Precancerous conditions are cellular or tissue abnormalities that are not cancer, but which may increase the risk of developing a malignant tumour over time. Not all precancerous lesions progress to cancer, and many remain stable or even disappear spontaneously. Appropriate monitoring helps identify those lesions that require treatment to prevent progression.

Breast Calcifications

Breast calcifications are small deposits of calcium that can be seen on a mammogram. They are common, particularly with increasing age, and are usually benign.

Macrocalcifications

  • Large, scattered calcium deposits.
  • Usually associated with benign age-related changes, inflammation, injury or other non-cancerous breast conditions.
  • Do not increase the risk of breast cancer and do not require specific treatment.

Microcalcifications

  • Smaller calcium deposits.
  • Most are also benign.
  • However, certain clustered patterns or suspicious features may be associated with precancerous lesions or very early-stage breast cancer.

If suspicious microcalcifications are identified, additional investigations may include:

  • Additional magnification mammography views.
  • Breast tomosynthesis (3D mammography).
  • Image-guided biopsy.

Classic Lobular Neoplasia (LCIS) and Lobular Lesions

The traditional term Lobular Carcinoma in Situ (LCIS) has evolved. LCIS is now considered primarily a risk lesion and a marker of increased breast cancer risk, rather than a true obligatory precancerous condition.

People with LCIS have an increased lifetime risk of developing breast cancer in either breast.

Typically:

  • It does not cause symptoms.
  • It is usually discovered incidentally during a biopsy performed for another reason.
  • Classic LCIS generally does not require extensive additional surgery when there is clinicoradiological-pathological concordance.

Follow-up may include:

  • Regular clinical examinations.
  • Routine mammography.
  • Breast MRI in selected high-risk individuals.
  • Individual assessment of family history and genetic risk.

Precancerous Cervical Lesions

Most precancerous cervical lesions are associated with persistent infection by high-risk Human Papillomavirus (HPV).

Current international guidelines primarily use the following classification:

Low-Grade Squamous Intraepithelial Lesion (LSIL)

  • Usually associated with HPV infection.
  • Often resolves spontaneously.
  • In many cases, monitoring is recommended rather than immediate treatment.

High-Grade Squamous Intraepithelial Lesion (HSIL)

  • Has a higher risk of progressing to cancer.
  • Usually requires colposcopic assessment and treatment.

The older CIN terminology is still used in pathology:

  • CIN 1 ≈ LSIL.
  • CIN 2 and CIN 3 ≈ HSIL.

These lesions are precancerous and are not the same as cancer. However, some may progress if not appropriately monitored or treated.

HPV vaccination and cervical screening programmes have significantly reduced the risk of progression to cervical cancer.

Monoclonal Gammopathy of Undetermined Significance (MGUS)

Monoclonal Gammopathy of Undetermined Significance (MGUS) is a benign condition characterised by the presence of a monoclonal protein (M protein or paraprotein) in the blood, produced by plasma cells.

Main Characteristics

  • Usually does not cause symptoms.
  • Most often detected incidentally during blood tests performed for other reasons.
  • Does not require specific treatment.

However, some individuals may eventually progress to:

  • Multiple myeloma.
  • AL amyloidosis.
  • Certain lymphomas or other haematological disorders.

For this reason, regular follow-up with blood tests is recommended.

Vaginal Intraepithelial Neoplasia (VaIN)

Vaginal Intraepithelial Neoplasia (VaIN) consists of precancerous changes in the cells lining the vagina. It is an uncommon condition.

Associated Risk Factors

  • Persistent high-risk HPV infection.
  • Immunosuppression.
  • A history of HPV-related cervical lesions.

Typically:

  • It causes no symptoms.
  • It is detected through gynaecological examinations, cervical screening or colposcopy.

Treatment depends on the extent and grade of the lesion and may include observation, ablative therapies or local surgical procedures.

Vulval Intraepithelial Neoplasia (VIN)

Current classification mainly distinguishes two entities:

HPV-Associated VIN (Usual VIN or uVIN)

Associated with persistent high-risk HPV infection.

Differentiated VIN (dVIN)

Less common but associated with a greater risk of progression to cancer. It is often linked to chronic inflammatory vulval conditions, particularly lichen sclerosus.

Symptoms may include:

  • Persistent itching.
  • Burning.
  • Pain.
  • Changes in the colour or texture of the vulval skin.

Treatment may include limited surgery, laser therapy or topical treatments depending on the type and extent of the lesion.

Vulval Lichen Sclerosus

Lichen sclerosus is a chronic inflammatory skin condition that most commonly affects the vulva.

It may cause:

  • Severe itching.
  • Pain.
  • Changes in skin colour.
  • Discomfort when urinating or during sexual intercourse.

Although most patients will never develop cancer, there is an increased risk of vulval squamous cell carcinoma, particularly when the condition is not adequately controlled.

Current standard treatment primarily consists of high-potency topical corticosteroids together with regular follow-up.

Barrett's Oesophagus

Barrett's oesophagus is a condition in which the normal lining of the oesophagus is replaced by tissue similar to that found in the intestine as a result of long-term exposure to gastro-oesophageal reflux.

Risk Factors

  • Chronic gastro-oesophageal reflux disease (GORD).
  • Obesity.
  • Male sex.
  • Increasing age.
  • Smoking.

Although most patients will never develop cancer, Barrett's oesophagus increases the risk of oesophageal adenocarcinoma.

Diagnosis

Diagnosis is made by:

  • Upper gastrointestinal endoscopy.
  • Biopsies of oesophageal tissue.

Treatment and Follow-up

Current recommendations include:

  • Control of reflux through lifestyle modifications and medical treatment.
  • Regular endoscopic surveillance.
  • Endoscopic treatment of dysplasia when present.