Pleomorphic lobular carcinoma in situ of the breast: Can the evidence guide practice?

The clinical significance of pleomorphic lobular carcinoma in situ (PLCIS) is a subject of controversy. As a consequence, there is a risk of providing inconsistent management to patients presenting with PLCIS. This review aims to establish whether the current guidelines for the management of PLCIS are consistent with current evidence. A systematic electronic search was performed to identify all English language articles regarding PLCIS management. The data was analysed, specifically looking at: incidence of concurrent disease, recurrence rates, long-term prognosis and PLCIS management. A search was also performed for PLCIS management guidelines for the United Kingdom, United States, Canada, Australia, Germany and pan-European. The results of the evidence analyses were compared to the guidelines in order to establish whether the recommended management is consistent with the published evidence. Nine studies (level 3-4 evidence), involving a total of 176 patients and five management guidelines (from United Kingdom, United States, Australia and pan-European) were included in the review. From the evidence, 46 of 93 (49%) patients were found to have PLCIS with concurrent invasive disease on excision specimen analysis. Regarding recurrence rates, 11 of 117 (9.4%) patients developed a recurrence of PLCIS. There were no instances of invasive disease or ductal carcinoma in situ (DCIS) on recurrence histology. There were no studies assessing long-term outcomes in PLCIS cases. With regards to the management guidelines, the Association of Breast Surgery (United Kingdom) and the National Breast and Ovarian Cancer Care (Australia) do not mention PLCIS. The National Comprehensive Cancer Network (United States) suggest considering excision of PLCIS with negative margins. The NHS Breast Screening Programme (United Kingdom) and the European Society of Medical Oncology (pan-European) recommend PLCIS should be treated as with DCIS. We conclude that high quality evidence to inform guidance is lacking, thus recommendations are relatively vague. However, based on the available evidence, it would seem prudent to treat PLCIS in a similar manner to DCIS.