乳腺小叶原位癌 NCCN指南2015v3

Lobular Carcinoma in Situ (Stage 0, Tis, N0, M0)WorkupRecommended workup includes history and physical examination, diagnostic bilateral mam

正文

Lobular Carcinoma in Situ (Stage 0, Tis, N0, M0)

Workup

Recommended workup includes history and physical examination, diagnostic bilateral mammography, and pathology review.

Primary Treatment

Controversy exists regarding whether an open surgical excision should be performed of the region of LCIS diagnosed by core biopsy and that is not associated with a mammographic structural abnormality or residual mammographic calcifications.

Small retrospective studies have concluded that excision following the diagnosis of LCIS on core needle biopsy is not necessary.

Other studies have shown that 17% to 27% of patients with LCIS diagnosed by core needle biopsy are upgraded to having invasive cancer or DCIS after larger excisional biopsy.

Based on core needle biopsies, it may be possible to identify subsets of patients with LCIS who can be safely spared a surgical excision.

There are some data of small groups of patients suggesting that LCIS subtypes, including pleomorphic LCIS and LCIS associated with necrosis, carry a risk for associated invasive carcinoma similar to DCIS.

Therefore, according to the NCCN Panel, it is reasonable to perform surgical excision of LCIS found in a core biopsy to exclude an associated invasive cancer or DCIS.

More than 4 foci of LCIS may also increase the risk for upstaging on surgical biopsy.

The NCCN Panel recommends that LCIS of the usual type (involving<4 terminal ductal lobular units in a single core) found on core biopsy, as a result of routine screening for calcifications and without imaging discordance, may be managed by imaging follow-up.

There is evidence to support the existence of histologically aggressive variants of LCIS (eg, “pleomorphic” LCIS), which may have a greater potential than classic LCIS to develop into invasive lobular carcinoma.

Clinicians may consider complete excision with negative margins for pleomorphic LCIS.

However, outcome data regarding treatment of patients with pleomorphic LCIS are lacking, due in part to a paucity of histologic categorization of variants of LCIS.

Therefore, recommendations on the treatment of pleomorphic LCIS as a distinct entity of LCIS have not been made by the panel.

Patients with a confirmed diagnosis of LCIS should be counseled regarding reducing the risk of developing invasive cancer (see NCCN Guidelines for Breast Cancer Risk Reduction).

小叶原位癌(0期,TisN0M0)

检查

推荐的检查包括病史与体格检查、诊断性双侧乳腺摄影以及复阅病理。

初始治疗

关于根据空芯针活检确诊的小叶原位癌区域是否应该实施开放式手术切除存在争议而与乳房摄影结构异常或剩余乳房摄影钙化无关。

小型回顾性研究已经得出结论在空心针穿刺活检诊断的小叶原位癌后没有必要切除。

其它研究已证明通过空心针穿刺活检确诊的小叶原位癌17%-27%的患者在更大的割除性活检后升级为侵袭性肿瘤或导管内原位癌。

根据空心针穿刺活检,也许可能识别出可安全地省略手术切除的小叶原位癌患者亚群。

一些小型患者群信息提示小叶原位癌亚型、包括多形性小叶原位癌与具有坏死的小叶原位癌,浸润性癌相关风险与导管内原位癌相似。

因此,根据NCCN小组,对空芯针活检排除相关的侵袭性肿瘤或导管内原位癌的小叶原位癌实施手术切除是合理的。

超过4个病灶的小叶原位癌在手术活检时也可能升期风险增加。

NCCN小组建议在空芯针活检时发现的常见类型的小叶原位癌(单个芯针中累及<4个终末导管小叶单位),由于常规钙化筛检和影像没有冲突,可影像随访。

有证据支持存在小叶原位癌的组织学侵袭性变种(例如“多形性”小叶原位癌),其可能比经典的小叶原位癌具有更大的潜能发展成为浸润性小叶癌。

对于多形性小叶原位癌临床医生可以考虑切缘阴性完全切除。

但是,缺乏有关多形性小叶原位癌患者治疗的预后信息,在某种程度上是由于缺乏小叶原位癌变种的组织学分类。

因此,作为一种截然不同的小叶原位癌类型关于多形性小叶原位癌的治疗小组没有做出推荐。

应该忠告确诊小叶原位癌的患者有关降低发展为侵袭性肿瘤的风险(见NCCN降低乳腺癌风险指南)。

Surveillance

Follow-up of patients with LCIS includes interval history and physical examinations every 6 to 12 months.

Annual diagnostic mammography is recommended in patients being followed with clinical observation; see also the NCCN Guidelines for Breast Cancer Screening and Diagnosis.

Patients receiving a risk reduction agent should be monitored as described in the NCCN Guidelines for Breast Cancer Risk Reduction.

监测

小叶原位癌患者的随访包括病史与体格检查间隔时间每6-12个月。

正在临床随访观察的患者中推荐每年诊断性乳腺摄影;参见NCCN乳腺癌筛查与诊断指南。

正在接受降低风险药物的患者应该如NCCN降低乳腺癌风险指南中所述进行监测。

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