Atypical Lobular Hyperplasia (ALH)

  • ALH is generally an incidental finding:
    • Without specific defining characteristics on mammography, ultrasound, or MRI
  • A palpable breast mass which yields ALH at core needle biopsy:
    • Is not clinically concordant and should prompt further diagnostic workup with a second biopsy:
      • Either core or excisional
  • ALH alone confers a 4 to 5 fold increased risk of breast cancer
  • Risk reducing mastectomy (RRM):
    • Can be considered in patients with a lifetime risk of breast cancer ≥ 20% based on history of:
      • ADH / ALH or family history:
        • But this risk must be quantified using a risk assessment tool such as the Gail or Tyrer-Cuzick model
  • ALH should only be considered for observation:
    • When it is diagnosed incidentally and there is radiologic, pathologic, and clinical concordance
  • Relevant indications for genetic testing include:
    • Personal history of breast cancer ≤ 45 years of age
    • Triple negative breast cancer ≤ 60 years of age
    • A first-degree relative with breast cancer ≤ 50 years of age
    • 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
  • The Gail Model:
    • Should only be used in patients ≥ 35 years of age:
      • May underestimate risk in patients with strong family history or non-Caucasian ethnicity
  • The Tyrer-Cuzick model:
    • May be more appropriate in this setting
  • 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: 227-238. National Comprehensive Cancer Network (NCCN) Guidelines (Login Required): Genetic/Familial High-Risk Assessment: Breast, Ovarian, and Pancreatic, Version 1.2021. Breast Cancer Risk Reduction, Version 1.2020.

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