La patologia preinvasiva e rischio di neoplasia conclamata

1
La patologia preinvasiva e rischio di neoplasia
conclamata Anna Sapino Dip. di Scienze
Biomediche e Oncologia Umana Università di
Torino Anna.sapino_at_unito.it
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Risk of subsequent invasive breast carcinoma
after in situ breast carcinoma in a population
covered by national mammographic screening R
Rawal, J Lorenzo Bermejo and K Hemminki British
Journal of Cancer (2005) 92, 162 166
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The risk was higher for in situ carcinomas
diagnosed before the age of 50 years
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The risk was higher for in situ carcinomas
diagnosed before the age of 50 years
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pre-operative diagnosis
FOLLOW-UP
SURGERY
post-operative diagnosis
EXCISION MARGINS
FOLLOW-UP
SURGERY
RADIATION TERAPHY
HORMONE TERAPHY
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WHO 2003
Precursor lesions Lobular neoplasia Intraductal
proliferative lesions Microinvasive
carcinoma Intraductal papillary neoplasms
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• Lobular carcinoma in situ
• Atypical lobular hyperplasia

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LIN in core biopsy EWGPBP 2005 B3 lesioni di
incerta evoluzione
LIN (regrouping ALH and LCIS) should be
classified as B3 this process does not
necessarily have the same management implications
as a diagnosis of DCIS but surgical diagnostic
excision might be considered.
LIN is frequently a co-incidental finding in a
core biopsy from a screen-detected lesion and
multidisciplinary discussion is essential as the
abnormality identified radiologically may not be
represented (B1?).
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FREQUENCE OF LIN ON CORE BIOPSY
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Lobular neoplasia on core needle biopsy clinical
significance.Arpino G, Allred DC, Mohsin SK,
Weiss HL, Conrow D, Elledge RM.Cancer. 2004 Jul
15101(2)242-50.
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LIN pre-operative diagnosis
FOLLOW-UP
SURGERY
post-operative diagnosis
EXCISION MARGINS
FOLLOW-UP
SURGERY
RADIATION TERAPHY
HORMONE TERAPHY
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Association with carcinoma
Surgical excision
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Lobular neoplasia on core-needle biopsy-clinical
significance.Arpino G, Cancer. 2004 Jul
15101(2)242-50.
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Radiology 2004 231813819
CONCLUSION Lesions in 17 of patients with LCIS
or ALH at CNB were upgraded to invasive cancer or
DCIS this rate was similar to the upgrade rate
in patients with ADH. Excisional biopsy is
supported when LCIS, ALH, or ADH is diagnosed at
CNB.
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CLINICAL FOLLOW UP
Lobular carcinoma in situ diagnosed by core
needle biopsy when should it be
excised?Middleton LP, Grant S, Stephens T,
Stelling CB, Sneige N, Sahin AA. Mod Pathol.
2003 Feb16(2)120-9.
We show data that supports clinically following
patients with lobular carcinoma in situ and
atypical lobular hyperplasia on core needle
biopsy when the lesion is not associated with a
mass
4 cases
The management of lobular neoplasia identified on
percutaneous core breast biopsy.Bauer VP,
Ditkoff BA, Schnabel F, Brenin D, El-Tamer M,
Smith S. Breast J. 2003 Jan-Feb9(1)4-9.
The diagnosis of LN alone on percutaneous biopsy
without a synchronous contralateral breast cancer
may not warrant routine surgical biopsy
8 cases
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EWGBSP
Pleomorphic LIN may also be classified as B5.
There is at present, however, no definite
follow-up information on these lesions and
management should be discussed in a
multidisciplinary forum.
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Protocollo di Torino
LIN CAUSA DELLA LESIONE MAMMOGRAFICA e/o LIN3
(pleomorfo)
ESCISSIONE CHIRURGICA
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Protocollo di Torino
RISCONTRO CASUALE di LIN1 e/o LIN2
CLINICAL FOLLOW-UP
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LIN pre-operative diagnosis
FOLLOW-UP
SURGERY
post-operative diagnosis
EXCISION MARGINS
FOLLOW-UP
SURGERY
RADIATION TERAPHY
HORMONE TERAPHY
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Cancer 200410023844.
We do not consider it warranted to advocate free
margins as a routine consideration in the
surgical treatment of patients with LCIS,
particularly if it would interfere with cosmesis.
Our pathologic study of the effects of
preoperative chemotherapy revealed that LCIS is
morphologically unaltered by this treatment
method, suggesting that radiation may be
ineffective for the treatment of LCIS.
In contrast, the universal presence of estrogen
and progesterone receptors in cells of LCIS1
indicates the propriety of estrogen antagonists
for its treatment according to a preventative
regimen that has demonstrated at least a twofold
reduction in the development ofinvasive breast
carcinoma for patients with LCIS.
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LN-WHO 2003

• Risk factor and not obligate precursors of
  invasive breast
• cancer in either breast
• Recommended menagement
• Life long follow up with or without tamoxifen
  treatment.
• Re-excision should be considered in cases of
• massive acinar distension and when pleomorphic,
  signet ring or necrotic variants are identified
  at or close to margin

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Sapino A. et al. Virch Arch 2000, 436412-430
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WHO 2003
Precursor lesions Lobular neoplasia Intraductal
proliferative lesions Microinvasive
carcinoma Intraductal papillary neoplasms
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WHO 2003
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WHO 2003
Flat epithelial atypia

• Synonyms
• Ductal intraepithelial neoplasia 1A (DIN1A)
• Clinging carcinoma, monomorphous type
• Atypical cystic lobules
• Atypical lobules, type A
• Atypical columnar changes

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2003
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Iperplasia a CC
Modificazioni a CC
Modificazioni a CC con atipie
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Work-up and management reccomendations for CC
lesions
.columnar cell change with atypia and columnar
cell hyperplasia with atypia should not be taken
into consideration 1)when determining the size
of a coexistent DCIS lesion 2)in the evaluation
of the status of the margins of excision, even
when they are composed of cells that are
cytologically similar to those in the diagnostic
areas of DCIS.
SCHNITT and SALOMON 2003
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associatin
CCH and LIN
CCA and tubular carcinoma
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WHO 2003
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Casting type (coarse branching)
Crush-stone like (coarse clustered)
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SEZIONI MULTIPLE in EE MICROINVASIONE IL
DIAMETRO DEL CARCINOMA INVASIVO NON SUPERA 1 MM
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powdery
Columnar cell
LIN
DCIS low/intermediate grade
adenosis
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Tabar L et al. Cancer 2004 101 1745-1759
Istologically proven 1-9 mm
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WHO 2003
Precursor lesions Lobular neoplasia Intraductal
proliferative lesions Microinvasive
carcinoma Intraductal papillary neoplasms
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Cancer Research 2002 62, 6667-6673
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1- Pathological typing/grading Ospedale SantAnna
e Molinette
N
N
P 0.006
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conclusioni
La patologia preinvasiva e rischio di neoplasia
conclamata
Discussione multidisciplinare
Decisione clinico/terapeutica