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 So i have decided to create a newer version of this page with more up-to-date information on Non-Invasive Breast Lesions.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%.

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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.

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References

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