Is breast reduction recommended for patients with atypical lobular hyperplasia (ALH)?

Management of Atypical Lobular Hyperplasia: Breast Reduction Considerations

Breast reduction surgery is not specifically recommended for patients with atypical lobular hyperplasia (ALH) as a management strategy for the condition itself, but can be performed if otherwise clinically indicated with appropriate surveillance and risk reduction measures in place.

Understanding Atypical Lobular Hyperplasia

Atypical lobular hyperplasia (ALH) is considered a high-risk breast lesion that:

• Increases breast cancer risk by 4-10 fold compared to the general population 1
• Represents a 5-year risk of 3-5% and a 10-year risk of 5-10% for developing breast cancer 1
• Serves as both a risk indicator and potential precursor lesion for breast cancer 2

Management Approach for ALH

Primary Management Options

1. Risk-Reduction Therapy:

   • All women with ALH who are age 35 years or older should be offered endocrine risk-reduction therapy 1
   • Options include:
     • Tamoxifen (standard 20mg dose or low-dose 5mg)
     • Raloxifene (for postmenopausal women)
     • Aromatase inhibitors (exemestane, anastrozole) 1

2. Surveillance:

   • Regular breast screening with mammography 1
   • Clinical breast examinations every 6-12 months for 1-2 years following diagnosis 1
   • Recent evidence supports active surveillance as a favorable option for pure ALH on biopsy 3

3. Surgical Management:

   • When ALH is diagnosed on core needle biopsy:
     • Surgical excision has traditionally been recommended due to potential upgrade rates to malignancy 4
     • Recent studies show low upgrade rates (2.1%) and support active surveillance as an alternative 3

Breast Reduction in the Context of ALH

For patients with ALH who are considering breast reduction for other clinical reasons:

1. Pre-Surgical Considerations:

   • Complete evaluation of any suspicious findings before proceeding with reduction
   • Ensure all areas of concern have been biopsied and assessed 1
   • Consider timing in relation to surveillance protocols

2. Surgical Planning:

   • Inform the surgeon about the ALH diagnosis
   • Ensure proper handling of all breast tissue removed during reduction
   • Complete pathological examination of all excised tissue 1

3. Post-Reduction Management:

   • Continue risk-reduction therapy if previously initiated 1
   • Maintain regular breast cancer screening despite reduced breast volume
   • Follow-up with both plastic surgeon and breast specialist

Evidence on Outcomes

• No studies specifically address outcomes of breast reduction in patients with ALH
• Recent research shows ALH lesions managed by active surveillance remained stable (50%), resolved (47%), or decreased in size (3%) over a median follow-up of 22.5 months 3
• The ipsilateral breast shows especially high risk for breast cancer in the first 5 years after diagnosis of atypia 2

Important Considerations and Pitfalls

• Pathology Communication: Ensure clear communication between the plastic surgeon and pathologist about the patient's history of ALH
• Specimen Handling: All tissue removed during breast reduction should undergo thorough pathological examination
• Risk Counseling: Patients should understand that breast reduction does not eliminate the increased breast cancer risk associated with ALH
• Surveillance Challenges: Reduced breast volume may change the appearance of breast tissue on imaging, requiring radiologists to be informed of prior reduction

Conclusion

While breast reduction is not specifically indicated for ALH management, it can be performed when clinically necessary with appropriate precautions. The primary management of ALH should focus on risk-reduction therapy and surveillance, with the decision for breast reduction made independently based on standard clinical indications for the procedure.