Problems in Breast Core Needle Biopsy Interpretation
Moderator: Dr. Frances O’Malley
Atypical Lobular Hyperplasia and Atypical Ductal Hyperplasia Involving a Fibroadenoma
Jean F Simpson, MD
Department of Pathology,
Vanderbilt University Medical Canter
A 41 year old woman underwent an ultrasound guided biopsy for a mass. The resulting diagnosis was
discordant with the ultrasound impression, and an excision was performed.
The excisional biopsy specimen shows a circumscribed fibroglandular lesion.
Within the epithelial component, there is a proliferation of monomorphic cells that fill acinar
structures. The individual cells have round, regular nuclei with inconspicuous nucleoli, and homogenous
pale cytoplasm, and occasional intracytoplasmic lumina. In these areas there are no well-developed cell
borders; the cells grow in a dyshesive manner. Other areas contain a monomorphic population of cells
that are arranged with distinct cell borders, and focally rigid architectural configurations.
Final Diagnosis: Atypical lobular hyperplasia and atypical ductal hyperplasia involving a
We use the term "lobular neoplasia" to indicate the full range of in situ changes with characteristic
cells initially diagnosed as LCIS in 1941. Lobular neoplastic breast disease in women has been
considered a special type of premalignancy since 1941  in a paper that also described the related
pattern of "infiltrating lobular carcinoma". During the 20-30 years following description of lobular
carcinoma in situ (LCIS), the term "lobular neoplasia" (LN) has been used for a spectrum of lobulocentric
distortion by characteristic cells that varied from marked 
(lobular carcinoma in situ) to minimal 
– (minimally atypical lobular hyperplasia, not recognizing a risk as high as well developed ALH).
Atypical lobular hyperplasia (ALH) is the diagnostic term most frequently used
to denote most
lesions in this series. The cancer risk implications of ALH have been verified in formal follow-up
Cancer risk assessment is quantitatively elevated if the advanced patterns of lobular carcinoma in
situ are present – this demands extensive distortion, filling and distention of a lobular unit , and
is usually seen in a background of many lobular units with diagnostic ALH. Another pattern that adds
somewhat to risk is the involvement of true ducts with cells of ALH in the present of ALH in lobular
units . However, this finding is restricted to a single study, and the implication of raising
subsequent risk of cancer from a range of 4 times to 7 times that of the general population is not
reliable as a predictor for an individual woman.
The distinction of atypical ductal hyperplasia and low grade ductal carcinoma in
situ is based on the extent of the lesion. Both of these entities are characterized by a uniform,
monomorphic population of cells. In this example, the ADH is limited in its extent; none of the few
involved spaces is completely populated by the same uniform cells.
The atypical hyperplasia (both ALH and ADH) were confined to the fibroadenoma in
this case; surrounding breast parenchyma was devoid of atypical hyperplasia. When atypical hyperplasia
is confined to a fibroadenoma, the risk implications are less than when AH is present in the more
characteristic setting of a lobular unit.
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