Atypical Hyperplasia of the Breast: Follow-up and Management
Atypical hyperplasia of the breast is a benign but high-risk condition that can be either ductal (ADH) or lobular (ALH); these occur with equal frequency and together are found in about 10% of breast biopsies. Either entity confers a long-term risk of breast cancer that approaches 30% at 25 years of follow-up.
Surgically excise atypical hyperplasia when found on a core-needle biopsy
Necessary to avoid missing invasive cancer due to sampling error
DCIS or invasive cancer found in 10 to 20% of cases
Exception: Clinical and radiologic follow-up appropriate when atypical hyperplasia is an incidental finding at the site of a targeted biopsy
Current breast cancer risk assessment models perform poorly among women with atypical hyperplasia
Atypical hyperplasia associated with a relative risk of approximately 4 for future breast cancer
Follow-up screening recommendations include annual mammography, breast awareness, and clinical encounter every 6 to 12 months
Annual MRI to begin at diagnosis
Based on emerging evidence, ACOG also recommends consideration of yearly breast MRI for atypical hyperplasia
Encourage pharmacologic risk reduction with either a selective estrogen-receptor modulator (SERM) or an aromatase inhibitor (AI) for prevention of breast cancer
Counsel about healthy lifestyle including ideal body weight and alcohol reduction
Atypical hyperplasia is generally not an indication for surgical risk-reduction / mastectomy
Atypical hyperplasia of the breast reflects proliferation of dysplastic epithelial cell populations. It is felt to be a transitional zone between benign and malignant breast disease, containing some but not all features of a cancer. Although statistically the long-term risk of breast cancer equals or exceeds that conferred by family history and other risk factors, current guidelines in screening do not reflect this. Similarly, pharmacologic risk reduction strategies have been adopted by <1% of women who could potentially benefit from them.
Atypical lobular hyperplasia is histologically similar to lobular carcinoma in situ, but less extensive
Atypical ductal hyperplasia and ductal carcinoma in situ share histologic features
Both types of hyperplasia share molecular characteristics and gene expression, indicating possibly a continuum of abnormalities
While multiple disciplines are required to diagnose and manage both benign breast disorders and breast cancer, the most important interaction with a patient remains the initial office visit
Obtain careful history of all breast related symptoms including duration, changes in symptoms over time, presence and color of nipple discharge
Identify risk factors for breast cancer, including
Advanced age (over 65)
Positive family history
Age >30 at first birth
Menopausal hormone therapy
Alcohol use (not clear what the threshold is)
Visually inspect and manually palpate the breasts, axillae and supraclavicular nodal regions
Clinical documentation of any mass should include size, consistency, distance from areola and clock position in the breast
Diagnostic imaging includes ultrasonography, mammogram or digital tomosynthesis
Manage breast lesion based on age, clinical suspicion, Breast Imaging Reporting and Data System (BI-RADS) and other imaging findings
Ultrasound can differentiate solid from cystic lesions
Histology can be obtained from fine needle aspiration (FNA), core needle biopsy or excisional biopsy, procedures that are usually performed by radiologists or surgeons
Women ≥30 years and older with palpable mass
Mammogram followed by ultrasound, if necessary
Women under 30 years with a palpable mass: Ultrasound is the primary imaging modality
If ultrasound imaging is suspicious for cancer, follow up with tissue biopsy
If ultrasound does not suggest malignancy but clinical suspicion remains, perform a diagnostic mammogram
If ultrasound imaging suggests a benign cyst or a benign appearing solid mass options are to follow-up with physical exam +/- ultrasound/diagnostic mammogram every 6-12 months for 1-2 years to assess stability
Women presenting due to a mass that cannot be palpated by patient or clinician should not be dismissed and must be followed up with imaging
Benign breast lesions can be categorized as nonproliferative (breast cysts), proliferative without atypia (fibroadenoma, intraductal papilloma, fibrocystic change) which may carry a small risk (1.5 to 2 times above general population) for breast cancer and atypical hyperplasia (ductal or lobular). The latter category carries a substantially increased risk of subsequent invasive cancer in either breast (see ‘Related ObG Topics’, below). Nipple discharge is common, and usually benign. Unilateral, uniductal and spontaneous discharge carries a higher risk of malignancy and should be further evaluated with ultrasound.
Women ≥30 years with palpable breast masses shown to be solid on imaging should be biopsied if BI-RADS 4-5, or if BI-RADS 1-3 with high clinical suspicion
Observation an option if BI-RADS 1-3 and low clinical suspicion (see ‘Related ObG Topics’ below)
Women with simple cysts can undergo routine follow-up
Consideration for biopsy should be given to complicated cysts with BI-RADS 1-3
Complex cysts with BI-RADS 4-5 on imaging require biopsy
When common skin problems are identified in the breast such as psoriasis, eczema, contact dermatitis, Candida infections, standard treatment should be used
Skin edema, warmth and erythema as well as ulceration, nipple retraction/crusting/scaling should raise concerns for malignancy and require tissue diagnosis
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This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications.
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presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.
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