What is the management for a patient with lobular carcinoma in situ (LCIS) and free margins after fibroadenoma excision?

Management of Lobular Carcinoma In Situ (LCIS) After Fibroadenoma Excision

Follow-up (R0) is the appropriate management for a patient with lobular carcinoma in situ (LCIS) with free margins after fibroadenoma excision. 1

Understanding LCIS and Its Management

LCIS is fundamentally different from ductal carcinoma in situ (DCIS) in terms of management approach:

• LCIS is considered a marker of increased risk for subsequent breast cancer rather than a malignant lesion requiring surgical excision 1
• The risk increase applies to both breasts and is likely lifelong
• Unlike DCIS, the relation between LCIS and surgical margins is not important 1

Management Algorithm

1. Initial Management:

   • No further surgical intervention is needed since:
     • LCIS is an incidental finding that doesn't require additional excision
     • Free margins have already been achieved with the fibroadenoma excision
     • LCIS is a risk marker, not a true precursor lesion requiring removal 1, 2

2. Follow-up Protocol:

   • Regular clinical breast examinations
   • Annual mammography for at least 5 years 3
   • Consider longer surveillance given the lifelong increased risk

3. Risk Reduction Options:

   • Consider chemoprevention with selective estrogen receptor modulators:
     • Tamoxifen may be considered to decrease risk of future breast cancer 4
     • Raloxifene is an alternative for postmenopausal women 5

Evidence Supporting Conservative Management

The conservative approach (follow-up without additional surgery) is supported by multiple lines of evidence:

• Studies show that observation alone after LCIS diagnosis is appropriate, with cancers that develop during follow-up likely to be detected at an early, curable stage 2
• A long-term follow-up study found that only 25% of women with LCIS who chose observation developed a second breast event requiring biopsy, with only a small percentage developing invasive cancer 2
• Current guidelines specifically state that LCIS is a risk marker rather than a malignant lesion requiring surgical excision 1

Important Considerations and Caveats

• Distinguish between classic LCIS and pleomorphic LCIS variants:

  • Management of pleomorphic LCIS variants is less defined due to lack of information about natural history 1
  • Some surgeons treat pleomorphic LCIS more aggressively 3

• Despite current recommendations for conservative management, there has been a trend toward increased use of mastectomy for LCIS in some regions 6

  • This trend contradicts evidence-based guidelines and should be avoided

• Patient education is crucial:

  • Explain that LCIS increases risk for future breast cancer in either breast
  • Emphasize that this is not cancer but a risk marker
  • Discuss the excellent prognosis with observation alone

Conclusion

For a patient with LCIS found incidentally after fibroadenoma excision with free margins, the most appropriate management is follow-up (option D). This approach aligns with current guidelines that recognize LCIS as a risk marker rather than a malignancy requiring aggressive surgical intervention.