What breast screening is recommended for atypical lobular hyperplasia?

Breast Screening Recommendations for Atypical Lobular Hyperplasia

For patients with atypical lobular hyperplasia, annual mammography screening is recommended, with consideration for supplemental breast MRI due to the increased risk of developing breast cancer. 1

Risk Assessment

• Atypical lobular hyperplasia (ALH) is classified as a proliferative lesion with atypia, which significantly increases breast cancer risk 1
• Women with ALH have a 4-5 times higher risk of developing invasive breast cancer compared to the general population 2
• This risk doubles (to approximately 8-10 times) if there is also a family history of breast cancer in a first-degree relative 2
• Approximately 25% of women with excision for proliferative lesions with atypia may develop breast cancer 1

Screening Recommendations

Mammography

• Annual screening mammography is recommended for all women with ALH starting from the time of diagnosis, but not before age 30 1
• Digital breast tomosynthesis (DBT) is preferred over standard mammography as it:
  • Increases cancer detection rates 1
  • Decreases false-positive recall rates 1
  • Shows particular advantages in women under 50 and those with dense breasts 1

Supplemental Screening with MRI

• Breast MRI with intravenous contrast should be considered as supplemental screening for women with ALH 1
• The American College of Radiology supports MRI screening in women with ALH due to their elevated risk of developing breast cancer 3
• When combined with mammography, MRI has a sensitivity of 91-98% for breast cancer detection in high-risk women 3
• In a study of women with atypical lesions who underwent MRI surveillance, additional workup was required in about 24% of cases, with a positive predictive value of 20% for detecting malignancy 4

Management Considerations

• While surgical excision is typically recommended for atypical ductal hyperplasia found on core biopsy, management of ALH has more varied practice 1, 5
• Recent evidence suggests that minimal ALH (≤3 foci) found incidentally on core biopsy may be managed with imaging surveillance rather than surgical excision in select cases 6, 5
• When ALH is found adjacent to microcalcifications on core biopsy, careful radiologic-pathologic correlation is essential as up to 27% of such cases may have higher-risk lesions (atypical ductal hyperplasia) and 9% may have ductal carcinoma in situ on excision 7

Practical Approach

• Begin annual mammography screening at diagnosis of ALH (if patient is ≥30 years old) 1
• Consider supplemental annual breast MRI with contrast, particularly if:
  • Patient has additional risk factors (family history, dense breasts) 3
  • The ALH was extensive or multifocal 1
• Continue screening as long as the patient remains in good health and has a life expectancy of at least 5-7 years 1
• Be aware that mammography may have lower specificity (higher false-positive rate) in women with ALH compared to average-risk women 1

Common Pitfalls to Avoid

• Failing to recognize ALH as a significant risk factor that warrants enhanced screening beyond routine recommendations 1, 2
• Delaying initiation of screening in younger women with ALH (screening should begin at diagnosis if ≥30 years old) 1
• Overlooking the potential benefit of supplemental MRI screening in this higher-risk population 1, 3
• Assuming that surgical excision is always necessary for ALH found on core biopsy - management approaches are evolving toward more selective excision 6, 5