A 46-year-old female comes to see you in the office to follow-up her breast biopsy results. She does not have any family history of breast cancer. She had a screening mammogram done about a month ago, which identified an area of microcalcification suspicious for malignancy in her left breast. She subsequently underwent core needle biopsy of the lesion. The biopsy results revealed the presence of lobular carcinoma in situ (LCIS) in the left breast. Which of the following is the most appropriate next step in the management of this patient?

Question

A 46-year-old female comes to see you in the office to follow-up her breast biopsy results.  She does not have any family history of breast cancer.  She had a screening mammogram done about a month ago, which identified an area of microcalcification suspicious for malignancy in her left breast.  She subsequently underwent core needle biopsy of the lesion.  The biopsy results revealed the presence of lobular carcinoma in situ (LCIS) in the left breast.  Which of the following is the most appropriate next step in the management of this patient?

Quizplus · Accepted Answer

Explanation: Lobular carcinoma in situ (LCIS) is a nonmalignant lesion that arises in the terminal ducts and lobules of the breast. It is an occasional incidental finding on breast biopsy that has no mammographic or clinical correlate. While the lesion itself has no malignant potential, it signifies an increased risk of developing invasive lobular or ductal carcinoma in either breast (roughly 7-18 times the risk of the general population). It is recommended that cases where LCIS is diagnosed by needle biopsy proceed to excisional biopsy since up to 38% of cases may be upstaged to ductal carcinoma in situ (DCIS) or invasive cancer when the entire lesion is removed. After the lesion has been excised, management is more controversial. The most common management course is follow-up surveillance. Chemoprevention with selective estrogen receptor modulators (SERMs), such as tamoxifen or raloxifene, is an alternative option. Some patients may request prophylactic bilateral mastectomy which is also a viable alternative. (Choice B) Mastectomy is not necessary unless requested by the patient. Radiation therapy would be unnecessary for LCIS alone, since LCIS itself has no malignant potential. (Choice C) Sentinel node biopsy is unnecessary since LCIS has no malignant potential, but excisional biopsy of the lesion should be performed since LCIS gets upgraded to a more serious lesion in a significant percentage of patients secondary to sampling error from needle biopsy. (Choice D) Yearly mammogram surveillance would be indicated for this patient given her increased risk of developing breast cancer. However, an excisional biopsy of the lesion is necessary before beginning this surveillance program. Educational objective: Lobular carcinoma in situ (LCIS) is a nonmalignant lesion, but has a significant association with future development of invasive breast cancer and at minimum close surveillance is required for the duration of the patient's life. If LCIS is detected on needle biopsy, excisional biopsy is recommended since a significant percentage of cases are upstaged to either invasive cancer or DCIS.

A 46-Year-Old Female Comes to See You in the Office