High-risk breast lesions and management

	Diagnosis	Management after core needle biopsy^[1]	Upgrade rate with excision	Management of margins after excision	Relative risk for invasive cancer	Risk reduction with active surveillance and chemoprevention
Atypical ductal hyperplasia (ADH)	Found on biopsy performed for microcalcifications on screening mammogram	Surgical excision for most patients	10 to 20%^[2]	No re-excision for margins	3.1 to 4.7^[2]	Yes
Atypical lobular hyperplasia (ALH)	Incidental finding on biopsy performed for other reasons	Surgical excision for discordance or presence of other high-risk lesion Observation for other lesions	<3% for concordant, small-volume disease^[2]	No re-excision for margins	3.1 to 5.9^[2]	Yes
Lobular carcinoma in situ (LCIS)	Incidental finding on biopsy performed for other reasons	Surgical excision for non-classic features (pleomorphic, comedo necrosis, signet ring, or apocrine), or for discordance Observation for concordant classic LCIS	<5% for concordant, small-volume disease^[2]	Re-excision to negative margins for pleomorphic LCIS No re-excision for margins for classic LCIS	6.9 to 11^[2]	Yes
Flat epithelial atypia (FEA)	Found on biopsy performed for microcalcifications on screening mammogram	Surgical excision for discordance or FEA associated with residual microcalcification Observation for concordant pure FEA	0 to 3.2% for pure FEA^[2]	No re-excision for margins	1.47^[3]	No for pure FEA (return to routine surveillance)

References:

https://www.breastsurgeons.org/docs/statements/Consensus-Guideline-on-Concordance-Assessment-of-Image-Guided-Breast-Biopsies.pdf (Accessed on April 15, 2019).
Morrow M, Schnitt SJ, Norton L. Current management of lesions associated with an increased risk of breast cancer. Nat Rev Clin Oncol 2015; 12:227.
Boulos FI, Dupont WD, Simpson JF, et al. Histologic associations and long-term cancer risk in columnar cell lesions of the breast: a retrospective cohort and a nested case-control study. Cancer 2008; 113:2415.

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