A retrospective study comparing the individual modalities of triple assessment in the pre-operative diagnosis of invasive lobular breast carcinoma

doi:10.1053/ejso.2001.1236

European Journal of Surgical Oncology (EJSO)

Volume 28, Issue 3, April 2002, Pages 203-208

https://doi.org/10.1053/ejso.2001.1236 Get rights and content

Abstract

Aims: Early invasive lobular breast carcinoma (ILC) is associated with few symptoms and signs. The individual sensitivity of clinical examination, mammography, ultrasonography, cytology and core biopsy have each been reported to be of limited value. The aim of this study was to evaluate the accuracy of triple assessment in the pre-operative detection of patients identified to have ILC from their surgical pathology. Methods: Pure ILC was defined as tumours containing at least 90% lobular features. The triple assessment of 273 patients diagnosed primarily at our institution were reviewed. Results: 87.5% of women were symptomatic and 12.5% were screen detected. The mean patient age was 59 (range 30–81) years and the median tumour size was 26 (range 5–110) mm. The main mammographic abnormalities were a spiculated lesion (33.3%), an ill-defined mass (33.3%) or architectural distortion (23.5%). The sensitivities for detecting ILC of each modality were: clinical examination (76.6%), mammography (79.8%), ultrasound examination (93.9%), fine-needle aspiration cytology (FNAC) (60.5%) and core biopsy (90.8%). Combining the three modalities of clinical examination, imaging and cyto/pathology increased the pre-operative detection rate of ILC. Conclusion: Triple assessment is useful in the diagnosis of ILC. As the features of ILC may be subtle, a high index of suspicion is required to facilitate early diagnosis.

