Therapeutic Management for Non-Invasive Breast Lesions at Screening
A non-invasive lesion discovered through screening mammography presents a number of challenges in terms of appropriate follow-up. While there is little danger of anything too serious happening, there are decisions to be made as to the most prudent and least invasive follow-up measures. The first issue is really whether or not enough is known about the make up of the lesion based on mammography alone to warrant a biopsy. If the suspicious lesion appears to be proliferative, then the doctors will want to know whether or not there is anything ‘atypical‘ about the new cell growth. Most proliferative lesions turn out to be benign, so unless there is evidence of clear atypica, clinical follow-up alone may be recommended. In terms of proliferative non-invasive breast lesions that that may raise concerns for increased breast cancer risk and more rigourous follow-up, these findings would likely include typical and atypical ductal hyperplasia, lobular neoplasia, lobular neoplasia in situ, and ductal carcinoma in situ.
I just want to let you know that this page is getting somewhat old.. So i have decided to create a newer version of this page with more up-to-date information on Non-Invasive Breast Lesions. Don’t get me wrong though, this page still has great material, and I would still use it as well.
Ductal hyperplasia, ADH, lobular neoplasia, and DCIS
Ductal Hyperplasia refers to an unusually rapid cell growth of some kind within the breast ducts. Lobular Neoplasia and LCIS is a similar finding new new cell growth, but occurring in the breast lobules. LCIS is considered a serious risk factor for cancer development, but not an imminent threat. DCIS, however, is a very serious indicator of potential breast cancer development and the recommendation is usually for immediate and aggresive treatment. DCIS or ‘ductal carcinoma in situ‘, is not a specific finding but a range of indicators. DCIS is a vague term really, and is described in a little more detail here. DCIS however is still a much preferable diagnosis which much better survival rates, than a finding of an actual breast cancer tumor.
Follow-up may involve clinical examination, excisional biopsy, or lumpectomy
From the table below we can see various management recommendations when screening has detected the presence of a precancerous indicator, but not yet an invasive lesion. The RR or relative risk is the risk of developement of breast cancer, and described more fully here.
|Lesions||Relative Risk||Clinical Exam||Diagnostic Mammography||Management|
|Ductal Hyperplasia||1.5-2||annual||annual for 3 years if core biopsy||clinical follow up|
|Atypical Ductal Hyperplasia||4-5||annual||annual||excisional biopsy|
|Atypical ductal Hyperplasia and family history||6-8||annual||annual||excisional biopsy|
|Lobular Neoplasia, LCIS||4-10||annual||annual||clinical follow-up|
|DCIS||8-10||annual||annual||tumorectomy with radiotherapy|
Atypical ductal hyperplasia may be related to occult breast carcinoma
Recent studies have shown, however, that about one-third of patients with atypical ductal hyperplasia do have an occult carcinoma, as revealed by a core biopsy. Generally speaking, the probability of underestimating a diagnosis of atypical ductal hyperplasia on the basis of radiological features is less of an issue for lesions greater than 20mm in diameter. A breast lesion of greater than 2cm diameter and biopsied will usually come back as a diagnosis of either breast carcinoma or benign fibroadenoma. When the biopsy report for lesions this large suggests a finding of atypical ductal hyperplasia, this would be a bit of a suprise, and the radiologist may wonder whether or not the biopsy ‘target‘ area was properly sampled. ADH usually doesn’t form into ‘target‘ lesions that measure 2cm or more.
‘Borderline’ breast lesions: biopsy or not?
Whether or not a ‘borderline‘ breast lesion should be biopsied or not is often a question for the radiologist. The decision to biopsy is informed by various aspects of the screening mammography, including the patterns of microcalcifications in breast tissue. Vaccuum assisted biopsy is the most common method of tissue sampling when it is required in borderline breast lesions. Statistically, about 20% of borderline lesions, when biopsied, will show clearly benign pathology, while about 55% will remain just as borderline as before. But, about 24% of borderline breast lesions do turn out to be malignant, and of these around 17% will show a non-invasive malignancy and about 7% with invasive malignancy.
DCIS requires immediate treatment
With DCIS, there can be a range of opinions as to how best to proceed. Most experts agree that a lymph node dissection is not necessary, although a sentinel lymph node biopsy might be undertaken. If some evidence of ‘microinvasion‘ is present into the duct wall, then perhaps a lymph node biopsy becomes a little more reasonable. DCIS is discovered by mammography screening about 62% of the time. Quite a high percentage of women (about 78%) have breast conserving surgery after being diagnosed with DCIS, which about 16% have mastecomy, and small percentage may have bilateral mastectomy. With clear positive margins and adjunct radiation therapy, it is reasonable to conclude that breast conserving surgery should be sufficient in the treatment of Ductal carcinoma in situ. If and when local recurrence occurs, it can be dealt with further at that time by re-excision, or mastectomy. Overall, the cure rate for DCIS is around 97%.
Below are a couple Q&A regarding this topic:
- What is invasive breast cancer? Invasive cancers are when cancers grow into normal, healthy tissues. Most breast cancers are invasive.
