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Lobular Carcinoma In Situ of the Breast

Posted Mar 31, 2013 Updated Apr 10, 2023
By Marion Scoggins MD , Savitri Krishnamurthy MD , Lumarie Santiago MD , Wei Yang MBBS FRCR
12 min read

Rationale and Objectives

The purpose of this study was to review the imaging findings associated with lobular carcinoma in situ (LCIS) of the breast with clinical and pathological correlation.

Materials and Methods

A database search of patients treated at our institution from 2002 to 2011 identified 26 patients with LCIS associated with an imaging abnormality that had imaging available for review. LCIS was diagnosed by core-needle or excision biopsy. Patients subsequently underwent excisional biopsy, mastectomy, or clinical follow-up. Patients’ mammography, ultrasonography (US), and magnetic resonance imaging (MRI) images were reviewed using the American College of Radiology Breast Imaging Reporting and Data System lexicon together with relevant clinical and pathology data.

Results

The 26 patients had 31 imaging lesions that yielded a histological diagnosis of LCIS by image-guided core-needle biopsy ( n = 29) or excision biopsy ( n = 2). Twenty-eight of 31 (90%) lesions yielding LCIS had a mammographic abnormality, 3/20 (15%) lesions had a US abnormality, and 6/7 (86%) had an abnormality on contrast-enhanced MRI. Calcifications were the most common mammographic finding, seen in 25/31 (80%) lesions. All three lesions seen on US were masses; the majority was irregular, hypoechoic, avascular, and had posterior shadowing. Non–mass-like enhancement was seen in five (71%) lesions with an MRI abnormality. Two (7%) patients developed subsequent malignancy at follow-up.

Conclusion

LCIS can have associated imaging abnormalities, most commonly grouped amorphous calcifications on mammography, a shadowing, avascular, irregular, hypoechoic mass on US, or heterogeneous non–mass-like enhancement with persistent enhancement kinetics on MRI.

Lobular carcinoma in situ (LCIS) is an uncommon, noninvasive lesion of the breast first described by Foote and Stewart in 1941. Histopathologically, it is a proliferation of atypical monotonous epithelial cells filling and distending the acinar units of a lobule. Depending on the appearance of these cells, LCIS can be categorized as classic or pleomorphic. LCIS is frequently multifocal and/or multicentric and often occurs bilaterally . Patients diagnosed with LCIS have an increased risk of invasive breast malignancy; Bodian et al reported an overall cumulative risk of breast cancer of 30%–35% in women who had had LCIS. It is generally accepted that both breasts are at increased risk of malignancy rather than only the breast where LCIS was detected , but not all studies show equal risk for both breasts . There is also some evidence of a precursor-product relationship between LCIS and invasive lobular carcinoma . LCIS has been described as clinically undetectable and with no known distinguishing radiologic features. It is often believed to be an incidental histopathological finding on image-guided or excisional biopsy that is performed for and targeted at a separate lesion . By retrospectively reviewing cases of LCIS directly associated with imaging findings which were the target for biopsy, we seek to better understand the spectrum of imaging findings that prompt image-guided biopsy and yield a diagnosis of LCIS. The histopathology and clinical outcomes of these patients were also documented.

Materials and methods

Patient Selection

Institutional review board approval was obtained for this study, which complied with the Health Insurance Portability and Accountability Act. We performed a database search of patients treated at our institution from January 1, 2002, to August 31, 2011, to identify all cases of LCIS associated with an imaging abnormality for which imaging findings were available for review. The single institution is a tertiary referral cancer center, where approximately 2000 patients are diagnosed with breast cancer each year. A total of 19,000 core-needle biopsies (CNB) were performed during the study period, 1994 of which yielded LCIS. Patients had to have been diagnosed with LCIS by image-guided CNB or excisional biopsy (EB), and LCIS had to be the highest grade lesion at the biopsy site. A total of 1963 of 1994 (98%) biopsies yielded LCIS as an incidental finding. We identified 26 patients with 31 LCIS lesions that met our inclusion criteria of LCIS associated with an imaging finding. Our institution’s electronic medical record was used to gather patients’ demographic and clinical information.

