Atypical ductal hyperplasia is a term applied to proliferative ductal lesions with any one of the following sets of features:
Ducts completely filled and exhibit sharp punched out spaces or micropapillae but lack uniform cytologic features
Presence of even a partial population of columnar cells, or
Presence of even focal streaming of cells
OR: Ducts filled by a uniform population of cells with cytologic features of low grade DCIS but lack architectural features
Only partial filling of ducts, or
Lack of uniformly sharp punched out spaces, microacini or characteristic micropapillae
Solid low grade DCIS is rare but must be excluded before using this feature to diagnose ADH
OR: Cytologic and architectural features met but failure to meet size criteria
Fewer than two duct spaces involved or less than 2-3 mm in aggregate dimension
High grade cytology excludes a lesion from consideration for atypical ductal hyperplasia, regardless of architecture or size
Richard L Kempson MD
Department of Pathology
Stanford University School of Medicine
Stanford CA 94305-5342
Original posting:: May 1, 2006
Supplemental studies
Immunohistology
E-cadherin appears to be a sensitive marker of classic ductal differentiation vs lobular differentiation; its utility in borderline lesions is currently uncertain.
Architectural complexity manifested by a) partial or complete filling of ducts or b) arcades or micropapillary formations
Lacks architectural complexity
All three have low grade nuclear atypia, except for some cases of ADH, which must have architectural complexity
Clinical
Atypical ductal hyperplasia is considered a marker of increased risk of carcinoma rather than a precursor lesion
Its presence in a core biopsy is an indication for excisional biopsy
In an excisional biopsy, margins are not relevant if it is the only lesion
If the excision is for DCIS or invasive carcinoma and ADH is at the margin it is probably best to suggest re-excision
Relative risk for development of invasive breast carcinoma
No increased risk
Non-proliferative fibrocystic change
Fibroadenoma
Solitary papilloma
Slightly increased risk (1.5 to 2 times)
Proliferative fibrocystic change
Usual ductal hyperplasia
Sclerosing adenosis (florid)
Radial scar
Complex fibroadenoma (approximately 3 times risk)
Moderately increased risk (4 to 5 times)
Atypical ductal hyperplasia (no family history)
Atypical lobular hyperplasia
High risk (8 to 10 times)
Ductal carcinoma in situ, low grade
Lobular carcinoma in situ
Atypical ductal hyperplasia, if history of carcinoma in primary relatives
Very high risk (precise level not known)
Ductal carcinoma in situ, high grade
Grading / Staging / Report
Grading is not applicable
Staging is not applicable
The surgical pathology report should contain or address the following:
Type of resection or biopsy and location
Results of any supplementary studies performed
Bibliography
Dupont WD, Parl FF, Hartmann WH, Brinton LA, Winfield AC, Worrell JA, Schuyler PA, Plummer WD. Breast cancer risk associated with proliferative breast disease and atypical hyperplasia. Cancer. 1993 Feb 15;71(4):1258-65.
Page DL, Dupont WD, Rogers LW, Rados MS. Atypical hyperplastic lesions of the female breast. A long-term follow-up study. Cancer. 1985 Jun 1;55(11):2698-708.
Tavassoli FA, Norris HJ. A comparison of the results of long-term follow-up for atypical intraductal hyperplasia and intraductal hyperplasia of the breast. Cancer. 1990 Feb 1;65(3):518-29.
Wells WA, Carney PA, Eliassen MS, Grove MR, Tosteson AN. Pathologists' agreement with experts and reproducibility of breast ductal carcinoma-in-situ classification schemes. Am J Surg Pathol. 2000 May;24(5):651-9.