- What is non-invasive breast cancer? Non-invasive cancers stay within the milk ducts or lobules in the breast. They do not grow into or invade normal tissues within or beyond the breast. Non-invasive cancers are sometimes called carcinoma in situ (in the same place) or pre-cancers. Whether the cancer is non-invasive or invasive, will determine your treatment choices and how you might respond to the treatments you receive.
- Can a cancer be both invasive and non-invasive at the same time? Yes. This means that part of the cancer has grown into normal tissue and part of the cancer has stayed inside the milk ducts or milk lobules. It would be treated as an invasive cancer.
- Moore,MM, Hargett,CW 3rd, Hanks,JB., Fajardo,LL., Harvey,JA., Frierson, HF Jr, and Slingluff, CL Jr.Association of breast cancer with the finding of atypical ductal hyperplasia at core breast biopsy. Department of Surgery, University of Virginia Health Sciences Center, Charlottesville, USA.1997
- Flegg KM, Flaherty JJ, Bicknell AM, Jain S. Surgical outcomes of borderline breast lesions detected by needle biopsy in a breast screening program. World J Surg Oncol.(Sept. 2010) 8;8:78.
- Jacobs TW, Connolly JL, Schnitt SJ: Nonmalignant lesions in breast core needle biopsies: to excise or not to excise? Am J Surg Pathol (2002), 26:1095-110.
- Levine, P., Simsir, A., Cangiarella, J. Management Issues in Breast Lesions Diagnosed by Fine-Needle Aspiration and Percutaneous Core Breast Biopsy. Am J Clin Pathol (2006);125(Suppl 1):S124-S134
- Liberman L, LaTrenta LR, Dershaw DD. Impact of core biopsy on the surgical management of impalpable breast cancer:
another look at margins [letter]. AJR Am J Roentgenol. 1997;169:1464-1465.
- Philpotts LE, Shaheen NA, Jain KS, et al. Uncommon high risk lesions of the breast diagnosed at stereotactic core needle biopsy: clinical importance. Radiology. 2000;216:831-837.
- Hoda SA, Rosen PP. Practical considerations in thepathologic diagnosis of needle core biopsies of the breast. Am J Clin Pathol. 2002;118:101-108.
- Kiluk., J., Hoover, SJ., High-Risk Benign Breast Lesions: Current Strategies in Management. Cancer Control. 2007;14(4):321-329.
- Schnitt S, Connolly J. Pathology of benign breast disorders. In: Harris JR, Lippman ME, Morrow M, et al, eds. Diseases of the Breast. 3rd ed. Philadelphia: Lippincott Williams and Wilkins; 2004.
- Jeffrey SS, Pollack JR. The diagnosis and management of pre-invasive breast disease: promise of new technologies in understanding pre-invasive breast lesions. Breast Cancer Res. (2003);5:320-328.
- Irfan K, Brem RF. Surgical and mammographic follow-up of papillary lesions and atypical lobular hyperplasia diagnosed with stereotactic vacuum-assisted biopsy. Breast J. 2002;8:230-233.
- Rosai J. Borderline epithelial lesions of the breast. Am J Surg PPPathol. 1991;15:209-221.
- Bodian CA, Perzin KH, Lattes R, et al. Prognostic significance of benign proliferative breast disease. Cancer. (1993);71:3896-3907.
- Wang J, Costantino JP, Tan-Chiu E, et al. Lower-category benign breast disease and the risk of invasive breast cancer. J Natl Cancer Inst. (2004);96:616-620.
- Dupont WD, Parl FF, Hartmann WH, et al. Breast cancer risk associated with proliferative breast disease and atypical hyperplasia. Cancer. (1993);71:1258-1265.
- Sakorafas, GH., Farley, DR., Optimal management of ductal carcinoma in situ of the breast. Surgical Oncology, (December 2003) Volume 12, Issue 4, Pages 221-240 Volume 12, Issue 4, Pages 221-240
- Verkooijen HM, Fioretta G, De Wolf C, Vlastos G, Kurtz J, Borisch B, Schäfer P, Spiliopoulos A, Sappino AP, Renella R, Pittet B, Schmid De Gruneck J, Wespi Y, Neyroud-Caspar I, Bouchardy C.Management of women with ductal carcinoma in situ of the breast: a population-based study. Ann Oncol. (Aug. 2002) 13(8):1236-45.
- Chang JH, Vines E, Bertsch H et al. The impact of a multidisciplinary breast cancer center on recommendations for patient management: the University of Pennsylvania experience. Cancer2001; 91: 1231–1237.
- Bedei, L., Falcini, F., Sanna, PA., Giunchi, DC., Innocenti, MP., Vigneutelli, P., Saragoni, L., Folli,S., Amadori, D., Atypical ductal hyperplasia of the breast: The controversial management of a borderline lesion: Experience of 47 cases diagnosed at vacuum-assisted biopsy. The breast. (April 2006) Volume 15, Issue 2, Pages 196-202
Back to breast cancer screening list or to the brand new homepage.