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

Table 1 Risk that ductal carcinoma in situ or invasive carcinoma is found on subsequent surgical excision pathology following a core biopsy diagnosis of pleomorphic lobular carcinoma in situ

Ref.	No. of PLCIS cases	Diagnosis oncore biopsy	Surgical procedure	PLCIS alone on surgical specimen	Concurrent DCIS or invasive carcinoma on surgical specimen	Concurrent DCIS (%)	Concurrent invasive cancer (%)
Carder et al[4]	10	10 PLCIS	2 DB, 8 WLE	7	3 ILC	0	30
Chivukula et al[3]	12	12 PLCIS	1 DB, 1 WLE, 8 SMx, 1Mx, 1BMx	9	3 ILC	0	25
Fasola et al[30]	34	13 PLCIS 21 PLCIS + DCIS or IC	PLCIS: 11 WLE, 2 Mx PLCIS with DCIS or IC: 9 WLE, 12 Mx	4	9 DCIS 15 ILC 6 IDC	26	62
Morris et al[31]	17	3 PLCIS 7 PLCIS + DCIS 7 PLCIS + IC	17 WLE	3	3 DCIS 11 IC	18	65
Niell et al[32]	5	5 PLCIS	5 WLE	1	1 DCIS 2 ILC 1 IDC	20	60
Georgian-Smith et al[33]	5	5 PLCIS	5 WLE	3	2 IC	0	40
Lavoue et al[34]	10	10 PLCIS	10 WLE	7	3 ILC	0	30
Total	93	58 PLCIS 7 PLCIS + DCIS 7 PLCIS + IC 21 PLCIS + DCIS or IC		34	13 DCIS 26 ILC 7 IDC 13 IC	14	49

At initial assessment PLCIS is diagnosed on a core biopsy specimen, this table details the subsequent histology from a surgical resection of the area, demonstrating how many of the core biopsies are upgraded to invasive carcinoma or DCIS. PLCIS: Pleomorphic lobular carcinoma in situ; DCIS: Ductal carcinoma in situ; ILC: Invasive lobular carcinoma; IDC: Invasive ductal carcinoma; IC: Invasive carcinoma (with type not specified); DB: Diagnostic biopsy; WLE: Wide local excision; Mx: Mastectomy; SMx: Segmental mastectomy; BMx: Bilateral mastectomy.

Table 2 Rate of recurrent disease after surgical excision of pleomorphic lobular carcinoma in situ

Ref.	No. of PLCIS cases	PLCIS at margin	Histology of recurrence	Time to recurrence	Local recurrence rate
Downs-Kelly et al[5]	26	13 cases ≤ 1 mm 4 cases 1.1-2 mm 9 cases > 2 mm	1 PLCIS	19 mo	3.8%
Khoury et al[35]	57	Not stated	7 PLCIS	Not stated	12.3%
Fasola et al[30]	34	Not stated	3 PLCIS	≤ 5 yr	8.85

This details the number of cases of histologically diagnosed recurrence following a previous excision of PLCIS. PLCIS: Pleomorphic lobular carcinoma in situ.

Table 3 Summary of guidelines for the management of in situ breast disease

Guideline source	Recommendation-PLCIS	Recommendation-CLCIS	Recommendation-DCIS
ABS, 2009[16] (United Kingdom)	PLCIS not mentioned	Should consider diagnostic biopsy Clear margins not required Post-op surveillance is appropriate (No adjuvant treatment mentioned) (No lymph node surgery required)	Resection with clear margins (> 1 mm) required (WLE or Mx) Intra-op radiography should be used for all DCIS as majority impalpable Lymph node surgery not usually required but may be considered in high risk cases
NCCN, 2013[20] (United States)	“Consider excision with negative margins”	Diagnostic biopsy Risk reducing treatment discussion with patient (options: risk reducing surgery, hormone therapy, no further treatment) Surveillance indicated	Consider MRI WLE or Mx Margin controversial but certainly > 1 mm SLNB usually not required but may be considered in high risk cases Consider RTx
ESMO, 2013[29] (pan-European)	“May behave similarly to DCIS and should be treated accordingly”	Risk factor for future development of invasive cancer and does not require active treatment	Resection with clear margin (≥ 2 mm) required (WLE or Mx) SLNB usually not required but may be considered in high risk cases
NBOCC, 2003[27] (Australia)	PLCIS not mentioned	Consider surgical biopsy Surveillance ≥ 15 yr No role for clear margin excision established	Clear margin excision Usually adjuvant RTx Consider hormone therapy
NHSBSP “In situ lobular neoplasia: overview and recommendations” [pending publication][17] (United Kingdom)	Should be classified B5a (as with DCIS) and excised with negative margins	Merits MDT discussion and usually diagnostic biopsy

ABS: Association of Breast Surgery; NCCN: National Comprehensive Cancer Network; ESMO: European Society of Medical Oncology; NBOCC: National Breast and Ovarian Cancer Care; NHSBSP: National Health Service Breast Screening Programme. PLCIS: Pleomorphic lobular carcinoma in situ; DCIS: Ductal carcinoma in situ.