Atypical Lobular Hyperplasia

• Atypical lobular hyperplasia (ALH):
  • Is generally an incidental finding on core needle biopsy:
    • Without specific defining characteristics on:
      • Mammography, ultrasound, or MRI
• A palpable breast mass which yields ALH at core needle biopsy is discordant:
  •  This should prompt further diagnostic work-up with a second biopsy:
    • Either core or excisional
• ALH should only be considered for observation:
  • When there is radiologic, pathologic, and clinical concordance:
    • As the risk of upstaging to carcinoma in this scenario is:
      • Less than 5%
• ALH alone:
  • Confers a 4 to 5-fold increased risk of future breast cancer in either breast
  • The probability of upgrade to invasive carcinoma with a diagnosis of atypical lobular hyperplasia (ALH) on core needle biopsy:
    • Is reported as less than 3%
• Excision to achieve negative margins in ALH:
  • Is generally not required
• Having a family history:
  • Does not appear to increase the risk associated with atypical hyperplasia
• Relevant indications for genetic testing include:
  • A personal history of breast cancer ≤ age 45
  • Triple negative breast cancer ≤ age 60
  • A first-degree relative with breast cancer ≤ age 50
  • Two or more first- or second-degree relatives with breast cancer at any age
  • Patient or relative with bilateral breast cancer
  • Male breast cancer in a relative at any age
• Risk-reducing mastectomy:
  • Can be considered in patients with very high lifetime breast cancer risk:
    • Usually reserved for women with high-penetrance gene mutations:
      • Such as BRCA 1 or BRCA 2
• References
  • Morrow M, Schnitt SJ, Norton L. Current management of lesions associated with an increased risk of breast cancer. Nat Rev Clin Oncol. 2015;12(4):227-238.
  • Murray MP, Luedtke C, Liberman L, Nehhozina T, Akram M, Brogi E. Classic lobular carcinoma in situ and atypical lobular hyperplasia at percutaneous breast core biopsy: outcomes of prospective excision. Cancer. 2013;119(5):1073-1079.
  • Middleton LP, Sneige N, Coyne R, Shen Y, Dong W, Dempsey P. Most lobular carcinoma in situ and atypical lobular hyperplasia diagnosed on core needle biopsy can be managed clinically with radiologic follow-up in a multidisciplinary setting. Cancer Med. 2014;3(3):492-499.
  • Hartmann LC, Sellers TA, Frost MH, Lingle WL, Degnim AC, Ghosh K, et al. Benign breast disease and the risk of breast cancer. N Engl J Med. 2005;353(3):229-237.
  • Degnim AC, Visscher DW, Berman HK, Frost MH, Sellers TA, Vierkant RA, et al. Stratification of breast cancer risk in women with atypia: a Mayo cohort study. J Clin Oncol. 2007;25(19):2671-2677.
  • Smart CE, Furnival CM, Lakhani SR. Chapter 17. High-Risk Lesions: ALH/LCIS/ADH. In: Kuerer HM ed. Kuerer’s Breast Surgical Oncology. New York, NY: McGraw-Hill, 2010.
  • The American Society of Breast Surgeons (2016). Consensus Guideline on Concordance Assessment of Image-Guided Breast Biopsies and Management of Borderline or High-Risk Lesions https://www.breastsurgeons.org/docs/statements/Consensus-Guideline-on-Concordance-Assessment-of-Image-Guided-Breast-Biopsies.pdf. Accessed February 23, 2020.

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