Atypical Ductal Hyperplasia of the Breast

Definition

A proliferative ductal lesion that demonstrates some but not all features of low or intermediate grade
ductal carcinoma in situ

Diagnostic Criteria

Low Grade DCIS and Intermediate Grade DCIS require cytologic, architectural and size criteria to be
met

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

Atypical Lobular Hyperplasia of the Breast

Definition

A proliferative lobular process that exhibits cytologic features of lobular carcinoma in situ but does not
fulfil the requirements for extent of involvement

Diagnostic Criteria

Same cytologic features as LCIS

 May be classic or pleomorphic

Classic: uniform, small, round, discohesive cells, has been subdivided as:

Type A - small completely bland cells

Type B - slightly larger, slightly irregular, small nucleoli

Pleomorphic: larger, sometimes irregular nuclei, often with prominent nucleoli

May exhibit pagetoid spread into ducts

No lobular unit completely fulfils the extent of involvement required for LCIS

No lobular units show complete filling of all the acini, OR

Even if all filled, fewer than half of the acini in the lobule expanded

There is no category of non-atypical lobular hyperplasia.

Columnar Cell Change and Columnar Cell Hyperplasia of the Breast

Definition

Breast lesions characterized by a variably proliferative, cytologically bland columnar epithelium, lining
dilated terminal duct-lobular units, often with luminal secretions and cytoplasmic blebs on the lining
cells

Diagnostic Criteria

Columnar cell change

Involves dilated terminal duct-lobular units

Lined by uniform, ovoid-to-elongate, non-atypical columnar cells

One or two cell layers thick

Chromatin evenly dispersed

Inconspicuous nucleoli

Columnar cell hyperplasia

Involves dilated terminal duct-lobular units

Lined by columnar cells identical to those seen in columnar cell change

Lining greater than two cells thick

 May form small mounds, tufts and micropapillations

Architectural complexity must be short of that seen in low grade ductal carcinoma in situ

No partial or complete filling of ducts

Arcades, microacini and micropapillary formations absent or very rare

Both frequently exhibit prominent apical snouts

Flat epithelial atypia (similar lesion but with nuclear atypia) is considered separately.

Ductal Carcinoma in Situ of the Breast

Definition

A lesion composed of neoplastic ductal cells, without stromal invasion

Diagnostic Criteria

Low and intermediate grade DCIS require cytologic, architectural and size criteria to be met

High grade DCIS requires only cytologic criteria

Link below to separate pages for each grade for complete criteria or select Grading at left for summary

Low grade

Round, regular to mildly irregular nuclei up to 2-3x the size of a RBC

No comedo necrosis

Intermediate grade

Round, regular to mildly irregular nuclei up to 2-3x the size of a RBC

Substantial comedo necrosis

High grade

Pleomorphic nuclei >3x the size of a RBC

Substantial comedo necrosis usually present, not required

Usual architectural types (see detailed descriptions on the various grades, links above)

Useful for recognition and description but grade is more clinically useful

Cribriform
 Micropapillary

Solid (mosaic, microacinar)

Comedo

Special types

Apocrine

Cystic hypersecretory

DCIS associated with mucocele-like lesion

Endocrine

Mucinous

Papillary

Pure micropapillary

Criteria for minimal stromal invasion

Ductal Carcinoma in Situ of the Breast

Minimal Stromal Invasion

Definition: Extension of cancer cells beyond the basment membrane into the adjacent tissue with no
focus more than 0.1 cm in greatest dimension (AJCC T1mic)

Diagnostic Criteria

Multiple foci are not added together for evaluation of the size criterion

Calponin and p63 stains can be useful

Focus should be outside the lobular unit or immediate periductal area

If cells are present in these areas, designate as "scattered cells in perilobular or periductal area"

Note in report that they do not meet the criteria for minimal stromal invasion

Note that their clinical significance is unknown

Significance

Less than 5% chance of metastases

Nearly 100% survival

 We avoid the term "microinvasion" because of its varying definitions

Flat Epithelial Atypia of the Breast

Definition

Breast epithelial proliferation of 1-5 cell layers composed of cells with low-grade nuclear atypia but
with architectural features not meeting the criteria for ductal carcinoma in situ

Alternate/Historical Names

Columnar cell alteration with prominent apical snouts and secretions (CAPSS) with atypia

Columnar cell change with atypia

Columnar cell hyperplasia with atypia

Diagnostic Criteria

Flat growth pattern

Proliferative epithelium 1-5 cell layers thick

Architectural complexity falls short of low grade DCIS and ADH (atypical ductal hyperplasia)

No partial or complete filling of ducts

Arcades and micropapillary formations absent or very rare

Tufts and mounds may be seen

Involves distended terminal duct lobular units

Low grade nuclear atypia

Nuclei 2-3x size of a RBC (10-15 microns)

Minimal pleomorphism

Short of high grade DCIS

Lined by cuboidal to round cells

Frequently with eosinophilic cytoplasm

Frequently with prominent apical snouts

Columnar cell change and hyperplasia (lesions without nuclear atypia) are considered separately.

Columnar Cell Change and Columnar Cell Hyperplasia of the Breast

Definition

Breast lesions characterized by a variably proliferative, cytologically bland columnar epithelium, lining
dilated terminal duct-lobular units, often with luminal secretions and cytoplasmic blebs on the lining
cells

Diagnostic Criteria

Columnar cell change

Involves dilated terminal duct-lobular units

Lined by uniform, ovoid-to-elongate, non-atypical columnar cells

One or two cell layers thick

Chromatin evenly dispersed

Inconspicuous nucleoli

Columnar cell hyperplasia

Involves dilated terminal duct-lobular units

Lined by columnar cells identical to those seen in columnar cell change

Lining greater than two cells thick

May form small mounds, tufts and micropapillations

Architectural complexity must be short of that seen in low grade ductal carcinoma in situ

No partial or complete filling of ducts

Arcades, microacini and micropapillary formations absent or very rare

Both frequently exhibit prominent apical snouts

Flat epithelial atypia (similar lesion but with nuclear atypia) is considered separately

Lobular Carcinoma in Situ of the Breast

Definition

A lesion composed of neoplastic lobular cells without stromal invasion

Diagnostic Criteria

Uniform population of cells with round, sometimes eccentric nuclei

 Two cytologic types (mixtures and intermediate forms may occur)

Classic

Small round nucleli

Fine chromatin, smooth nuclear contours

Nucleoli small, inconspicuous

Mitotic figures infrequent

Has been subdivided as:

Type A - small completely bland cells

Type B - slightly larger, slightly irregular, small nucleoli

Pleomorphic

Moderately large nuclei

Coarse chromatin

Promininent nucleoli

Mitotic figures not uncommon

Central necrosis may be seen

Requires confirmation of lobular nature with a negative E-cadherin stain

Lightly eosinophilic to vacuolated cytoplasm

Signet ring cells may be present

Discohesive pattern

Uniform cells (above) must fill all the acini in at least one lobular unit and half the acini must be
expanded

Expansion of acini apparent at low magnification

Expanded acini typically balloon-like

May form tiny acini but must not form cribriform spaces or micropapillae

Pagetoid spread into ducts is common

May completely fill ducts

 May involve sclerosing adenosis

Lesions fulfilling some but not all required features of LCIS are considered Atypical Lobular
Hyperplasia.