The management of lobular carcinoma in situ (LCIS). Is LCIS the same as ductal carcinoma in situ (DCIS)?

Breast Cancer Detection and Prevention Using Machine Learning

Breast cancer is a common cause of female mortality in developing countries. Early detection and treatment are crucial for successful outcomes. Breast cancer develops from breast cells and is considered a leading cause of death in women. This disease is classified into two subtypes: invasive ductal carcinoma (IDC) and ductal carcinoma in situ (DCIS). The advancements in artificial intelligence (AI) and machine learning (ML) techniques have made it possible to develop more accurate and reliable models for diagnosing and treating this disease. From the literature, it is evident that the incorporation of MRI and convolutional neural networks (CNNs) is helpful in breast cancer detection and prevention. In addition, the detection strategies have shown promise in identifying cancerous cells. The CNN Improvements for Breast Cancer Classification (CNNI-BCC) model helps doctors spot breast cancer using a trained deep learning neural network system to categorize breast cancer subtypes. However, they require significant computing power for imaging methods and preprocessing. Therefore, in this research, we proposed an efficient deep learning model that is capable of recognizing breast cancer in computerized mammograms of varying densities. Our research relied on three distinct modules for feature selection: the removal of low-variance features, univariate feature selection, and recursive feature elimination. The craniocaudally and medial-lateral views of mammograms are incorporated. We tested it with a large dataset of 3002 merged pictures gathered from 1501 individuals who had digital mammography performed between February 2007 and May 2015. In this paper, we applied six different categorization models for the diagnosis of breast cancer, including the random forest (RF), decision tree (DT), k-nearest neighbors (KNN), logistic regression (LR), support vector classifier (SVC), and linear support vector classifier (linear SVC). The simulation results prove that our proposed model is highly efficient, as it requires less computational power and is highly accurate.

DCIS: When is accelerated partial breast irradiation an option? A meta-analysis on outcomes and eligibility

BACKGROUND

The natural history of DCIS may not be progression to invasive breast cancer (IBC). Accelerated partial breast irradiation (APBI) has emerged as an alternative to whole breast radiotherapy (WBRT). The purpose of this study was to assess the impact of APBI on DCIS patients.

MATERIALS AND METHODS

Eligible studies from 2012 to 2022 were identified in PubMed, Cochrane Library, ClinicalTrials, and ICTRP. A meta-analysis was done comparing recurrence rates, breast-related mortality rates, and adverse events of APBI versus WBRT. A subgroup analysis of 2017 ASTRO Guidelines "Suitable" and "Unsuitable" groups was performed. Forest plots and quantitative analysis were done.

RESULTS

Six studies were eligible (3 on APBI versus WBRT, 3 on APBI suitability). All had a low risk of bias and publication bias. The cumulative incidence was the following for APBI and WBRT respectively: IBTR was 5.7% and 6.3% with odds ratio of 1.09, 95% CI [0.84, 1.42], mortality rate was 4.9% and 5.05%, and adverse events was 48.87% and 69.63%. All had no statistical significance between groups. Adverse events were found to favor the APBI arm. Recurrence rate was significantly less in the Suitable group with an odds ratio 2.69, 95% CI [1.56, 4.67], favoring it over the Unsuitable group.

CONCLUSION

APBI was comparable to WBRT in terms of recurrence rate, breast cancer-related mortality rate, and adverse events. APBI was not inferior to WBRT and showed better safety in terms of skin toxicity. Patients classified as suitable for APBI had significantly lesser recurrence rate.

Ductal carcinoma in situ: to treat or not to treat, that is the question

Ductal carcinoma in situ (DCIS) now represents 20-25% of all 'breast cancers' consequent upon detection by population-based breast cancer screening programmes. Currently, all DCIS lesions are treated, and treatment comprises either mastectomy or breast-conserving surgery supplemented with radiotherapy. However, most DCIS lesions remain indolent. Difficulty in discerning harmless lesions from potentially invasive ones can lead to overtreatment of this condition in many patients. To counter overtreatment and to transform clinical practice, a global, comprehensive and multidisciplinary collaboration is required. Here we review the incidence of DCIS, the perception of risk for developing invasive breast cancer, the current treatment options and the known molecular aspects of progression. Further research is needed to gain new insights for improved diagnosis and management of DCIS, and this is integrated in the PRECISION (PREvent ductal Carcinoma In Situ Invasive Overtreatment Now) initiative. This international effort will seek to determine which DCISs require treatment and prevent the consequences of overtreatment on the lives of many women affected by DCIS.

Hereditary lobular breast cancer with an emphasis on E-cadherin genetic defect

Recent studies have reported germline CDH1 mutations in cases of lobular breast cancer (LBC) not associated with the classical hereditary diffuse gastric cancer syndrome. A multidisciplinary workgroup discussed genetic susceptibility, pathophysiology and clinical management of hereditary LBC (HLBC). The team has established the clinical criteria for CDH1 screening and results' interpretation, and created consensus guidelines regarding genetic counselling, breast surveillance and imaging techniques, clinicopathological findings, psychological and decisional support, as well as prophylactic surgery and plastic reconstruction. Based on a review of current evidence for the identification of HLBC cases/families, CDH1 genetic testing is recommended in patients fulfilling the following criteria: (A) bilateral LBC with or without family history of LBC, with age at onset <50 years, and (B) unilateral LBC with family history of LBC, with age at onset <45 years. In CDH1 asymptomatic mutant carriers, breast surveillance with clinical examination, yearly mammography, contrast-enhanced breast MRI and breast ultrasonography (US) with 6-month interval between the US and the MRI should be implemented as a first approach. In selected cases with personal history, family history of LBC and CDH1 mutations, prophylactic mastectomy could be discussed with an integrative group of clinical experts. Psychodecisional support also plays a pivotal role in the management of individuals with or without CDH1 germline alterations. Ultimately, the definition of a specific protocol for CDH1 genetic screening and ongoing coordinated management of patients with HLBC is crucial for the effective surveillance and early detection of LBC.

