The Desmoid Tumor Research Foundation

July 2026

Management of High-Risk Breast Lesions: A Comprehensive Update

Author Information

Kathryn W Zamora 1, Miglena K Komforti 2, Elizabeth B Vorhis 3, Sona A Chikarmane 4, Kristen Coffey 5, Katerina Dodelzon 5, Madeline Evans 1, Anne E Kendell 6, Santo Maimone 7, Jessica H Porembka 8, Wenhui Zhou 9, Manisha Bahl 10

1University of Alabama at Birmingham, Department of Radiology, Birmingham, AL, USA. 2Mayo Clinic Florida, Department of Pathology, Jacksonville, FL, USA. 3Advanced Imaging Medical Consults, P.C., Fort Collins, CO, USA. 4Boston Medical Center, Department of Radiology, Boston, MA, USA. 5Weill Cornell Medicine, Department of Radiology, New York, NY, USA. 6University of Utah, Department of Radiology, Salt Lake City, UT, USA. 7Mayo Clinic Florida, Department of Radiology, Jacksonville, FL, USA. 8University of Texas Southwestern Medical Center, Department of Radiology, Dallas, TX, USA. 9University of Wisconsin, Department of Radiology, Madison, WI, USA. 10Massachusetts General Hospital, Department of Radiology, Boston, MA, USA.

Publication

J Breast Imaging

Summary

High-risk breast lesions (HRLs) encompass a heterogeneous group of pathologies that coexist with an adjacent or synchronous malignancy, confer an increased risk of future breast cancer, or warrant surgical consideration because of upgrade potential or local behavior. Despite their clinical importance, management of HRLs remains variable. The American Society of Breast Surgeons (ASBrS) and the Society of Breast Imaging are collaborating to establish unified, evidence-based guidelines for managing these lesions. While these recommendations are currently in development, this review summarizes the existing literature and current guidance, including ASBrS recommendations, to provide context for multidisciplinary management. The article reviews the histopathologic features, imaging appearance, and management strategies for HRLs, including atypical ductal hyperplasia (ADH), atypical lobular hyperplasia (ALH), lobular carcinoma in situ (LCIS), flat epithelial atypia (FEA), papillomas with and without atypia, radial scar/complex sclerosing lesion (RS/CSL), mucocele-like lesion (MLL), desmoid tumor, and pseudoangiomatous stromal hyperplasia (PASH). Recent literature supports nonoperative management for specific radiologic-pathologic concordant lesions, particularly limited ADH, pure FEA, and pure RS, highlighting the important role of multidisciplinary discussion for personalized care. Lesions such as LCIS subtypes, papilloma with atypia, and MLL with atypia continue to warrant excision due to higher reported upgrade rates to malignancy. Beyond short-term management, HRLs such as ADH, ALH, and LCIS serve as biomarkers of long-term breast cancer risk, informing recommendations for surveillance, risk assessment, and chemoprevention counseling. Achieving a consensus among radiology, pathology, and surgical disciplines is essential to ensure oncologic safety while minimizing overtreatment in the era of precision breast care.

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