Pleomorphic Lobular Carcinoma in Situ: A Divergent Entity With Emerging Significance - Cancer Network

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Pleomorphic Lobular Carcinoma in Situ: A Divergent Entity With Emerging Significance
The Kounalakis, Diamond, Rusthoven et al Article Reviewed [READ ARTICLE]
By Mamatha Chivukula, MD1 | 8 de abril de 2011
1Magee Women's Hospital of UPMC, Pittsburgh, Pennsylvania
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Many historical evolutions of concepts have emerged regarding lobular neoplasia (LN) since 1865, when Cornil first described this entity as “intraepithelial breast carcinoma in lobules.”[1] Currently, the term “lobular neoplasia” encompasses a spectrum of atypical changes in the lobule that include atypical lobular hyperplasia (ALH) and lobular carcinoma in situ (LCIS). According to Page criteria,[2,3] ALH and LCIS differ quantitatively and are composed of small, round, monomorphic, discohesive cells with an increased nuclear/cytoplasmic ratio. The SEER (Surveillance, Epidemiology, and End Results) data have shown that the age-adjusted, age-specific rates of LCIS among women in the United States have increased fourfold in the past 20 years, with a steep rise in LCIS incidence seen in postmenopausal women between the ages of 50 and 70 years.[4] LCIS has been established as a risk factor for subsequent invasive carcinoma, of either the ductal or lobular type. Although the SEER data show that the majority of invasive carcinomas that occur subsequent to lobular neoplasia are ductal, invasive lobular carcinomas comprised up to half of subsequent carcinomas, in comparison to the expected rate of invasive lobular carcinomas (5%–14%) in the general population.[4] Current NCCN (National Comprehensive Cancer Network) guidelines recommend counseling premenopausal patients about risk reduction with tamoxifen(Drug information on tamoxifen), and counseling postmenopausal patients about risk reduction with raloxifene(Drug information on raloxifene) (Evista).[5] LCIS is often multicentric and bilateral, and it is usually diagnosed incidentally following surgical excision of another breast abnormality.[6,7] There are no specific clinical findings (in particular, no palpable lump) associated with these lesions, and the lesion is rarely visible on mammography as a dominant mass.[8,9] When examining pathologic specimens, there are no gross macroscopic features characteristic of LCIS. Multifocality in clinically undetectable lesions makes subsequent management planning difficult. Furthermore, there is no standard of care for treatment when LCIS is the most significant finding on core needle biopsy (CNB). The current management guidelines for LCIS are not adopted uniformly; a follow-up surgical excision is performed when there are features overlapping with DCIS, when there is an association with other high-risk lesions, and when there is an imaging-pathology discordance.[10] The appropriate management when LN is encountered exclusively on CNB specimens has been addressed by some studies and remains controversial. The overall incidence of finding carcinoma on follow-up excision for LN on CNB specimens is reported to be up to 20%.[11,12] The risk of upstaging of CNB specimens is further increased when LN is associated with calcifications or columnar cell alterations.[12] Our study revealed a 13% incidence of upstaging to carcinoma in CNB specimens with LN and columnar cell alterations but only a 9.6% incidence of upstaging in cases with LN alone.[12]

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Pleomorphic Lobular Carcinoma in Situ: A Divergent Entity With Emerging Significance - Cancer Network