From the Guidelines
Management of atypical lobular hyperplasia (ALH) of the breast typically involves surgical excision when it is found on core needle biopsy to rule out more serious pathology, as approximately 10-20% of ALH cases may be upgraded to lobular carcinoma in situ (LCIS) or invasive cancer upon excision. If ALH is confirmed after surgical excision or if it is an incidental finding on excisional biopsy, no further surgery is needed. For risk reduction, patients should be offered chemoprevention with selective estrogen receptor modulators (SERMs) like tamoxifen (20 mg daily for 5 years) for premenopausal women or raloxifene (60 mg daily for 5 years) for postmenopausal women, or aromatase inhibitors like exemestane (25 mg daily for 5 years) or anastrozole (1 mg daily for 5 years) for postmenopausal women, as recommended by the American Society of Clinical Oncology (ASCO) 1. These medications can reduce breast cancer risk by 50-65% 1. Patients should undergo enhanced surveillance with annual mammography and clinical breast exams every 6-12 months. Some high-risk patients may benefit from additional screening with breast MRI. Lifestyle modifications including maintaining a healthy weight, limiting alcohol consumption, regular exercise, and avoiding hormone replacement therapy are also recommended 1. Genetic counseling should be considered, especially for patients with a family history of breast or ovarian cancer, to assess for hereditary cancer syndromes. Key points to consider in the management of ALH include:
- Surgical excision to rule out more serious pathology
- Chemoprevention with SERMs or aromatase inhibitors for risk reduction
- Enhanced surveillance with annual mammography and clinical breast exams
- Lifestyle modifications to reduce breast cancer risk
- Genetic counseling for patients with a family history of breast or ovarian cancer. The use of low-dose tamoxifen (5 mg daily) has also been shown to be effective in reducing breast cancer risk, with fewer side effects compared to the standard dose of 20 mg daily 1. However, the decision to use low-dose tamoxifen should be made on an individual basis, taking into account the patient's risk factors and medical history. Overall, the management of ALH should be tailored to the individual patient's needs and risk factors, with the goal of reducing the risk of breast cancer and improving quality of life.
From the Research
Management of Atypical Lobular Hyperplasia (ALH)
The management of atypical lobular hyperplasia (ALH) of the breast involves several options, including:
- Lifelong surveillance with the goal of detecting subsequent malignancy at an early stage 2
- Chemoprevention 2, 3
- Bilateral prophylactic mastectomy, which may be considered in selected situations, especially when patients have a family history of breast cancer or other risk factors 2, 4
- Imaging surveillance, which can be a reasonable alternative to surgical management for ALH diagnosed on core needle biopsy, in specific circumstances 5
Surgical Excision
Surgical excision is still recommended after diagnosis of ALH on core needle biopsy, especially when there is a high risk of cancer underestimation 6. However, recent studies suggest that imaging surveillance may be a viable option for some patients with ALH 5.
Risk Assessment
The risk of breast cancer associated with ALH is increased, ranging from a three- to four-fold increased risk 2, 3. The management of ALH depends on the individual patient's risk factors, including family history and genetic predisposition 4.
Clinical Implications
The diagnosis of ALH on core needle biopsy has significant clinical implications, including the need for further management to reduce the risk of breast cancer 3, 5. The choice of management option depends on the individual patient's circumstances and risk factors.