Pleomorphic LCIS what do we know? A UK multicenter audit of pleomorphic lobular carcinoma in situ

AIMS

Pleomorphic lobular carcinoma in situ (PLCIS) is a relatively newly described pathological lesion that is distinguished from classical LCIS by its large pleomorphic nuclei. The lesion is uncommon and its appropriate management has been debated. The aim of this study is to review data from a large series of PLCIS to examine its natural history in order to guide management plans.

MATERIALS AND METHODS

Comprehensive pathology data were collected from two cohorts; one from a UK multicentre audit and the other a series of PLCIS cases identified from within the GLACIER study cohort. 179 cases were identified of whom 176 had enough data for analysis.

RESULTS

Out of these 176 cases, 130 had invasive disease associated with PLCIS, the majority being of lobular type (classical and/or pleomorphic). A high incidence of histological grade 2 and 3 invasive cancers was noted with a predominance of ER positive and HER-2 negative malignancy. When PLCIS was the most significant finding on diagnostic biopsy the upgrade to invasive disease on excision was 31.8%, which is higher than pooled data for classical LCIS and DCIS.

CONCLUSION

The older age at presentation, high grade of upgrade to invasive cancer, common association with higher grade tumours suggest that PLCIS is an aggressive form of insitu disease. These findings support the view that PLCIS is a more aggressive form of lobular in situ neoplasia and supports the tendency to treat akin to DCIS.

Treatment and survival outcomes of lobular carcinoma in situ of the breast: a SEER population based study

Lobular carcinoma in situ (LCIS) represents 5.3% of in situ specimens, and is thought to carry a low risk for developing to the invasive lobular breast cancer (ILC). There is still no standard care approach for patients with LCIS. We aimed to define the impacts of surgical and radiation intervention on survival outcomes of LCIS. LCIS cases from 2004 to 2013 of the recent Surveillance, Epidemiology, and End Results (SEER) database were analyzed. Clinicopathologic features were analyzed in 16002 patients between 2004 and 2013. Treatment modalities included no surgery (NS), lumpectomy alone (LA), lumpectomy with radiation treatment (LRT), mastectomy alone (MA) and mastectomy with radiation treatment (MRT). The overall survival (OS) was calculated by the Kaplan-Meier method. Univariate and multivariate analyses were performed using the variables of treatment, race, hormone receptor status, grade and age. Among 16002 patients, median follow-up was 54 months. Patients treated with LA had superior OS for NS (P = 0.001), MA (P < 0.001) and MRT P = 0.018). LRT only had superior OS for MRT (P = 0.009). There was no statistically significance between LA and LRT (P = 0.317). Improved OS was also correlated with younger age (P < 0.001), progesterone receptor positive (P = 0.001). Black patients had the worst OS (P < 0.001). There was no obvious survival difference among grade groups (P = 0.536). The LCIS patients treated with LA or LRT had better survival comparing with other groups. Considering the medical expense and the risk of radiotherapy, LA may be the most appropriate therapy for patients with LCIS.

A Bayesian network and heuristic approach for systematic characterization of radiotherapy receipt after breast-conservation surgery

BACKGROUND

Breast-conservation surgery with radiotherapy is a treatment highly recommended by the guidelines from the National Comprehensive Cancer Network. However, several variables influence the final receipt of radiotherapy and it might not be administered to breast cancer patients. Our objective is to propose a systematic framework to identify the clinical and non-clinical variables that influence the receipt of unexpected radiotherapy treatment by means of Bayesian networks and a proposed heuristic approach.

METHODS

We used cancer registry data of Detroit, San Francisco-Oakland, and Atlanta from years 2007-2012 downloaded from the Surveillance, Epidemiology, and End Results Program. The samples had patients diagnosed with in situ and early invasive cancer with 14 clinical and non-clinical variables. Bayesian networks were fitted to the data of each region and systematically analyzed through the proposed Zoom-in heuristic. A comparative analysis with logistic regressions is also presented.

RESULTS

For Detroit, patients under stage 0, grade undetermined, histology lobular carcinoma in situ, and age between 26-50 were found more likely to receive breast-conservation surgery without radiotherapy. For stages I, IIA, and IIB patients with age between 51-75, and grade II were found to be more likely to receive breast-conservation surgery with radiotherapy. For San Francisco-Oakland, patients under stage 0, grade undetermined, and age >75 are more likely to receive BCS. For stages I, IIA, and IIB patients with age >75 are more likely to receive breast-conservation surgery without radiotherapy. For Atlanta, patients under stage 0, grade undetermined, year 2011, and primary site C509 are more likely to receive breast-conservation surgery without radiotherapy. For stages I, IIA, and IIB patients in year 2011, and grade III are more likely to receive breast-conservation surgery without radiotherapy.

CONCLUSION

For in situ breast cancer and early invasive breast cancer, the results are in accordance with the guidelines and very well demonstrates the usefulness of the Zoom-in heuristic in systematically characterizing a group receiving a treatment. We found a subset of the population from Detroit with ductal carcinoma in situ for which breast-conservation surgery without radiotherapy was received, but potential reasons for this treatment are still unknown.

Clinical and pathological assessment of high-risk ductal and lobular breast lesions: What surgeons must know

Terminology in pathology is sometimes over-complicated and may be misinterpreted by clinicians facing patients and having difficulty answering questions posed by them. This may especially be true for some breast lesions with an increased risk of malignant transformation, the complex terminology of which reflects attempts to stratify them according to potential risk. On the basis of morphological and molecular features, both ductal and lobular proliferations have been classified and named in different ways by pathologists, and this often makes it difficult for the treating physicians and the patients to fully understand the nature of the lesions and their associated risks. In order to clarify pathology reports, unambiguous and simple terms are needed.

Clonal relationships between lobular carcinoma in situ and other breast malignancies

Background

Recent evidence suggests that lobular carcinoma in situ (LCIS) can be a clonal precursor of invasive breast cancers of both the ductal and lobular phenotypes. We sought to confirm these findings with an extensive study of fresh frozen breast specimens from women undergoing mastectomy.