Imaging

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Mammography

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Sonography

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MRI

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Biopsies

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Histopathological Characteristics

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Results

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Mammographic Findings

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Table 1

Mammographic Findings of 31 LCIS Lesions

Mammographic Findings_n_ (%) ∗ Calcifications 25 (80) Morphology Amorphous 13 (42) Coarse heterogeneous 8 (26) Punctate 2 (6) Pleomorphic 1 (3) Dystrophic 1 (3) Distribution Diffuse 1 (3) Regional 2 (6) Segmental 2 (6) Group/cluster 20 (65) Architectural distortion 4 (13) Focal asymmetry 1 (3) No abnormality visualized 3 (10)

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Figure 1, A 62-year-old woman with lobular carcinoma in situ (LCIS) presenting as calcifications on screening mammography. Patient underwent biopsies of calcifications in left breast at four separate sites and times yielding LCIS. Patient has been followed for 6 years since initial LCIS diagnosis without evidence of breast malignancy. (a) Magnification mammogram shows clustered pleomorphic heterogeneous calcifications ( arrow ). Stereotactic biopsy yielded pleomorphic LCIS, which was subsequently excised. (b) A 45-year-old woman with LCIS presenting as calcifications on screening mammography. Magnification mammogram shows clustered punctate calcifications ( arrow ). Stereotactic biopsy showed classic LCIS. Patient underwent excisional biopsy with final histological diagnosis of intermediate-grade LCIS. Patient has been followed for 2 years with no evidence of breast malignancy. A 53-year-old woman with LCIS presenting as calcifications on diagnostic mammography. Patient underwent stereotactic biopsy of one group of calcifications followed by excisional biopsy of entire regional area of amorphous calcifications. Final histological diagnosis was low-grade LCIS. Patient is scheduled to undergo bilateral prophylactic mastectomies. (c) Mammography shows multiple groups of amorphous calcifications ( arrows ). (d) Magnification mammography shows amorphous calcifications.

Figure 2, A 60-year-old woman with lobular carcinoma in situ (LCIS) presenting as calcifications and architectural distortion on screening mammography. Ultrasound-guided core-needle biopsy showed low-grade classic LCIS and radial scar. Subsequent excisional biopsy showed low- to intermediate-grade classic LCIS. (a) Magnification mammography shows architectural distortion with associated calcifications ( arrow ). (b) Mammogram after ultrasound-guided biopsy shows clip marker within area of distortion ( arrowhead ). Additional marker clip in lateral breast marks site of benign biopsy 6 years prior. (c) Photomicrograph illustrates lobular carcinoma in situ ( arrows ) adjacent to radial scar (hematoxylin and eosin [H & E] image ×20). Acinar spaces are filled and distended by neoplastic cells. (d) Photomicrograph illustrates radial scar ( arrow ) identified in surgical excision specimen (H & E image ×20). Note presence of central area of fibroelastosis bordered by dilated ducts demonstrating mild ductal epithelial hyperplasia without atypia.

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Sonographic Findings

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MRI Findings

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Figure 3, A 46-year-old woman with lobular carcinoma in situ (LCIS) who initially underwent screening magnetic resonance imaging (MRI) because of dense breasts. (a) Postcontrast sagittal T1-weighted MRI shows regional non–mass-like enhancement measuring 10 cm in greatest dimension. Enhancement extends from anterior to posterior depth ( open arrows ). (b) Color map and kinetic curve show rapid initial enhancement with plateau in delayed phase. (c) Three-dimensional maximum intensity projection reconstructed MRI demonstrates regional non–mass-like enhancement in left breast ( arrows ). MRI-guided biopsy revealed LCIS. Patient opted for bilateral prophylactic mastectomies. Final pathology of left breast showed extensive lobular neoplasia.

Figure 4, A 60-year-old woman with lobular carcinoma in situ (LCIS) underwent magnetic resonance imaging (MRI) for right upper outer quadrant palpable abnormality. (a) Post-contrast axial delayed T1-weighted fat-suppressed MRI and (b) post-contrast sagittal T1-weighted MR image show focal heterogeneous non–mass-like enhancement in right breast ( arrows ). The associated kinetic curve showed slow initial rise with persistent enhancement in the delayed phase. (c) Second-look ultrasound after MRI shows oval circumscribed hypoechoic mass ( open arrow ) with lack of posterior features, correlating to non–mass-like enhancement on MRI. Ultrasound-guided core needle biopsy was performed of mass. (d) Photomicrograph shows LCIS, intermediate grade (H & E image ×20, inset ×40). Acinar spaces are distended by neoplastic cells. Histopathological findings were confirmed at excisional biopsy.

