Collaborative guidelines from the American Society of Breast Surgeons, Society of Breast Imaging, and College of American Pathology addressing the management of proliferative breast lesions with atypia (FEA, ADH, ALH) and lobular carcinoma in situ (classic, pleomorphic, and florid LCIS), covering risk assessment, pathology review, surgical excision, and margin requirements.
Key recommendations include: (1) ADH, ALH, and C-LCIS warrant comprehensive breast cancer risk assessment and counseling on risk-reducing strategies; (2) most ADH, P-LCIS, and F-LCIS found on core biopsy require diagnostic excision, with negative margins required for P-LCIS and F-LCIS but not ADH; (3) ALH and C-LCIS with radiographic-pathologic concordance can be safely observed without excision; (4) FEA alone with concordant imaging does not require diagnostic excision; (5) FEA is not associated with elevated future breast cancer risk.
Guidelines are consensus- and evidence-informed rather than derived from prospective randomized data; the magnitude of future breast cancer risk for P-LCIS and F-LCIS remains explicitly uncertain; some recommendations rely on strict multidisciplinary consensus criteria not yet widely standardized.
For ADH on core biopsy, excision is the default but select cases meeting strict criteria may be observed under multidisciplinary consensus; ALH and classic LCIS with radiographic-pathologic concordance do not need excision, but P-LCIS and F-LCIS do—with negative margins required. All patients with ADH, ALH, or C-LCIS should receive formal breast cancer risk assessment and discussion of risk-reducing medications.
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