Methods

Patients with a history of LCIS presenting for therapeutic mastectomy were identified prospectively. Frozen tissue blocks were collected, screened for lesions of interest, and subjected to microdissection and DNA extraction. Copy number profiling, whole-exome sequencing, or both were performed. Clonal relatedness was assessed using specialized statistical techniques developed for this purpose.

Results

After exclusions for genotyping failure, a total of 84 lesions from 30 patients were evaluated successfully. Strong evidence of clonal relatedness was observed between an LCIS lesion and the invasive cancer for the preponderance of cases with lobular carcinoma. Anatomically distinct in situ lesions of both ductal and lobular histology were also shown to be frequently clonally related.

Conclusions

These data derived from women with LCIS with or without invasive cancer confirm that LCIS is commonly the clonal precursor of invasive lobular carcinoma and that distinct foci of LCIS frequently share a clonal origin, as do foci of LCIS and ductal carcinoma in situ.

Electronic supplementary material

The online version of this article (doi:10.1186/s13058-016-0727-z) contains supplementary material, which is available to authorized users.

The radiological features, diagnosis and management of screen-detected lobular neoplasia of the breast: Findings from the Sloane Project

OBJECTIVES

To investigate the radiological features, diagnosis and management of screen-detected lobular neoplasia (LN) of the breast.

MATERIALS AND METHODS

392 women with pure LN alone were identified within the prospective UK cohort study of screen-detected non-invasive breast neoplasia (the Sloane Project). Demography, radiological features and diagnostic and therapeutic procedures were analysed.

RESULTS

Non-pleomorphic LN (369/392) was most frequently diagnosed among women aged 50-54 and in 53.5% was at the first screen. It occurred most commonly on the left (58.0%; p = 0.003), in the upper outer quadrant and confined to one site (single quadrant or retroareolar region). No bilateral cases were found. The predominant radiological feature was microcalcification (most commonly granular) which increased in frequency with increasing breast density. Casting microcalcification as a predominant feature had a significantly higher lesion size compared to granular and punctate patterns (p = 0.034). 326/369 (88.3%) women underwent surgery, including 17 who underwent >1 operation, six who had mastectomy and six who had axillary surgery. Two patients had radiotherapy and 15 had endocrine treatment. Pleomorphic lobular carcinoma in situ (23/392) presented as granular microcalcification in 12; four women had mastectomy and six had radiotherapy.

CONCLUSION

Screen-detected LN occurs in relatively young women and is predominantly non-pleomorphic and unilateral. It is typically associated with granular or punctate microcalcification in the left upper outer quadrant. Management, including surgical resection, is highly variable and requires evidence-based guideline development.

Targeted capture massively parallel sequencing analysis of LCIS and invasive lobular cancer: Repertoire of somatic genetic alterations and clonal relationships

PURPOSE

Lobular carcinoma in situ (LCIS) has been proposed as a non-obligate precursor of invasive lobular carcinoma (ILC). Here we sought to define the repertoire of somatic genetic alterations in pure LCIS and in synchronous LCIS and ILC using targeted massively parallel sequencing.

METHODS

DNA samples extracted from microdissected LCIS, ILC and matched normal breast tissue or peripheral blood from 30 patients were subjected to massively parallel sequencing targeting all exons of 273 genes, including the genes most frequently mutated in breast cancer and DNA repair-related genes. Single nucleotide variants and insertions and deletions were identified using state-of-the-art bioinformatics approaches.

RESULTS

The constellation of somatic mutations found in LCIS (n = 34) and ILC (n = 21) were similar, with the most frequently mutated genes being CDH1 (56% and 66%, respectively), PIK3CA (41% and 52%, respectively) and CBFB (12% and 19%, respectively). Among 19 LCIS and ILC synchronous pairs, 14 (74%) had at least one identical mutation in common, including identical PIK3CA and CDH1 mutations. Paired analysis of independent foci of LCIS from 3 breasts revealed at least one common mutation in each of the 3 pairs (CDH1, PIK3CA, CBFB and PKHD1L1).

CONCLUSION

LCIS and ILC have a similar repertoire of somatic mutations, with PIK3CA and CDH1 being the most frequently mutated genes. The presence of identical mutations between LCIS-LCIS and LCIS-ILC pairs demonstrates that LCIS is a clonal neoplastic lesion, and provides additional evidence that at least some LCIS are non-obligate precursors of ILC.

Feasibility of a prospective, randomised, open-label, international multicentre, phase III, non-inferiority trial to assess the safety of active surveillance for low risk ductal carcinoma in situ - The LORD study

BACKGROUND

The current debate on overdiagnosis and overtreatment of screen-detected ductal carcinoma in situ (DCIS) urges the need for prospective studies to address this issue. A substantial number of DCIS lesions will never form a health hazard, particularly if it concerns non- to slow-growing low-grade DCIS. The LORD study aims to evaluate the safety of active surveillance in women with low-risk DCIS.

DESIGN

This is a randomised, international multicentre, open-label, phase III non-inferiority trial, led by the Dutch Breast Cancer Research Group (BOOG 2014-04) and the European Organization for Research and Treatment of Cancer (EORTC-BCG 1401). Standard treatment will be compared to active surveillance in 1240 women aged ⩾ 45 years with asymptomatic, screen-detected, pure low-grade DCIS based on vacuum-assisted biopsies of microcalcifications only. Both study arms will be monitored with annual digital mammography for a period of 10 years. The primary end-point is 10-year ipsilateral invasive breast cancer free percentage. Secondary end-points include patient reported outcomes, diagnostic biopsy rate during follow-up, ipsilateral mastectomy rate and translational research.

FEASIBILITY

To explore interest in and feasibility of the LORD study we conducted a survey among EORTC and BOOG centres. A vast majority of EORTC and BOOG responding centres expressed interest in participation in the LORD study. The proposed study design is endorsed by nearly all centres.

