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Contemporary management of atypical breast lesions identified on percutaneous biopsy: a narrative review

The management of atypical breast lesions identified on core needle biopsy (CNB) for a breast imaging abnormality is a topic of controversy. While all these atypical lesions have routinely been excised in the past, contemporary management requires a multidisciplinary approach that does not have a one-size-fitsall option. Rigorous multidisciplinary review from the breast radiologist and the pathologist should confirm concordance. All discordant biopsies require surgical excision or additional sampling with more aggressive CNB. Concordant biopsies demonstrating pure flat epithelial atypia (FEA), atypical lobular hyperplasia (ALH), and classic type lobular carcinoma in situ (LCIS) should not routinely undergo surgical excision. Of all the atypical breast lesions, atypical ductal hyperplasia (ADH) has the highest risk of upgrade to underlying malignancy and may still be considered for excision, though opportunities for observation for low volume disease may exist. Presentation and extent of atypia, as well as the specific type of atypia should determine the need for excision to rule out underlying malignancy. With the exception of FEA, regardless of whether the site of atypia is excised or not, the patient is also at increased risk of future breast cancer in both breasts. The highest lifetime risk is in women with LCIS. Lifestyle modification, high-risk screening, discussion of chemoprevention, and even bilateral risk-reducing mastectomy may be appropriate for those at a lifetime