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Columnar Cell Lesions of the Breast

October 14, 2010

Christopher Montague, M.D.

The widespread use of mammography in conjunction with stereotactic-directed needle biopsy has resulted in increased detection of invasive and non-invasive breast lesions. Proliferative lesions of the terminal duct lobular units classified as columnar cell lesions breast are being encountered with increasing frequency due to the widespread use of screening mammography and the association of columnar cell lesions with microcalcifications. Recent studies would indicate that columnar cell lesions with atypia are neoplastic lesions that may represent early forms of low-grade ductal carcinoma in-situ (DCIS); however, the limited clinical follow-up data suggests that the risk of progression to invasive cancer is low.

Common non-invasive ductal lesions of the breast include ductal hyperplasia, atypical ductal hyperplasia (ADH), and DCIS. These diagnostic entities have established criteria for diagnosis, and their presence can be consistently classified by pathologists. Columnar cell lesions of the terminal ductal lobular units differ from ADH and DCIS because they lack significant intraepithelial proliferation and display mainly cytologic abnormalities. Many names have been used for these lesions, including columnar alteration of lobules, blunt duct adenosis, cancerization of small ectatic ducts of the breast by duct carcinoma in-situ, columnar alteration with prominent apical snouts and secretions, and clinging carcinoma in-situ. The variety of terminology historically employed to describe columnar cell lesions of breast reflects the spectrum of in-situ epithelial changes that range from benign columnar cell alteration to atypical ductal hyperplasia to ductal carcinoma in-situ. Of the many terms used, the currently accepted and most widely employed is columnar cell change of the breast.

Columnar cell change, also frequently referred to as blunt duct adenosis, is defined as an aggregate of ducts that end abruptly without forming lobules. These ducts may have dilated lumina, resulting in microcysts, or may manifest faulty layering of the epithelium. The lining is often columnar with luminal snouts and secretions. These changes are frequently associated with calcifications, are detected with increasing frequency by imaging, and are associated with other forms of hyperplasia. It appears that these lesions are a key to neoplastic change in the development of some forms of low-grade DCIS and invasive carcinoma and have been classified into different types, including simple columnar cell change, columnar cell hyperplasia, and columnar cell hyperplasia with atypia. To add to the confusion, these lesions are often grouped into the umbrella descriptive category of “flat epithelial atypia” which encompasses several different lesions rather than a specific diagnosis. Flat epithelial atypia in a pathology report describes either columnar cell changes having cytologic atypia or columnar cell hyperplasia with atypia.

When columnar cell change is identified, it is recommended that pathologists report the presence of columnar cell lesions with or without atypia and to designate the presence or absence of atypical ductal hyperplasia or ductal carcinoma in-situ. In a needle biopsy specimen, additional tissue sections can be examined. However, in an excisional biopsy, any remaining tissue should be submitted. Columnar cell lesions with atypia are treated similarly to that of atypical ductal hyperplasia and, if seen in a needle biopsy, follow-up excision is recommended. If seen in an excisional biopsy and no other features of ductal carcinoma in-situ or invasive carcinoma are identified, no additional therapy or treatment for the identified columnar cell lesion is warranted.

Some studies have established a relationship between some of these lesions(particularly those with atypia) and some forms of DCIS or low-grade invasive carcinoma (i.e., tubal carcinoma). Evidence for this association includes coexistence of these lesions in the same breast, as well as cytologic, immunophenotypic, and genetic similarities between columnar cell lesions and low-grade carcinoma. Recent genetic studies have identified similarities between columnar cell lesions and ductal carcinoma in-situ. These studies suggest that columnar cell lesions represent a link in the development of DCIS and invasive carcinoma.

While all observations indicate that columnar cell lesions are neoplastic, from a biological sense, the clinical implications are not as clear because very few outcome studies have been completed. Pathologic work-up and clinical management of patients with columnar cell lesions of the breast will evolve as conclusions from these studies emerge.

In summary, at the present time, it is suggested:

  • When columnar cell change alone or columnar cell hyperplasia without atypia is seen in needle core biopsy specimens, additional pathology work-up or excision is not required.
  • For lesions with atypia (flat epithelial atypia), subsequent excisions have shown more advanced lesions in up to one-quarter to one-third of cases, and excisional biopsy is recommended.
  • In excisional biopsies, as with core needle biopsies, no additional work-up or therapy is needed for columnar cell change or columnar cell hyperplasia without atypia. If atypia is found, a more thorough search for diagnostic features of atypical ductal hyperplasia or DCIS is warranted.
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