Lobular carcinoma in situ (LCIS) of the breast: is long-term outcome similar to ductal carcinoma in situ (DCIS)? Analysis of 200 cases

Background

Lobular carcinomas in situ (LCIS) represent 1-2% of all breast cancers. Both significance and treatment remain widely debated, as well as the possible similarities with DCIS.

Materials and methods

Two hundred patients with pure LCIS were retrospectively analyzed in seven centres from 1990 to 2008. Median age was 52 years; 176 patients underwent breast-conserving surgery (BCS) and 24 mastectomy. Seventeen patients received whole breast irradiation (WBRT) after BCS and 20 hormonal treatment (15 by tamoxifen).

Results

With a 144-month median follow-up (FU), there were no local recurrences (LR) among 24 patients treated by mastectomy. With the same FU, 3 late LR out of 17 (17%) occurred in patients treated by BCS and WBRT (with no LR at 10 years). Among 159 patients treated by BCS alone, 20 developed LR (13%), but with only a 72-month FU (17.5% at 10 years). No specific LR risk factors were identified. Three patients developed metastases, two after invasive LR; 22 patients (11%) developed contralateral BC (59% invasive) and another five had second cancer.

Conclusions

LCIS is not always an indolent disease. The long-term outcome is quite similar to most ductal carcinomas in situ (DCIS). The main problems are the accuracy of pathological definition and a clear identification of more aggressive subtypes, in order to avoid further invasive LR. BCS + WBRT should be discussed in some selected cases, and the long-term results seem comparable to DCIS.

Accuracy of screening mammography in women with a history of lobular carcinoma in situ or atypical hyperplasia of the breast

Women with lobular carcinoma in situ (LCIS), atypical lobular hyperplasia (ALH), atypical ductal hyperplasia (ADH), or atypical hyperplasia (AH) are at increased breast cancer (BC) risk. We investigated the accuracy and outcomes of mammography screening in women with histology-proven LCIS, ALH, ADH, or AH history who had screening through Breast Cancer Surveillance Consortium-affiliated mammography facilities. Screens from two cohorts, defined by LCIS/ALH or ADH/AH history, were compared to two cohorts without such history mammogram-matched for age-group, breast density, family history, screen-year, and mammography registry. Overall 359 BCs (277 invasive BC) occurred within 1 year from screening among 52,380 screens. In the LCIS/ALH cohort [versus comparator screens] cancer incidence rates, cancer detection rates (CDR), and interval cancer rates (ICR) were significantly higher (all P < 0.001); although ICR was 4.4/1,000 screens [versus 0.9/1,000; P < 0.001] the proportion that were interval cancers did not differ between compared cohorts (P = 0.43); screening sensitivity was 76.1 % [versus 82.3 %; P = 0.43], however, specificity was significantly lower at 85.1 % [versus 90.7 %; P < 0.0001]. In the ADH/AH cohort [versus comparator] cancer rates and CDR were significantly higher (P < 0.001); although ICR was 2.6/1,000 screens [versus 0.9/1,000; P = 0.002] the proportion that were interval cancers did not differ between cohorts (P = 0.74); screening sensitivity was 81.0 % [versus 82.6 %; P = 0.74] and specificity was lower at 86.2 % [versus 90.2 %; P < 0.0001]. Mammography screening sensitivity in LCIS/ALH and ADH/AH cohorts did not significantly differ from that of matched screens, however, specificity was lower, and ICRs were higher (reflecting underlying cancer rates). Adjunct screening may be of value in these women if it reduces ICR without substantially reducing specificity.

Adverse Histopathology and Imaging Findings in Reduction Mammaplasty Day-surgery Patients

Background and Aims:

Reduction mammaplasty is a popular procedure in plastic surgery. Occasionally, occult invasive breast carcinoma or findings demonstrating increased risk of breast cancer occur in reduction mammaplasty specimens. The incidences have been studied elsewhere, but in Finland, the data on this subject are lacking. Our aim was to analyze the incidence of occult invasive and in situ carcinoma and benign breast disease causing increased risk of breast cancer in reduction mammaplasty specimens. We also analyzed preoperative mammograms and ultrasound images and compared findings with reduction mammaplasty specimens.

Material and Methods:

We performed a retrospective study of 100 women who underwent reduction mammaplasty during 1 January 2007 to 30 April 2009 in Jorvi Hospital day-surgery unit. Demographic data, findings in preoperative imaging, pathology reports, postoperative follow-up, and retrospective reanalysis of preoperative imaging were recorded.

Results:

Histological abnormality occurred in 14.6% of the patients. In situ carcinoma was diagnosed in 4.5% of the patients, and findings demonstrating increased risk of breast cancer were diagnosed in 13.5% of the patients. More than one lesion demonstrating increased risk of breast cancer was diagnosed in 4.5% of the patients. No invasive carcinoma occurred. Preoperative mammogram was performed for the majority (94.0%) of the patients.

Conclusions:

We detected a considerable amount of findings in reduction mammaplasty specimens with prognostic value with regard to future breast cancer risk. We recommend histological analysis for reduction mammaplasty specimens and focus attention on systematically performed preoperative imaging.

When is excision necessary for atypical lobular hyperplasia and lobular carcinoma in situ?

SUMMARY This management perspective briefly covers the histology and molecular features of lobular in situ neoplasia and provides an in-depth discussion of the need for surgical excision if lobular in situ neoplasia is diagnosed on core-needle biopsy. The management of lobular in situ neoplasia found on core-needle biopsy has been an area of recent study with varying results. Emerging data suggest that low-risk patients with a limited extent of isolated classic lobular in situ neoplasia found on core-needle biopsy may not require subsequent surgical excision. However, high-risk patients, those with extensive lobular in situ neoplasia, or other high-risk lesions noted on core-needle biopsy likely benefit from surgical excision. Most authors recommend surgical excision when pleomorphic lobular carcinoma in situ is found on core-needle biopsy due to its higher association with invasive carcinoma. However, the natural history of this more recently described variant of lobular carcinoma in situ is not fully defined, and the clinical management of pleomorphic lobular carcinoma in situ on excisional biopsy is yet to be determined.

