What is the management approach for patients with Lobular Carcinoma In Situ (LCIS) versus Atypical Lobular Hyperplasia (ALH)?

Management of Lobular Carcinoma In Situ (LCIS) vs Atypical Lobular Hyperplasia (ALH)

For patients with LCIS, complete surgical excision is recommended, while ALH can be safely managed with imaging surveillance if limited (≤3 foci) and radiologically concordant, with both conditions requiring risk reduction strategies including chemoprevention and long-term surveillance.

Understanding the Risk Profile

Both LCIS and ALH are part of the spectrum of lobular neoplasia, but they carry different risk levels for future breast cancer development:

• ALH: Associated with a 4-5 times increased risk of developing breast cancer (0.5-1.0% per year) 1
• LCIS: Associated with an 8-10 times increased risk of developing breast cancer 2

Initial Management After Core Needle Biopsy

For ALH:

• Assessment criteria:

  • Extent of ALH (number of foci)
  • Presence of other high-risk lesions
  • Radiologic-pathologic concordance 1

• Management recommendations:

  • Limited ALH (≤3 foci) with radiologic-pathologic concordance: Imaging surveillance is appropriate 1, 3
  • Extensive ALH (>4 terminal ductal units) or radiologic-pathologic discordance: Surgical excision is required 1, 3
  • ALH associated with microcalcifications: Consider surgical excision 3

For LCIS:

• Standard LCIS: Complete surgical resection is recommended 4
• Pleomorphic LCIS: More aggressive variant requiring surgical excision due to higher risk of developing into invasive lobular carcinoma 1
• Extensive LCIS or LCIS associated with microcalcifications: Surgical excision is strongly recommended 3

Risk Reduction Strategies

Chemoprevention:

1. Premenopausal women with ALH or LCIS:

   • Tamoxifen for 5 years reduces invasive breast cancer risk by approximately 46% (hazard ratio 0.54) 1, 5

2. Postmenopausal women with ALH or LCIS:

   • Options include:
     • Tamoxifen: Reduces invasive breast cancer risk by 44% 5
     • Raloxifene: Indicated for high-risk postmenopausal women, including those with LCIS or ALH 1, 6
     • Aromatase inhibitors (exemestane or anastrozole): Particularly effective for postmenopausal women 1

Surveillance:

• Regular clinical examinations every 6-12 months 1
• Annual diagnostic mammography 1
• Consider supplemental screening with breast MRI, especially for women with dense breasts 1
• Bilateral surveillance is essential as risk affects both breasts 1

Surgical Risk Reduction:

• Bilateral risk-reduction mastectomy may be considered in special circumstances:
  • Women with BRCA1/2 mutations
  • Strong family history of breast cancer
  • Patient preference after thorough counseling 1

Key Differences in Management Approach

Aspect	ALH	LCIS
Surgical excision	Only if extensive (>3-4 foci), associated with microcalcifications, or radiologic-pathologic discordance	Complete resection recommended for all types; essential for pleomorphic LCIS
Chemoprevention	Recommended for all patients	Recommended for all patients
Surveillance	Required for decades	Required for decades

Common Pitfalls to Avoid

1. Overtreatment: Unnecessary surgical excision for limited ALH (≤3 foci) with radiologic-pathologic concordance 1

2. Inadequate follow-up: The risk of breast cancer persists long-term, requiring consistent surveillance for decades 1

3. Failure to discuss risk reduction options: All women with ALH or LCIS should be informed about chemoprevention options 1

4. Overlooking age considerations: For women diagnosed with LCIS at age 65 and older, surveillance alone may be preferred for optimizing quality-adjusted life expectancy, while chemoprevention shows greater benefit for women ages 40-60 1

5. Insufficient pathologic review: Thorough pathologic assessment is essential to distinguish between ALH, LCIS, and early invasive carcinoma 1

By following these evidence-based management strategies, clinicians can appropriately address the different risk profiles of LCIS and ALH while minimizing both overtreatment and undertreatment.