic (CLCIS), florid (FLCIS), and pleomorphic (PLCIS). Given the rarity of FLCIS and PLCIS, information on their clinico-pathologic features and biologic potential remains limited. We evaluated the upgrade rates at excision of FLCIS and PLCIS diagnosed on inhouse core needle biopsy (CNB) and their clinical presentation and follow-up. Over a period of 11 and a half years, there were a total of 36 inhouse CNBs with pure PLCIS (n = 8), FLCIS (n = 24), or LCIS with pleomorphic features (LCIS-PF) (n = 4). The upgrade rates to invasive carcinoma or ductal carcinoma in situ (DCIS) were 25% for PLCIS (2/8), 17% for FLCIS (4/24), and 0% for LCIS-PF (0/4). The overall upgrade rate of PLCIS and FLCIS combined was 19% (6/32). All but one case (not upgraded at excision) were radiologic–pathologic concordant. Apocrine features, previously reported only in PLCIS, were also noted in FLCIS. HER2 overexpression was seen in 13% of cases. This study highlights the more aggressive biologic features of PLCIS and FLCIS compared to CLCIS and supports surgical management for these lesions.
... In our series, the PPV for malignancy after LN was 29%, with one patient having tubulo-lobular carcinoma, 2 having intermediate-grade DCIS, and one having high-grade DCIS combined with pleomorphic LCIS. Interestingly, the upgrade rate increased when LN was associated with FEA (2/3, 66%), providing evidence of the need for surgical excision after classical LN diagnosis on breast biopsy if an additional B3 lesion is concurrently detected [47]. ...
Purpose:
Breast lesions classified as of "uncertain malignant potential" represent a heterogeneous group of abnormalities with an increased risk of associated malignancy. Clinical management of B3 lesions diagnosed on vacuum-assisted breast biopsy (VABB) is still challenging: surgical excision is no longer the only available treatment and VABB may be sufficient for therapeutic excision. The aim of the present study is to evaluate the positive predictive value (PPV) for malignancy in B3 lesions that underwent surgical excision, identifying possible upgrading predictive factors and characterizing the malignant lesions eventually diagnosed. These results are compared with a subset of patients with B3 lesions who underwent follow-up.
Methods:
A total of 1250 VABBs were performed between January 2006 and December 2017 at our center. In total, 150 B3 cases were diagnosed and 68 of them underwent surgical excision. VABB findings were correlated with excision histology. A PPV for malignancy for each B3 subtype was derived.
Results:
The overall PPV rate was 28%, with the highest upgrade rate for atypical ductal hyperplasia (41%), followed by classical lobular neoplasia (29%) and flat epithelial atypia (11%). Only two cases of carcinoma were detected in the follow-up cohort, both associated with atypical ductal hyperplasia at VABB.
Conclusion:
Open surgery is recommended in case of atypical ductal hyperplasia while, for other B3 lesions, excision with VABB only may be an acceptable alternative if radio-pathological correlation is assessed, if all microcalcifications have been removed by VABB, and if the lesion lacks high-risk cytological features.
Key points:
• Surgical treatment is strongly recommended in case of ADH, while the upgrade rate in case of pure FEA, especially following complete microcalcification removal by VABB, may be sufficiently low to advice surveillance as a management strategy. • The use of 11-G- or 8-G-needle VABB, resulting in possible complete diagnostic excision of the lesion, can be an acceptable alternative in case of RS, considering open surgery only for selected high-risk patients. • LN management is more controversial: surgical excision may be recommended following classical LN diagnosis on breast biopsy if an additional B3 lesion is concurrently detected while in the presence of isolated LN with adequate radiological-pathological correlation follow-up alone could be an acceptable option.
... In our series, the PPV for malignancy after LN was 29%, with one patient having tubulo-lobular carcinoma, 2 having intermediate-grade DCIS, and one having high-grade DCIS combined with pleomorphic LCIS. Interestingly, the upgrade rate increased when LN was associated with FEA (2/3, 66%), providing evidence of the need for surgical excision after classical LN diagnosis on breast biopsy if an additional B3 lesion is concurrently detected [47]. ...