Atypical lobular hyperplasia and lobular carcinoma in situ at core breast biopsy: use of careful radiologic-pathologic correlation to recommend excision or observation

PURPOSE

To assess the utility of precise radiologic and pathologic correlation for establishing imaging-histologic concordance or discordance as a method to limit the number of patients requiring surgical excision when atypical lobular hyperplasia (ALH) or lobular carcinoma in situ (LCIS) is diagnosed at core biopsy.

MATERIALS AND METHODS

This study was approved by the institutional review board, and the requirement to obtain informed consent was waived. The pathology database was searched from 2000 to 2010 for core biopsies yielding ALH or LCIS devoid of any additional lesion that independently necessitated excision. All cases had to have either subsequent surgical excision or a minimum of 2 years of imaging follow-up. This yielded 50 cases from 49 women aged 40-73 years (mean age, 59 years). The authors performed detailed radiologic-pathologic analysis while blinded to subsequent follow-up information, comparing all biopsy-related images with the histologic findings at core biopsy and then designating each core biopsy finding as concordant or discordant. Then, results of subsequent surgery or extended follow-up for each case were unblinded and compared with original concordant or discordant designations. Outcomes and confidence intervals (CIs) were calculated.

RESULTS

Of the 43 benign concordant core biopsy findings, none were upgraded at surgery (n = 38) or extended follow-up (n = 5) (95% CI: 0%, 8%). Of the seven discordant biopsy findings, two were upgraded to ductal carcinoma in situ at surgery (n = 5); none of the cases were upgraded at follow-up (n = 2).

CONCLUSION

When careful radiologic-pathologic correlation is performed and concordance is achieved, women with ALH or LCIS at core biopsy can be observed.

Usefulness and limitations of E-cadherin and β-catenin in the classification of breast carcinomas in situ with mixed pattern

Background

The distinction between lobular neoplasia of the breast and ductal carcinoma in situ has important therapeutic implications. In some cases, it is very difficult to determine whether the morphology of the lesion is ductal or lobular. The aim of this study was to evaluate the value of E-cadherin and β-catenin expression through the immunophenotypical characterization of carcinoma in situ with mixed pattern (CISM).

Methods

A total of 25 cases of CISM were analyzed considering cytology/mixed architecture (ductal and lobular), nuclear pleomorphism, loss of cell cohesion, and presence of comedonecrosis. The immunophenotype pattern was considered E-cadherin positive and β-catenin positive, or negative.

Results

Nineteen (76%) cases presented a mixed cytology and / or architectural pattern, two (8%) presented nuclear pleomorphism, two (8%) presented mixed cytology and nuclear pleomorphism, and two (8%) presented comedonecrosis and nuclear pleomorphism. A complete positivity for E-cadherin and β-catenin was observed in 11 cases (44%). In one case, the lesion was negative for both markers and showed nuclear pleomorphis. Thirteen lesions showed negative staining in areas of lobular cytology and positive staining in cells presenting the ductal pattern.

Conclusions

The expression of E-cadherin and β-catenin, combined with cytological and architectural analysis, may highlight different immunophenotypes and improve classification of CISM.

Virtual Slides

The virtual slide(s) for this article can be found here: http://www.diagnosticpathology.diagnomx.eu/vs/1693384202970681

Classic lobular neoplasia on core biopsy: a clinical and radio-pathologic correlation study with follow-up excision biopsy

There are no consensus guidelines for the management of lobular neoplasia diagnosed on core biopsy as the highest risk factor for cancer. This study aimed to assess the risk of upgrade (invasive carcinoma or ductal carcinoma in situ) at the site of the lobular neoplasia and any clinical, radiological or pathologic factors associated with the upgrade. We reviewed all cases with a diagnosis of lobular neoplasia on core biopsy from June 2006 to June 2011. Any cases with radio-pathologic discordance, coexistent lesion that required excision (atypical ductal hyperplasia, flat epithelial atypia, duct papilloma or radial scar) or non-classic variant of lobular carcinoma in situ (pleomorphic, mixed ductal and lobular, lobular carcinoma in situ with necrosis) were excluded from the study. Core biopsy indications included calcification in 35 (40%), non-mass like enhancement in 19 (22%), mass lesion in 31 (36%) and mass as well as calcification in two cases (2%). Follow-up excisions were studied for the presence of upgrade. The study cohort included 87 cases and showed an upgrade of 3.4% (95% confidence interval: 1-10%). Three cases showed an upgrade (one ductal carcinoma in situ and two invasive cancers). All upgraded cases were breast imaging-reporting and data system score ≥4 and associated with atypical duct hyperplasia or in situ or invasive cancer in prior or concurrent biopsies in either breast. The number of cores and lobules involved, pagetoid duct involvement, presence of microcalcification in lobular neoplasia, needle gauge and number of cores obtained showed no correlation with the upgrade. Our results suggest that with radio-pathologic concordance and no prior biopsy proven risk for breast cancer, core biopsy finding of lobular neoplasia as the highest risk lesion can be appropriately and safely managed with clinical and radiologic follow-up as an alternative to surgical excision.

Long-term follow-up of lobular neoplasia (atypical lobular hyperplasia/lobular carcinoma in situ) diagnosed on core needle biopsy

BACKGROUND

Lobular neoplasia (LN) includes atypical lobular hyperplasia (ALH) and lobular carcinoma in situ (LCIS). LN often is an incidental finding on breast core needle biopsy (CNBx) and management remains controversial. Our objective was to define the incidence of malignancy in women diagnosed with pure LN on CNBx, and identify a subset of patients that may be observed.

METHODS

Patients diagnosed with LN on CNB between January 1993 and December 2010 were identified. Patients with an associated high-risk lesion or ipsilateral malignancy at time of diagnosis were excluded. All cases were reviewed by dedicated breast pathologists and breast imagers for pathologic classification and radiologic concordance, respectively.

