When a breast tissue biopsy shows atypical lobular hyperplasia (ALH) or lobular carcinoma in situ (LCIS), it is standard clinical practice to surgically excise these lesions because of their association with a higher risk for cancer.
However, a retrospective study published online July 30 inRadiology suggests that surgery is not always necessary.
"Some women can be safely triaged to observation," say lead author Kristen Atkins, MD, from the University of Virginia in Charlottesville, and colleagues.
When the pathology and radiology findings are both benign and in agreement with one another, these women can be followed with periodic imaging and clinical examination, the authors suggest. "The benefits of reducing the number of surgeries would be obvious from both an economic and patient perspective," they add.
ALH and LCIS appear as incidental findings on image-guided core biopsy. "From a pathology perspective, ALH and LCIS are often tiny lesions, so we wondered why they were getting excised," Dr. Atkins said in a statement. "These surgeries may involve general anesthesia and possible disfigurement," she pointed out.
However, these breast tissue abnormalities lead to a 4- to 10-fold increase in the the risk of developing breast cancer.
"Because of the possibility of an upgrade to cancer, the bulk of the published literature says that the prudent thing to do is excise ALH and LCIS," explained second author Michael Cohen, MD FACR, from the Emory University School of Medicine in Atlanta. He was previously at the University of Virginia, and often discussed with Dr. Atkins how to balance the risk for cancer with the costs and potential complications of surgery.
In the team's search for a way to limit the number of patients requiring surgery, they focused on imaging–histologic concordance.
10 Years of Data Studied
They studied 10 years of pathology and radiology data and 141 core biopsies with ALH or LCIS; they then excluded biopsies that contained other lesions (such as papilloma or flat epithelial atypia) that would have required excision.
Fifty biopsies from 49 women 40 to 73 years of age (mean, 59 years) were available for radiologic–pathologic analysis. Two biopsies came from the same woman, but were taken at different times and from different breasts. The team was blinded to subsequent follow-up information.
The authors found that imaging and histology results were benign and in agreement with one another (concordant) in 43 cases. Once the results were unblinded, they learned that 38 of these cases had been managed with excision and 5 were followed with imaging for 3 to 8 years. None of the 43 cases with concordant findings were subsequently upgraded to cancer.
The radiology and histology findings were discordant in the remaining 7 cases. Five of these cases had been managed with surgery and 2 had been followed with imaging for 3 to 5 years.
Of these 7 discordant cases, 2 (29%) were subsequently upgraded to ductal carcinoma in situ.
Because none of the concordant cases were subsequently upgraded to cancer, "observation in these patients would have been a viable alternative to surgery," the authors conclude.
"When there's no discordance between the radiologist and pathologist after thorough radiology–pathology correlation, there's no upgrade from ALH or LCIS in our study," Dr. Cohen said in a statement.
"These findings show that some women can avoid surgery, and that yearly mammograms, along with MRI or ultrasound as second-line screening tools, may suffice," he said.
However, the authors acknowledge that the relatively small number of cases they investigated is a limitation of their study, and additional validation is required before this approach can be universally applied.
JosephH. Tashjian, MD, who specializes in diagnostic radiology at Regions Hospital, St. Paul, Minnesota, who was asked by Medscape Medical News to comment, noted that "this is a very important paper."
"The real key is the meticulous attention to concordance," Dr. Tashjian explained. I believe they had such good results because they excluded lesions such as florid or pleomorphic LCIS from the recommendation to avoid surgery, he pointed out.
Frustrating to Recommend Surgery for All
"Currently, we do recommend surgery for all patients who have ALH or LCIS, even if it is incidental to the mammographic abnormality," he told Medscape Medical News in an email. "This is not an unusual finding, and it is frustrating because, already, many people are concerned about overdiagnosis in breast radiology."
Dr. Tashjian said that he and his colleagues plan to "look back over our cases of ALH and LCIS to see if we could have avoided the additional surgery."
"It has always been my hunch that sending these cases to surgery has not been fruitful," he said.
There are reasons to avoid surgical biopsy. There is anxiety associated with any type of surgery, postoperative deformity in a small breast can be significant, and it can lead to delays in operating room slots for women who actually have cancer, he explained. In addition, there is a cost to surgery for both to the community and the patient.
Although only 50 cases were examined, Dr. Tashjian noted that this is "a good number to begin such a study with."
Once there are larger numbers, there may be exceptions, he explained. "I would be surprised if there were 500 cases and the statistics were the same. It occasionally happens that we find an incidental cancer in a woman with a mastectomy that was not diagnosed either on mammography, ultrasound, or MRI. I am sure that eventually the same will be true with this," he note. "It is unlikely, though, that detecting these cancers a year later will make much difference."
The authors and Dr. Tashjian have disclosed no relevant financial relationships.
Radiology. Published online July 30, 2013. Abstract
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