The arrival of the COVID-19 pandemic originated by the SARS-CoV-2 virus has required a quick response by multiple medical specialties, including Imaging. Lung Ultrasound is an exam that has previously demonstrated its utility in other lung diseases, with high availability, low cost, absence of ionizing radiation and the possibility to have a bed-side assessment. In some of the countries that experienced earlier and more intense effects of the pandemic, as China and Italy, it has been used as an imaging modality for evaluation and follow-up for COVID-19 patients. In order to achieve a satisfactory result, adequate equipment, protection, disinfection and protocol must be chosen. The US findings described so far in the literature are nonspecific, but their combination and anatomical distribution in a compatible clinical and epidemiologic context, made them highly suggestive of this disease and allow for a serial follow-up. The current literature is scarce and more evidence is needed to truly estimate the usefulness of this imaging modality in the evaluation of COVID-19 patients.
... [11][12][13][14][15][16] PLCIS and FLCIS are typically considered to be more aggressive than CLCIS, 2,4,5,8,9,[17][18][19] but management remains controversial due to a limited understanding of their biology and natural history. In contrast to the low (~1% to 4%) excisional upgrade rate of CLCIS to invasive carcinoma in studies with radiologic-pathologic correlation, [20][21][22][23][24][25][26] upgrade rates of PLCIS range from~25% to 60%. 10,17,18,[27][28][29][30][31][32] The upgrade rate of FLCIS is unknown. ...
The natural history and optimal treatment of pleomorphic (PLCIS) and florid (FLCIS) lobular carcinoma in situ variants remains uncertain. We reviewed the clinicopathologic features and management of LCIS variants at our institution over a 20-year period. Of 85 cases (61 PLCIS, 24 FLCIS), 77% were associated with invasive carcinoma (84% lobular, 13% ductal/lobular, 3% ductal) and only 17% (9 PLCIS, 5 FLCIS) were pure. Most (81%) invasive carcinomas were grade 2, with all grade 3/pleomorphic invasive lobular carcinomas (ILC) associated with PLCIS, and all grade 1 tumors associated with FLCIS. PLCIS-associated invasive carcinomas were more often ER- (21%) or HER2+ (14%) than FLCIS-associated tumors (100% ER+, 6% HER2+). LCIS variants were unifocal and co-localized with invasive carcinoma in 20/20 selected spatially mapped cases, whereas classic LCIS (CLCIS) was multifocal with wider distribution (10/17). Of 21 pure LCIS variants on core biopsy, all represented the radiographic (95%) or palpable (5%) target. The excisional upgrade rate was similar for PLCIS (38%) and FLCIS (33%). Pure LCIS variants on core biopsy were often (20%) HER2+ and had a higher Ki-67-index than synchronous CLCIS (P=0.002). Lower ER expression in LCIS variants versus CLCIS was due to ER- apocrine PLCIS. ER and HER2 were consistently concordant between LCIS variants and upgraded ILC but discordant between synchronous CLCIS and LCIS variants in 5/14 (36%). Pure LCIS variants were excised to negative margins and frequently (58%) treated with endocrine but not radiation therapy without recurrences. In summary, PLCIS and FLCIS demonstrate features of direct precursor lesions warranting surgical excision.
... 6,19,41,61,[66][67][68][69] As expected, many studies include few patients, including some with fewer than 5 patients. 52,64,70,71 A meta-analysis by Pieri et al 68 that included 42 patients with pleomorphic LCIS on core biopsy from 5 studies showed an upgrade rate of 36% (15 of 42; 14 invasive carcinomas, 1 DCIS). Most upgraded lesions in these studies were invasive lobular carcinomas, which were seen in close proximity to the florid or pleomorphic LCIS. ...
Context:
- Lobular carcinoma in situ (LCIS) refers to a neoplastic proliferation of cells that characteristically shows loss of E-cadherin expression and has long been regarded as a risk factor for invasive breast cancer. Long-term outcome studies and molecular data have also implicated LCIS as a nonobligate precursor to invasive carcinoma. In the past few decades, pleomorphic and florid LCIS have been recognized as morphologic variants of LCIS with more-aggressive histopathologic features, less-favorable biomarker profiles, and more-complex molecular features compared with classic LCIS. There is still a lack of consensus regarding certain aspects of managing patients with LCIS.