RESULTS

The study cohort was comprised of 184 (1.3 %) cases of pure LN (147 ALH, 37 LCIS) from 180 patients. Pathologic-radiologic concordance was achieved in 171 (93 %) cases. Excision was performed in 101 (55 %) cases and 83 (45 %) were observed. Mean follow-up was 50.3 (range, 6-212) months. Of cases excised, 1 of 81 (1.2 %) ALH and 1 of 20 (5 %) LCIS cases were upstaged to ductal carcinoma in situ (DCIS) and invasive lobular carcinoma (ILC), respectively. Only 1 of 101 (1 %) concordant lesions was upstaged on excision. Of the cases observed, 4 of 65 (6.2 %) developed ipsilateral cancer during follow-up: 1 of 51 (2 %) case of ALH and 3 of 14 (21.4 %) cases with LCIS (2 ILC, 2 DCIS). During follow-up, 2.9 % (4/138) patients with excised or observed LN developed a contralateral cancer.

CONCLUSIONS

These data support that not all patients with LN diagnosed on CNB require surgical excision. Patients with pure ALH, demonstrating radiologic-pathologic concordance, may be safely observed.

Therapeutic potential of stem cells expressing suicide genes that selectively target human breast cancer cells: evidence that they exert tumoricidal effects via tumor tropism (review)

Breast cancer is the most prevalent cancer in women worldwide and is classified into ductal and lobular carcinoma. Breast cancer as well as lobular carcinoma is associated with various risk factors such as gender, age, female hormone exposure, ethnicity, family history and genetic risk factor-associated genes. Genes associated with a high risk of developing breast cancer include BRCA1, BRCA2, p53, PTEN, CHEK2 and ATM. Surgery, chemotherapy, radiotherapy and hormone therapy are used to treat breast cancer but these therapies, except for surgery, have many side-effects such as alopecia, anesthesia, diarrhea and arthralgia. Gene-directed enzyme/prodrug therapy (GEPT) or suicide gene therapy, may improve the therapeutic efficacy of conventional cancer radiotherapy and chemotherapy without side-effects. GEPT most often involves the use of a viral vector to deliver a gene not found in mammalian cells and that produces enzymes which can convert a relatively non-toxic prodrug into a toxic agent. Examples of these systems include cytosine deaminase/5-fluorocytosine (CD/5-FC), carboxyl esterase/irinotecan (CE/CPT-11), and thymidine kinase/ganciclovir (TK/GCV). Recently, therapies based on genetically engineered stem cells (GESTECs) using a GEPT system have received a great deal of attention for their clinical and therapeutic potential to treat breast cancer. In this review, we discuss the potential of GESTECs via tumor tropism effects and therapeutic efficacy against several different types of cancer cells. GESTECs represent a useful tool for treating breast cancer without inducing injuries associated with conventional therapeutic modalities.

Management of lobular carcinoma in-situ and atypical lobular hyperplasia of the breast--a review

OBJECTIVES

To determine the incidence of malignancy (invasive carcinoma or DCIS) in patients diagnosed with lobular neoplasia (B3) on core needle biopsy (CNB) of breast lesions by reviewing the published literature.

METHODS

Medline, Embase, OVID-database and reference lists were searched to identify and review all English-language articles addressing the management of LN diagnosed on CNB. Studies on mixed breast pathologies were excluded.

RESULTS

Of 1229 LN diagnosed on CNB, 789 (64%) underwent surgical excision. 211 (27%) of excisions contained either DCIS or invasive disease. 280 of the excision specimens were classified as ALH, 241 as LCIS, 22 as pleomorphic LCIS and 246 unspecified LN on the original CNB. After surgical excision, 19% of the ALH cases, 32% of the LCIS cases and 41% of the PLCIS cases, contained malignancy. 29% of the unspecified LNs were upgraded to malignancy. The higher incidence of malignancy within excision specimens for LCIS and PLCIS compared to ALH was significant (P < 0.04, <0.003 respectively).

CONCLUSION

There is a significant underestimation of malignancy in patients diagnosed with breast LN on CNB. 27% cases of CNB-diagnosed LN were found to contain malignancy following surgical excision. All patients diagnosed with LN on CNB should be considered for surgical excision biopsy.

A case of lobular carcinoma in situ presenting as a solid mass

A patient presented with a 2 cm lump in the lower outer quadrant of the left breast. Mammogram and ultrasonography showed a solid mass with a microlobulated contour, partially irregular border and microcalcifications. MRI showed an irregular mass with early enhancement and high signal intensity, and the late-phase image demonstrated a partial washout pattern. These findings suggest that the tumour was a malignant invasive carcinoma. Non-invasive ductal carcinoma was diagnosed after a fine needle aspiration and core needle biopsy followed by a partial breast excision and sentinel lymph node (SLN) biopsy. A pathological examination of the lesion displayed characteristic small monomorphic cells, solid proliferation and massive distension within the lobular unit. The tumour was immunohistochemically negative for E-cadherin and pure lobular carcinoma in situ (LCIS) was diagnosed. Pure LCIS is very rare and there have been no previous reports of pure LCIS forming a solid mass.

Breast cancer precursors revisited: molecular features and progression pathways

Increasingly more coherent data on the molecular characteristics of benign breast lesions and breast cancer precursors have led to the delineation of new multistep pathways of breast cancer progression through genotypic-phenotypic correlations. It has become apparent that oestrogen receptor (ER)-positive and -negative breast lesions are fundamentally distinct diseases. Within the ER-positive group, histological grade is strongly associated with the number and complexity of genetic abnormalities in breast cancer cells. Genomic analyses of high-grade ER-positive breast cancers have revealed that a substantial proportion of these tumours harbour the characteristic genetic aberrations found in low-grade ER-positive disease, suggesting that at least a subgroup of high-grade ER-positive breast cancers may originate from low-grade lesions. The ER-negative group is more complex and heterogeneous, comprising distinct molecular entities, including basal-like, HER2 and molecular apocrine lesions. Importantly, the type and pattern of genetic aberrations found in ER-negative cancers differ from those of ER-positive disease. Here, we review the available molecular data on breast cancer risk indicator and precursor lesions, the putative mechanisms of progression from in situ to invasive disease, and propose a revised model of breast cancer evolution based on the molecular characteristics of distinct subtypes of in situ and invasive breast cancers.