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Follow-up Findings

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Table 2

Clinical, Radiological, and Histopathological Features of 31 Lesions in 26 Patients with LCIS Found on Core Needle or Excisional Biopsy

Pt Age (y) R/L Size (cm) Imaging Modality CNB EB LCIS Grade Mx F/U (y) Subsequent Cancer MG US MRI Histology R/L Interval between LCIS and Cancer (y) Same Site as LCIS 1 49 R 5 AB N AB ND Benign 1–2 ND 2.1 — 2 ∗ 40 R 8 AB N AB Benign Benign 1 ND 4.9 — 3 62 L 0.4 AB ND ND Benign Benign 2–3 ND 2.5 — 4 46 L 10 N N AB Benign ND 1 PM 3.3 — 5 † 66 L 0.9 AB N ND Benign ND 1 ND 4.4 — 6 ‡ 62 L 1.3 AB ND ND Benign Benign 2–3 PM 6.1 — 62 L 0.5 AB ND ND Benign Benign 2 PM 6.1 — 62 L 0.3 AB ND ND Benign ND 2 PM 6.1 — 64 L 1.0 AB N ND Benign ND 2 PM 6.1 — 7 ‡ , § 40 L 2 AB N ND Benign ND 1 ND 9.1 — 42 L diffuse AB ND ND Benign ND 1 TM 7.1 IDC, DCIS L 6.9 Yes 8 52 R 7 AB AB ND Benign Benign 1–2 ND 4.9 — 9 62 R 0.8 AB ND ND Benign Benign 1 ND 1.5 — 62 L 1 N N AB Benign Benign 2–3 ND 1.5 — 10 60 R 2 AB AB ND Benign Benign 1–2 ND 1.3 — 11 50 R 2.5 AB N N Benign ND 1–2 ND 0.5 — 12 54 L 0.5 AB N ND Benign ND 1 ND 8.4 — 13 60 R 1.5 N AB AB Benign Benign 2 ND 5.3 — 14 57 L 4.3 AB N AB Benign Benign 1 ND 1.8 — 15 65 R 0.6 AB N ND Benign ND 1 ND 2 — 16 § 62 R 1 AB ND ND Benign Benign 1–2 ND 9.7 — 17 56 R 0.5 AB ND ND Benign ND 1 SM 9.4 ILC L 8.6 No SM 9.4 DCIS R 9.3 Yes 18 44 R 0.5 AB N ND Benign Benign 1 ND 1.5 — 19 55 L 6.5 AB N ND Benign Benign 2–3 ND 4.9 — 20 45 L 0.5 AB N ND ND Benign 1 ND 5.6 — 21 § 68 L 0.4 AB N ND Benign ND 1 ND 0.6 — 22 63 R 2 AB N ND Benign Benign 2–3 ND 0.5 — 23 60 R 0.3 AB N ND Benign ND 1 ND 2.5 — 24 59 L 2.8 AB ND ND Benign ND 1 ND 4.2 — 25 45 L 0.6 AB ND ND Benign Benign 2 ND 2.4 — 26 43 L 0.3 AB ND ND Benign ND 1 ND 4 —

AB, abnormal; B, bilateral; CNB, core needle biopsy; DCIS, ductal carcinoma in situ; EB, excisional biopsy; F/U, follow-up; IDC, invasive ductal carcinoma; ILC, invasive lobular carcinoma; L, left; LCIS, lobular carcinoma in situ; MG, mammogram; MRI, magnetic resonance imaging; Mx, mastectomy; N, normal; ND, not done; NA, not available; Pt, patient; PM, prophylactic mastectomy; R, right; SM, segmental mastectomy; TM, therapeutic mastectomy; US, ultrasound; y, years.

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Discussion

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Academic Radiology, Volume 20, Issue 4
Journals General Radiology
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