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Management of High-Risk Breast Lesions: A Comprehensive Update
Kathryn W Zamora1, Miglena K Komforti2, Elizabeth B Vorhis3
1University of Alabama at Birmingham, Department of Radiology, Birmingham, AL, USA.
Insights
Management of high-risk breast lesions (HRLs) is variable. New guidelines aim for unified, evidence-based care, balancing oncologic safety with minimizing overtreatment for conditions like atypical ductal hyperplasia and lobular carcinoma in situ.
Area of Science:
- Breast pathology and oncology
- Radiology and medical imaging
- Surgical management of breast disease
Background:
- High-risk breast lesions (HRLs) present diagnostic and management challenges due to their association with malignancy or increased future cancer risk.
- Current management strategies for HRLs are inconsistent, necessitating standardized, evidence-based guidelines.
- Multidisciplinary collaboration is crucial for optimizing patient care and outcomes.
Purpose of the Study:
- To review current literature and guidance on the histopathologic features, imaging, and management of various HRLs.
- To provide context for developing unified, evidence-based guidelines for HRL management.
- To highlight the role of multidisciplinary discussion in personalized breast cancer care.
Main Methods:
- Comprehensive literature review of existing studies and current clinical guidance on HRLs.
- Analysis of histopathologic and imaging characteristics of specific HRLs.
- Synthesis of management strategies, including surgical and nonoperative approaches.
Main Results:
- Nonoperative management is supported for select radiologic-pathologic concordant lesions (e.g., limited atypical ductal hyperplasia, pure flat epithelial atypia, pure radial scar).
- Excision remains indicated for lesions with higher upgrade rates, such as lobular carcinoma in situ subtypes, papilloma with atypia, and mucocele-like lesions with atypia.
- HRLs serve as biomarkers for long-term breast cancer risk, influencing surveillance and chemoprevention recommendations.
Conclusions:
- Achieving consensus among radiology, pathology, and surgery is essential for safe and effective HRL management.
- Personalized care, informed by multidisciplinary discussion, is key to minimizing overtreatment while ensuring oncologic safety.
- Standardized guidelines will improve consistency in managing HRLs, impacting future breast cancer risk assessment and patient counseling.
Abstract:
High-risk breast lesions (HRLs) encompass a heterogeneous group of pathologies that coexist with an adjacent or synchronous malignancy, confer an increased risk of future breast cancer, or warrant surgical consideration because of upgrade potential or local behavior. Despite their clinical importance, management of HRLs remains variable. The American Society of Breast Surgeons (ASBrS) and the Society of Breast Imaging are collaborating to establish unified, evidence-based guidelines for managing these lesions. While these recommendations are currently in development, this review summarizes the existing literature and current guidance, including ASBrS recommendations, to provide context for multidisciplinary management. The article reviews the histopathologic features, imaging appearance, and management strategies for HRLs, including atypical ductal hyperplasia (ADH), atypical lobular hyperplasia (ALH), lobular carcinoma in situ (LCIS), flat epithelial atypia (FEA), papillomas with and without atypia, radial scar/complex sclerosing lesion (RS/CSL), mucocele-like lesion (MLL), desmoid tumor, and pseudoangiomatous stromal hyperplasia (PASH). Recent literature supports nonoperative management for specific radiologic-pathologic concordant lesions, particularly limited ADH, pure FEA, and pure RS, highlighting the important role of multidisciplinary discussion for personalized care. Lesions such as LCIS subtypes, papilloma with atypia, and MLL with atypia continue to warrant excision due to higher reported upgrade rates to malignancy. Beyond short-term management, HRLs such as ADH, ALH, and LCIS serve as biomarkers of long-term breast cancer risk, informing recommendations for surveillance, risk assessment, and chemoprevention counseling. Achieving a consensus among radiology, pathology, and surgical disciplines is essential to ensure oncologic safety while minimizing overtreatment in the era of precision breast care.