Preinvasive breast cancer

Preinvasive breast cancer accounts for approximately one-third of all newly diagnosed breast cancer cases in the United States and constitutes a spectrum of neoplastic lesions with varying degrees of differentiation and clinical behavior. High-throughput genetic, epigenetic, and gene-expression analyses have enhanced our understanding of the relationship of these early neoplastic lesions to normal breast tissue, and they strongly suggest that preinvasive breast cancer develops and evolves along two distinct molecular genetic and biological pathways that correlate with tumor grade. Although unique epigenetic and gene-expression changes are not observed in the tumor epithelial compartment during the transition from preinvasive to invasive disease, distinct molecular alterations are observed in the tumor-stromal and myoepithelial cells. This suggests that the stromal and myoepithelial microenvironment of preinvasive breast cancer actively participates in the transition from preinvasive to invasive disease. An improved understanding of the transition from preinvasive to invasive breast cancer will pave the way for novel preventative and therapeutic strategies.

Genetic and phenotypic characteristics of pleomorphic lobular carcinoma in situ of the breast

The clinical, pathologic, and molecular features of pleomorphic lobular carcinoma in situ (PLCIS) and the relationship of PLCIS to classic LCIS (CLCIS) are poorly defined. In this study, we analyzed 31 cases of PLCIS (13 apocrine and 18 nonapocrine subtypes) and compared the clinical, pathologic, immunophenotypic, and genetic characteristics of these cases with those of 24 cases of CLCIS. Biomarker expression was examined using immunostaining for E-cadherin, gross cystic disease fluid protein-15, estrogen, progesterone, androgen receptor, human epidermal growth factor receptor2, CK5/6, and Ki67. Array-based comparative genomic hybridization to assess the genomic alterations was performed using microdissected formalin-fixed paraffin-embedded samples. Patients with PLCIS presented with mammographic abnormalities. Histologically, the tumor cells were dyshesive and showed pleomorphic nuclei, and there was often associated necrosis and microcalcifications. All lesions were E-cadherin negative. Compared with CLCIS, PLCIS showed significantly higher Ki67 index, lower estrogen receptor and progesterone receptor expression, and higher incidence of HER2 gene amplification. The majority of PLCIS and CLCIS demonstrated loss of 16q and gain of 1q. Apocrine PLCIS had significantly more genomic alterations than CLCIS and nonapocrine PLCIS. Although lack of E-cadherin expression and the 16q loss and 1q gain-array-based comparative genomic hybridization pattern support a relationship to CLCIS, PLCIS has clinical, mammographic, histologic, immunophenotypic, and genetic features that distinguish it from CLCIS. The histologic features, biomarker profile, and genomic instability observed in PLCIS suggest a more aggressive phenotype than CLCIS. However, clinical follow-up studies will be required to define the natural history and most appropriate management of these lesions.

The expression of ERalpha, ERbeta and PR in lobular carcinoma in situ of the breast determined using laser microdissection and real-time PCR

AIMS

To determine the status of oestrogen receptor (ER) subtypes (ERalpha and ERbeta) in lobular carcinoma in situ (LCIS) of the breast.

METHODS AND RESULTS

Forty-seven cases of LCIS and six cases with normal breast lobules were subjected to immunohistochemistry and evaluated for ERalpha, ERbeta and progesterone receptor (PR) expression. mRNA for ERalpha, ERbeta1 and ERbeta2 were quantified in LCIS and normal lobules using laser microdissection coupled with real-time polymerase chain reaction. LCIS showed a higher level of steroid receptor protein expression than normal lobules. There was no difference in ERbeta1 gene or ERbeta protein expression between normal lobules, pure LCIS, or LCIS associated with invasive breast cancer. No significant difference in expression of either ERalpha or ERbeta was found between pure LCIS and LCIS associated with invasive cancer. However, PR was significantly lower in those cases of LCIS with associated invasive than in those without synchronous invasive disease.

CONCLUSIONS

Increased expression of steroid receptors in LCIS suggests their possible role in the biology of LCIS and, for PR, could influence the predisposition of women diagnosed with LCIS to develop invasive breast carcinoma.

Epidemiology, genetics, and risk evaluation of postmenopausal women at risk of breast cancer

Breast cancer risk factors have been studied for the past three decades, and the single most important risk factor is age. Hormonally linked adult reproductive and anthropometric risk factors contribute to the etiology of postmenopausal breast cancer. The risk of breast cancer increases among women older than 50 years of age who have benign breast disease, especially those with atypical ductal or lobular hyperplasia. Lobular carcinoma in situ increases risk significantly, as do a family history of breast cancer in first-degree relatives and the presence of BRCA1 or BRCA2 mutations. Diet, exercise, and environmental factors play a very small role in overall risk. Mammographic breast density increases relative risk fivefold among women with the highest density, and breast cancer risk is two to three times greater in women with elevated serum levels of estradiol or testosterone. Multivariate risk models allow determination of composite relative risks and cumulative lifetime risk, although improved models for African American women are required. For postmenopausal women, newer risk models are being developed and validated that include age, breast density, race, ethnicity, family history of breast cancer, a previous breast biopsy, body mass index, age at onset of natural menopause, hormone therapy, and previous false-positive mammography. A simpler model that includes only age, breast cancer in first-degree relatives, and previous breast biopsy performs well for estrogen receptor-positive breast cancer in postmenopausal women. As many as 10 million women in the United States are at increased risk, and clinicians are obligated to identify these women and manage their risk appropriately.

Presence of lobular carcinoma in situ does not increase local recurrence in patients treated with breast-conserving therapy

BACKGROUND

Lobular carcinoma in situ (LCIS) is known to be a risk factor for the development of invasive breast cancer. Debate continues as to whether LCIS is also a precursor lesion. We hypothesized that, if LCIS were a precursor, its presence in the lumpectomy specimen, particularly at the margin, could increase local recurrence (LR) after breast-conserving therapy (BCT).

