Atypical Ductal Hyperplasia (ADH) Identified on Core Needle Biopsy – Upgrade Risk to Malignancy

  • Excisional biopsy:
    • Is recommended for most ADH lesions diagnosed on core needle breast biopsy (CNB)
  • The chance of upgrade at excision to:
    • Ductal carcinoma in situ (DCIS) or invasive carcinoma is generally in the:
      • 12% to 22% range in the literature
  • The need for routine excision of pure flat epithelial atypia (FEA) has been less clear:
    • Some authors have reported an upgrade rate of 9.6% following excision of lesions that show pure FEA without ADH when the vast majority of biopsies were done with a 14-gauge spring-loaded core biopsy device:
      • It is not clear that biopsy with a vacuum-assisted device would yield the same results:
        • In fact, in one study reporting biopsy of low-risk calcifications with a vacuum-assisted device, pure FEA never resulted in an upgrade to malignancy
      • An article from the Mayo Clinic:
        • Showed that FEA does not seem to convey an independent risk of breast cancer beyond that of associated proliferative disease without atypia or associated ADH
  • The risk of upgrade at surgical excision for ADH:
    • Has been reported to correlate with the number of ducts or terminal duct lobular units involved on vacuum-assisted core biopsy:
      • With two or fewer foci of involvement:
        • There was no upgrade on excision
      • With four or more foci of involvement:
        • There was a strong probability of upgrade to ductal carcinoma in situ or invasive carcinoma at excision
  • Work continues to try to define a low-risk group who could potentially avoid excisional biopsy:
    • Particularly those with small areas of calcifications completely removed with core needle biopsy and only focal ADH on pathology
  • Apocrine metaplasia, florid epithelial hyperplasia of the usual variety, and columnar cell change without atypia:
    • Do not confer a significant risk of upgrade and do not require excision
  • References
  • Eby PR, Ochsner JE, DeMartini WB, Allison KH, Peacock S, Lehman CD. Is surgical excision necessary for focal atypical ductal hyperplasia found at stereotactic vacuum-assisted breast biopsy? Ann Surg Oncol. 2008;15(11):3232-3238.
  • Ely KA, Carter BA, Jensen RA, Simpson JF, Page DL. Core biopsy of the breast with atypical ductal hyperplasia: a probabilistic approach to reporting. Am J Surg Pathol. 2001;25(8):1017-1021.
  • Khoumais NA, Scaranelo AM, Moshonov H, Kulkarni SR, Miller N, McCready DR, et al. Incidence of breast cancer in patients with pure flat epithelial atypia diagnosed at core-needle biopsy of the breast. Ann Surg Oncol. 2013;20(1):133-138.
  • Said SM, Visscher DW, Nassar A, Frank RD, Vierkant RA, Frost MH, et al. Flat epithelial atypia and risk of breast cancer: a Mayo cohort study. Cancer. 2015;121(10):1548-1555.
  • McGhan LJ, Pockaj BA, Wasif N, Giurescu ME, McCullough AE, Gray RJ. Atypical ductal hyperplasia on core biopsy: an automatic trigger for excisional biopsy? Ann Surg Oncol. 2012;19(10):3264-3269.

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