What Is Atypical Lobular Hyperplasia (ALH)?
Atypical lobular hyperplasia (ALH) is a benign (non-cancerous) breast condition characterized by the abnormal growth of cells within the breast's lobules. While it is not cancer itself, it is considered a marker of increased risk for developing breast cancer in either breast. This diagnosis is often an incidental finding during a core needle biopsy performed for another reason, such as investigating a suspicious area seen on a mammogram or ultrasound.
How ALH Is Diagnosed
Diagnosis of ALH is made by a pathologist who examines breast tissue obtained during a biopsy. The core needle biopsy is a common method, where a small tissue sample is extracted. The finding of ALH on a core biopsy is what most often raises the question of whether a larger, surgical excisional biopsy is necessary to ensure no more significant pathology, such as cancer, was missed.
The Role of Excisional Biopsy for ALH
Historically, surgical excision was the standard recommendation following an ALH diagnosis on core needle biopsy. This was primarily due to the risk of sampling error, where the core biopsy might not have captured a more serious lesion, such as ductal carcinoma in situ (DCIS) or invasive cancer, that was present nearby. In these cases, the ALH finding was said to be 'upgraded' to a cancer diagnosis after the surgical excision.
Factors Influencing the Excision Decision
Today, the decision to proceed with surgical excision is more nuanced and often involves a discussion between the patient and a breast specialist. Several key factors are considered:
- Radiological-Pathological Correlation: This is a critical factor. If the imaging findings (from the mammogram or ultrasound) perfectly match the benign ALH diagnosis from the biopsy, the case is considered 'concordant'. If there is a mismatch (a 'discordant' finding), surgical excision is more likely to be recommended to investigate further.
- Extent and Location of the Lesion: If the biopsy reveals multiple foci of ALH or if the area is extensive, surgical excision might be considered.
- Type of Lesion: ALH is part of a spectrum of breast lobular neoplasia. A similar but more advanced lesion, lobular carcinoma in situ (LCIS), carries a higher risk and more often warrants excision.
- Patient Risk Factors: A patient's personal history of breast cancer, family history, and genetic predisposition (e.g., BRCA mutations) can influence the decision. Higher-risk patients may be more likely to opt for excision.
- Patient Preference: The patient's comfort level with risk and follow-up is a key component of shared decision-making. Some may prefer surgical removal to eliminate uncertainty, while others may opt for a surveillance approach.
Conservative Management: Observation and Surveillance
Recent studies have shown that for carefully selected patients, observation and surveillance may be a safe alternative to immediate surgical excision. This is particularly true for those with an incidental diagnosis of isolated ALH found on a core needle biopsy with strong radiological-pathological concordance.
For patients who follow a surveillance-only approach, a typical monitoring plan may include:
- Enhanced Imaging: More frequent screening mammograms, often annually.
- Supplemental Screening: Annual breast MRI is often recommended, especially for higher-risk individuals.
- Regular Clinical Breast Exams: Physical examinations by a healthcare professional at regular intervals.
Other Management Strategies
Beyond excision or observation, other strategies can help manage the increased breast cancer risk associated with ALH:
- Chemoprevention: Medications such as tamoxifen or raloxifene can be used to reduce the risk of future breast cancer. These hormone-blocking medicines are typically taken for five years and are a significant consideration for high-risk patients.
- Lifestyle Modifications: Recommendations for reducing overall breast cancer risk include maintaining a healthy weight, regular exercise, and limiting alcohol consumption.
- Genetic Counseling: For patients with a strong family history of breast or ovarian cancer, genetic counseling can assess hereditary cancer syndromes, which may affect the management strategy.
Comparison of Management Approaches for ALH
| Feature | Excisional Biopsy | Active Surveillance (Observation) |
|---|---|---|
| Primary Goal | Remove the lesion, ensure no cancer is present, and obtain definitive pathology. | Closely monitor the lesion and surrounding breast tissue over time for any changes. |
| Best For | Cases with discordant radiology/pathology, multiple or extensive lesions, or high-risk patients. | Cases with isolated ALH, concordant findings, and lower-risk patients. |
| Invasiveness | Surgical procedure, either with local or general anesthesia. | Non-invasive, relying on regular imaging and clinical exams. |
| Upgrade Risk | Eliminates uncertainty regarding upgrade to cancer at the biopsy site. | Retains a small risk of occult cancer not captured by the initial biopsy. |
| Scarring | Potential for scarring at the surgical site. | No scarring from the procedure itself. |
| Benefit | Peace of mind from definitive diagnosis. | Avoids surgery and its associated risks; personalized approach. |
Conclusion
While an ALH diagnosis naturally prompts the question, "Does ALH need to be excised?", the answer is not a simple yes or no. The management of ALH has evolved from a mandatory surgical approach to a more nuanced, personalized strategy. For patients with a diagnosis based on core biopsy, the decision-making process involves careful consideration of radiological and pathological findings, individual risk factors, and patient preference. In cases with concordant findings and low-risk features, close observation may be a suitable path, possibly combined with risk-reducing medication. Every patient should have a thorough discussion with a breast specialist to develop a personalized management plan that is right for them.
For more information on breast hyperplasia and its management, consult the guidelines provided by trusted medical sources like the National Comprehensive Cancer Network (NCCN).