METHODS

2894 patients treated with BCT for ductal carcinoma in situ (DCIS), stage I or II breast cancer between 1/80 and 5/07 were identified. Patients with DCIS or invasive cancer at the margins or those receiving neoadjuvant therapy were excluded. Group A had 290 patients with LCIS in the lumpectomy; 84 had LCIS at the final margin. Group B included 2604 patients with no evidence of LCIS.

RESULTS

Median patient age in group A and B was 57 and 58 years, respectively (P = 0.05); 12% and 13%, respectively, of patients in group A and B had margins <2 mm (P = NS). The histologic distribution of tumor types in group A was lobular in 47.2%, ductal in 34.5%, DCIS in 11.4%, and other invasive histologies in 6.9%, compared with 4.1%, 76.3%,13.6%, and 6.0% for group B, respectively (P < 0.0001). There was no significant difference between the groups in tumor-node-metastasis (TNM) stage. The crude rate of LR was 4.5% in group A and 3.8% in group B (P = NS). Five- and 10-year actuarial LR rates for LCIS at the margin were 6% and 6%, 1% and 15% for LCIS present but not at the margin, and 2% and 6% for no LCIS (P = NS), for group A and B, respectively. In multivariate analysis, menopausal status and adjuvant therapy use were significant predictors of LR. LCIS, either in the specimen or at the margin, was not significantly associated with LR.

CONCLUSION

Presence of LCIS, even at the margin, in BCT specimens does not have an impact on LR. Re-excision is not indicated if LCIS is present or close to margin surfaces. These findings do not support consideration of LCIS as a precursor to the development of invasive lesions.

Histopathological findings and follow-up after prophylactic mastectomy and immediate breast reconstruction in 100 women from families with hereditary breast cancer

AIM

To survey the histopathological abnormalities in breasts of women who have undergone risk reducing mastectomy and to evaluate the effect of this measure on future breast cancer development.

PATIENTS/METHODS

Between August 1995 and October 2006 100 consecutive women with a hereditary increased risk of breast cancer underwent prophylactic mastectomy (PM) at Malmö University Hospital. Fifty of the 100 women had no previous breast cancer. Fifty were BRCA1 or BRCA2 mutation carriers. All breast specimens have been examined histopathologically according to a prospective protocol. Follow-up data was collected from medical records and data in the Regional Cancer Registry.

RESULTS

In the PM specimens abnormal lesions were found in 18 women (three with invasive cancers, eight in situ cancers and seven atypical hyperplasia). In previously healthy women lesions were more frequent after the age of 40 than among younger women (p=0.03). BRCA mutation carriers were more likely to present with ADH (atypical ductal hyperplasia)/ALH (atypical lobular hyperplasia) compared to the non-carriers/untested cases (p=0.01). After a median follow-up of 52 months (range 1-136 months) none of the women have developed breast cancer in the area of the prophylactically removed breast.

CONCLUSIONS

Prevalent atypical or malignant lesions are relatively a common finding in PM specimens in asymptomatic women with hereditary increased risk of breast cancer. Such findings were significantly more common above age 40 in women without previous breast cancer. The risk of newly formed breast cancer after PM is small. The clinical importance of detecting a premalignant or preinvasive lesion in the breast at PM is still unclear.

In situ and invasive lobular neoplasia of the breast

Lobular neoplasia of the breast represents a group of related malignancies with clinical implications ranging from risk lesions [atypical lobular hyperplasia and lobular carcinoma in situ (LCIS)] through to aggressive invasive lesions, notably invasive pleomorphic lobular carcinoma. The diversity in lobular carcinoma is evident at the morphological level, at the molecular marker level and in cytogenetic profiles. Research in these areas is already changing the face of the disease group, for example suggesting that some lobular and ductal carcinomas are closely related and even that one of the lobular group, the tubulo-lobular carcinomas, should, in fact, be regarded as a ductal cancer. More research is required to understand the long-term pathogenic implications of a diagnosis of in situ lobular neoplasia, particularly pleomorphic LCIS, and to understand the genetics behind the well-recognized high risk of bilateral disease. For invasive carcinoma, molecular studies will allow refinement of therapy and the possibility of novel targeted therapies, for example directed against fibroblast growth factor receptor 1.

Immunohistochemical expression of estrogen receptors alpha and beta in lobular neoplasia

The designation lobular neoplasia (LN) of the breast includes atypical lobular hyperplasia and lobular carcinoma in situ. Estrogen receptors (ER) play a significant role in breast carcinogenesis. In the present study, ER-alpha and ER-beta status are evaluated in 30 breast tissue specimens from patients whose main lesion was LN. A standard immunohistochemical procedure, using monoclonal antibodies for ER-alpha and ER-beta, was applied to the lesion and the adjacent normal breast tissues, the latter serving as control. In all cases, both receptors were expressed in LN as well as in normal breast ducts and lobules. Concerning ER-alpha, the Allred score and the percentage of ER-alpha-positive cells were significantly higher in LN than in the adjacent normal breast tissue. On the contrary, regarding ER-beta, the Allred score and the percentage of ER-beta-positive cells were significantly lower in LN compared with normal adjacent breast tissue. Greater increase in the percentage of ER-alpha-positive cells was associated with a smaller reduction in the percentage of ER-beta-positive cells and vice versa (Spearman's rho = -0.5044, p = 0.001). In conclusion, upregulation of ER-alpha and downregulation of ER-beta may represent two discrete molecular events in LN pathogenesis. Of notice, a mutually limiting interaction may exist between the two events.

Surgical management of breast cancer

Breast cancer treatment outcomes have improved as a result of early detection and multidisciplinary treatment approaches. Treatment options continue to expand as understanding increases regarding the relationship between disease burden, biology, and outcome. In this article we present the current principles and challenges that face the clinician who is treating breast disease. Better understanding of the biology of high-risk lesions and the significance of minimal metastatic disease permits better treatment. Advances in reconstructive surgery, continued refinement of resection techniques, and the management of less common presentations of breast cancer are presented.