Objectives:
- To review recently published literature on LCIS and to provide an overview of the current morphologic classification of LCIS, recent molecular advances, and trends in patient management.
Data sources:
- Sources included peer-reviewed, published journal articles in PubMed (US National Library of Medicine, Bethesda, Maryland) and published guidelines from the National Comprehensive Cancer Network (Fort Washington, Pennsylvania).
Conclusions:
- Lobular carcinoma in situ represents a marker for increased risk of breast cancer, as well as a nonobligate precursor to invasive carcinoma. Morphologic variants of LCIS-florid and pleomorphic LCIS-are genetically more-complex lesions and are more likely to be associated with invasive carcinoma. Further investigation into which molecular alterations in LCIS are associated with progression to invasive carcinoma is needed to help guide medical and surgical management.
... (2) Lobular carcinoma in situ (LCIS) (a) Usual variant (b) High-risk variants (i) Pleomorphic and pleomorphic-apocrine LCIS (ii) Florid LCIS (iii) Signet ring cell LCIS <10 % for occult lesions with LIN on core biopsy [61, 62]. Lobular neoplasia is classified as a lesion of unknown malignant potential (B3) [1], but pleomorphic LCIS or LCIS with mixed duct and lobular features is classified as B5a. ...
In this chapter, a brief overview will be given about the histopathology of noninvasive (premalignant) lesions and invasive tumors of the breast. The histologic diagnosis still is the basis for the planning of surgical and adjuvant treatment, but also the basis for risk assessment, and for further immunohistologic and molecular evaluation of the lesions. Therefore, a competent histologic workup, preferentially by a specialized breast pathologist, is indispensable in the management of breast disease.
... Most lesions present incidentally without any palpable mass and less than half of classical LN lesions have associated calcification. Published data on the risk of developing breast cancer after diagnosis on CNB or VAB show, a relative risk of 1-2 % per year, 15-17 % after 15 years, and 35 % after 35 years with relatively equal rates of ipsi-and contralateral breast cancer (8.7 and 6.7 %, respectively) [2,[49][50][51][52][53]. The upgrade rate after classical LN diagnosis on CB or VAB is variable in the literature, ranging from 0 to 50 % which can at least partially be explained by variation in study design and inconsistent use of ALH, LCIS, and LN nomenclatures [2,41]. ...
... The upgrade rate after classical LN diagnosis on CB or VAB is variable in the literature, ranging from 0 to 50 % which can at least partially be explained by variation in study design and inconsistent use of ALH, LCIS, and LN nomenclatures [2,41]. In one study, underestimation was found to be 4 % in classical LN cases when LN was an incidental finding and 18 %, when LN represented the radiologic targets by D'Alfonso et al. [50]. Higher upgrade rates were associated with cases that demonstrated mass lesions and calcification on imaging or with radiopathological discordance. ...
... Higher upgrade rates were associated with cases that demonstrated mass lesions and calcification on imaging or with radiopathological discordance. Lower underestimation rates were detected in classical LN cases, where no residual calcification was found after biopsy, calcification was incidental, and there was complete concordance between histological and imaging findings [2,41,50]. ...
The purpose of this study is to obtain a consensus for the therapy of B3 lesions. The first International Consensus Conference on lesions of uncertain malignant potential in the breast (B3 lesions) including atypical ductal hyperplasia (ADH), flat epithelial atypia (FEA), classical lobular neoplasia (LN), papillary lesions (PL), benign phyllodes tumors (PT), and radial scars (RS) took place in January 2016 in Zurich, Switzerland organized by the International Breast Ultrasound School and the Swiss Minimally Invasive Breast Biopsy group—a subgroup of the Swiss Society of Senology. Consensus recommendations for the management and follow-up surveillance of these B3 lesions were developed and areas of research priorities were identified. The consensus recommendation for FEA, LN, PL, and RS diagnosed on core needle biopsy or vacuum-assisted biopsy (VAB) is to therapeutically excise the lesion seen on imaging by VAB and no longer by open surgery, with follow-up surveillance imaging for 5 years. The consensus recommendation for ADH and PT is, with some exceptions, therapeutic first-line open surgical excision. Minimally invasive management of selected B3 lesions with therapeutic VAB is acceptable as an alternative to first-line surgical excision.