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Locally advanced invasive lobular carcinoma presenting as skin erythema, with multimodality imaging correlation
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Anatomic structures are preserved during early tumor growth and the associated desmoplastic reaction, if present at all, is often far less prominent than that seen with invasive ductal carcinomas [6]. Therefore, ILC often fails to form a palpable mass and is challenging to detect on clinical exam [7]. These growth characteristics result in lower mammographic and sonographic sensitivities for detection of ILC compared to IDC, as well as potential underestimation of ILC size which may hamper the surgeon's ability to obtain negative margins [6,8,9].
Invasive lobular carcinoma comprises 10-15% of invasive carcinomas of the breast. Its inconspicuous pattern of proliferation may lead to tumor manifestations that can be challenging to detect on mammography and clinical exam, which can result in tumor detection at advanced size and stage. This case demonstrates a locally advanced invasive lobular carcinoma and its subtle growth pattern illustrated on several imaging modalities, as well as its unique initial clinical presentation of skin erythema mistaken for rash.
Preoperative cytological and histological diagnosis of breast lesions: A critical review
2010, European Journal of Surgical Oncology
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As such, many centres prefer CNB to individualize the choice to perform axillary staging. Second, CNB can better distinguish invasive lobular from invasive ductal carcinoma than FNA as the infiltrating pattern is characteristic on histology and epithelial markers can confirm the diagnosis.53,54 Preoperative knowledge of specific tumour histology is fundamental to planning the extent of surgery since lobular carcinoma carries an increased risk of positive lumpectomy margins and synchronous contralateral disease.55,56
Non-operative pathology diagnoses constitute an essential part of the work-up of breast lesions. With fine needle aspiration (FNA) and core needle biopsy (CNB) both having unique advantages, there is an increasing acceptance of CNB. This paper aims to outline the scientific basis of this trend. Additionally, we provide an update on novel techniques that derive cytological specimens from CNB (i.e., touch imprint (TI) and core wash (CW) cytology) in an attempt to get the best of both worlds.
In addition to using the authors' experience, we performed a search of the Medline database combining the search terms “breast cancer diagnosis”, “core needle biopsy”, “fine needle aspiration”, “touch imprint cytology”, “core wash cytology” and “complications”. We defined a conclusive non-operative diagnosis as “malignant” in lesions that were malignant on follow-up and “benign” in lesions that were benign on follow-up.
CNB was more often conclusive than FNA in benign and malignant lesions in 4 prospective studies. Although the more rapid diagnoses by FNA result in less patient anxiety during diagnostic work-up, CNB allows for fairly reliable estimation of invasion, histological type, grade, and receptor expression. CW and TI cytology seem promising techniques with conclusiveness rates that are roughly comparable to that of FNA.
All new suspicious breast lesions require careful non-operative investigation by CNB. However, additional cytological assessment by FNA can still be useful as a same-day diagnosis decreases patient anxiety and facilitates surgical treatment planning. TI and CW cytology techniques are promising same-day diagnosis modalities.
The Effectiveness of MR Imaging in the Assessment of Invasive Lobular Carcinoma of the Breast
2010, Magnetic Resonance Imaging Clinics of North America
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There is no association of ILC with microcalcifications, and the tumors are often isodense to fibroglandular tissue.22,25,27,31,32 Common descriptors include ill-defined mass (7%–33%),23,26,29 architectural distortion (10%–24%),23,26–29 and asymmetry (4%–14%).23,26 The wide ranges reported probably reflect interreader variability of the descriptive terminology.
Lobular breast carcinoma and its variants
2010, Seminars in Diagnostic Pathology
Citation Excerpt :
Another problem related to ILC diagnosis is cellular uniformity, particularly in low-grade lesions, and the lack of stromal response, which create a challenge for cytologic diagnosis on fine needle aspiration or histologic diagnosis on NCB. The reported failure rates for detection of ILC on fine needle aspiration range from 4% to 40% depending on the series.64-66 This high rate usually is attributed to inadequate sampling or poor cellularity and to difficulties in interpretation because of the presence of only mild atypia and more frequent small cells.
Lobular carcinoma is a special type of breast cancer that shows distinct clinical presentation, morphologic and molecular features, and clinical behavior, and its incidence is rising in recent years. Infiltrating lobular carcinoma (ILC) and its precursor lesions may result in diagnostic difficulties, particularly in the screening settings and their management may be problematic. Variants of lobular carcinoma, such as the pleomorphic variant, although not common, exist and some show differences in behavior warranting their recognition in view of requirements for different management strategies. Here we present a review of lobular carcinomas with particular attention to lobular in situ lesions, epidemiology, subtypes, diagnosis, molecular pathology, and grading of ILC in addition to the clinical behavior, response to therapy, and outcome of patients with ILC.
Mammographic detection and staging of invasive lobular carcinoma
2006, Clinical Imaging
The aim of the study was to evaluate mammography in detecting and staging of invasive lobular carcinoma (ILC) in order to assess the performance and impact of observer variability. Forty-two cases of ILC were retrospectively evaluated twice by two breast radiologists. Mammographic performance as well as intra- and interobserver variations was evaluated. Thirty-five percent to 37% of the cases were understaged. The largest differences between radiologists were found in the breast imaging reporting and data system (BIRADS) classification and staging performance. These results can have serious influence on patient management.
Infiltrating lobular carcinoma - A comparison of diagnosis, management and outcome with infiltrating duct carcinoma
2004, Breast
The treatment and outcomes for 182 patients with lobular carcinoma were compared with 1612 patients with infiltrating ductal carcinoma managed concurrently at The Strathfield Breast Centre. The lobular carcinomas were larger (P<0.0001) but of lower grade (P<0.0001). Diagnosis with mammography and FNA was less sensitive in ILC (mammography P=0.0002, FNA P<0.0001). Although similar numbers of patients underwent initial attempted conservation, patients with ILC were more likely to have positive margins at attempted breast conservation surgery and the final mastectomy rate was higher (58.2% ILC versus 47% IDC, P=0.0041). Of the patients who had successful conservation, the local recurrence rates for ILC (3.9%) were equivalent to the patients with IDC (5.3%). There was no significant difference in overall survival (90% ILC, 87% IDC, median follow-up 3.6 years ILC, 4.3 years IDC) or disease free survival (87.9% ILC, 81.6% IDC). Although mastectomy is more likely to be necessary to obtain clear margins, breast conservation therapy is reasonable in patients with infiltrating lobular carcinoma where clear margins can be obtained.

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^f1: Correspondence to: Mr G. P. H. Gui, Consultant Breast Surgeon, Royal Marsden NHS Trust, 203 Fulham Road, London SW3 6JJ, UK. Fax: +44 (0) 7808 2673; E-mail: [email protected]

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A retrospective study comparing the individual modalities of triple assessment in the pre-operative diagnosis of invasive lobular breast carcinoma